ERS44 Taking Care Of Patients With Diabetes

Question 1

Care for chronic diseases

Answer 1

Chronic disease is a major burden to health care systems

• wide range of complications
• require long-term follow-up
• repeated hospitalisation
• ↑ burden with ageing, epidemiological shift (from CD to NCD), ↑ health care costs

Good chronic disease management:

1. Improve Patient care
2. Improve Service quality
3. ↓ Costs

Question 2

Epidemiology of DM

Answer 2

• Type 2 DM most common
• ***~50% undiagnosed
• Major burden on health + health care system
  —> many comorbidities (e.g. hypertension, cancer, infections)
  —> wide range of microvascular / macrovascular complications —> expensive, difficult to treat, require long-term care + follow-up
• Prevalence ↑ with age
• More common in urban, economic developed areas
• Diabetes health expenditure continuously ↑ over last decade

USA:
- Diabetes health expenditure&raquo_space;> No. of diabetic patient

China:
- No. of diabetic patient&raquo_space;> Diabetes health expenditure

Question 3

Care of patient with Diabetes

Answer 3

1. Patient education / empowerment
2. Glycaemic control
   - Non-pharmacological: Diet, Exercise
   - Pharmacological: Oral medications +/- Insulin
3. Management of risk factors, comorbidities
   - e.g. hypertension, dyslipidaemia, depression
4. Prevent microvascular / macrovascular complications
   - screening, monitoring, management

Question 4

Challenges in delivery of diabetes care

Answer 4

1. Time-demanding for busy clinicians
2. Large amount of clinical information (∵ wide range of complications)
3. Unique risk profile for each patient (—> many different treatments)
4. Non-adherence to treatment
5. Non-attendance / Loss to follow-up (∵ chronic nature)
6. Organisation of care for diabetes

Question 5

***Organisation of care for diabetes

Answer 5

1. Models of care for chronic disease
   - Chronic care model
   - Innovative care for chronic conditions model
   - Public health model
   - Continuity of care model
   - Life course model
2. Primary care and focused factories
3. Shared care
4. Referral system in HK

Question 6

Chronic care model

Answer 6

• Best known framework
• ***Focuses on linking:
  1. Informed, active people with long-term conditions
  2. Pro-active teams of professionals
• Acknowledges a substantial portion of chronic care takes place ***outside formal healthcare settings
• 6 components of model: based on research evidence of system changes —> improve quality of chronic disease management
• Widely applied in diabetes care

6 components:

1. ***Health systems
2. ***Decision support (based on evidence + patients’ preference / needs)
3. Clinical information systems (to ***organise patient / population data)
4. Patient ***self-management
5. Delivery system design (for ***clinical care and patient support)
6. Community ***resources and policies (to mobilise patient resources)

How effective?

• Improvements in diabetes biomarkers
• Benefits in patient adherence to therapy, health behaviours, patient satisfaction
• Interventions incorporating >=1 element —> improved outcomes, care processes

Question 7

Innovative care for chronic conditions model (個人, 社區, 城市)

Answer 7

Chronic care model: conceptualised from Primary care perspective

Innovative care for chronic conditions model:

• adapted by WHO
• focus on Community + Policy aspects on improving chronic care

Focus on improving care on ***3 different levels:

1. Micro (individual, family)
2. Meso (health care organisation, community)
3. Macro (policy)

Question 8

Public health model (最小—>最大服務)

Answer 8

3 levels of ***intervention to improve burden of chronic conditions

1. Population-wide policies (最大)
2. Community activities
3. Health services (最細)
   - preventive services
   - ongoing care for patients

• Identify + address ***interactions between the 3 levels of action
• **Systems-wide perspective (Prevention and Care continuum): from **prevention to care
• Emphasise ***Determinants of disease + Social, Cultural, Economic factors on quality / quantity of care

Question 9

Continuity of care model (大班人—>病人)

Answer 9

Outline **How chronic disease develops in response to **Risk factors in population
- track ***disease pathway (no. of people become smaller):
—> from general population
—> to people with >=1 risk factors
—> patients with terminal disease

Suggests points to target interventions at ***varying stages of disease pathway:

• Different prevention schemes
• Medical interventions
• Treatment, Rehabilitations, Palliative care

Question 10

Life course model (人生每一階段所需都不同)

Answer 10

Currently used by Primary Care Office in HK
- HK Reference Framework for Diabetes

Based on Continuity of care model (~ principles)

Risk of developing chronic diseases are influenced by ***factors acting at all stages of life

• Biological (as in Continuity of care model) + Behavioural + Environmental + Psychosocial factors
• Preconception, Fetal, Neonatal, Infancy, Childhood, Adolescents, Adult, Elderly stage

Suggest **different strategies for prevention + control of chronic diseases according to needs + risks **specific to each stage of life

***簡單而言: Different people —> Different needs —> at Different stages of life

Strategies:

• Primary prevention, Lifestyle modification, Risk factor screening, Treatment, Care of complications, Rehabilitations
• Multi-disciplinary team + Local communities + Other levels of healthcare + Non-healthcare sectors

Question 11

Levels of healthcare

Answer 11

Primary
- 1st point of contact for patients

Secondary
- services provided by specialist that typically do not have 1st contact with patients

Tertiary
- specialised consultative health care provided by hospitals / facilities for advanced investigations + treatment

Quaternary

• an extension of tertiary care for advanced level of medicine
• highly specialised, not widely accessed

Question 12

Primary care

Answer 12

• 1st level of contact
• constitutes 1st element of a continuing health care process
• accessible
• comprehensive, continuing, coordinated, person-centred
• wide range of services:
  —> health promotion, prevention, risk assessment, treatment, self management, rehabilitative, palliative care
• ***not cheap but provide better value for money

Functions:

1. ***Gatekeeping
   - provide services for common needs
   - coordinate service for more specialised need
   - prevent unnecessary escalation of care / misuse of scarce resources
2. ***Delivery of continuous / longitudinal care
   - sustained relationship between patient and doctor
   - treat patient as a whole —> values, preferences are considered —> improve patient satisfaction

• **How effective?
• Improvement in various population health outcomes (e.g life expectancy, mortality)
• Reduce total cost of health services (∵ reduce unnecessary use of specialist care)
• Improve quality of care (∵ improved adherence to guidelines, emphasise patient as a person)
• Improve preventive health care + early management of health problems

Providers in HK:
Public
- HA
—> GOPC
—> Chinese medicine outpatient clinics
—> Community nursing service
- DoH
—> Family health service (e.g. MCHC)
—> Student health service
—> Elderly health service

Private (bigger portion)

• Solo clinics
• Health maintenance organisation
• NGO
• Hospitals

Question 13

Challenges to primary care in HK

Answer 13

1. Population ageing and increasing epidemic of NCD
   —> large demand
2. Higher expectations from public / consumers
3. ***↑ Health care costs
4. ***Fragmentation of health system
   - Lack of primary care network —> little sharing of information
   - Doctor shopping, excessive use of ambulatory care
5. ***Little gatekeeping
   - patients do not need referrals to see specialists in private sector
   —> over-reliance on hospital / specialist care for management of common chronic diseases
6. Many primary care physicians not formally trained in Family Medicine specialty
   - little recognition on the specialty

Question 14

Focused factories model

Answer 14

A plant established

• focus manufacturing system on limited, concise, manageable set of products and technologies
• defined by company’s strategy and economics

In health care system:
- Work together based on common objectives e.g. treatment of specific patient group
E.g. Hospital just for hernia surgery

Advantage:
- Clinical + Financial economies of scale may ***↑ efficiency + ↓ costs

Disadvantage:
- ***Focus on disease rather than patient
- Patient may have multiple diseases
—> encourage ***further fragmentation
—> antithesis of primary care?

Question 15

Focus factories for diabetes

Answer 15

Multi-disciplinary team to treat all problems of diabetes

1. Primary care physicians
2. Specialists for various complications e.g. endocrinologists, ophthalmologists, cardiologists
3. Nurses, home care aides
4. Allied heath e.g. eye care professionals, nutritionists, physiotherapists

Question 16

Shared care

Answer 16

Manage different levels of care

Joint participation of sectors in planned delivery of care

• informed by ***enhanced information exchange
• over and above routine discharges and referrals

Across different interfaces depending on health system

• primary + specialty care
• public + private sectors

Used in management of various chronic diseases esp. diabetes
- Specialist care for chronic disease + Generalist care for comorbidities

Question 17

Forms of shared care

Answer 17

1. ***Community clinics
   - specialists attend clinic in primary care setting
2. Basic model
   - specific, regular communication system between primary / specialty care
   - enhanced by administrators who organise appointments
3. ***Liaison
   - regular meetings by primary care + specialty care provider to discuss management of patients
4. ***Shared care record card
   - communication through shared record card carried by patient
5. Computer-assisted
   - coordinated care through computer database / email

Question 18

How effective is shared care?

Answer 18

• Some improvement in BP management
• Clear improvement in mental health outcomes esp. depression
• No clear different in patient-reported outcomes, hospital admissions, service utilisation, patient health behaviours

Question 19

Shared care in HK

Answer 19

1. GOPC Public Private Partnership Programme
   - for clinically stable patients at GOPC with hypertension / diabetes
   - manage demand at GOPC
   - subsidised visits to private doctors
2. Risk Assessment and Management Programme (RAMP)
   - multi-disciplinary teams set up at GOPC
   - provide structured risk assessment + targeted interventions for patients with diabetes / hypertension
3. Electronic Health Record (eHR) Sharing System
   - improve sharing of clinical information between public / private sectors

Question 20

Referral patterns in HK

Answer 20

Patients can enter health system at multiple points:

• can directly seek specialist care
• public / private
• ambulatory / in-patient care

1st point of contact depends various factors:

1. Disease presentation
2. Patient preference
3. Waiting times

Referral patterns depend on sector / health care provider

• Public sector: usually go through sequential levels e.g. ED —> secondary care —> tertiary care
• Some sharing of care from public to private sectors e.g. Public Private Partnership Programme
• ***No formal referral system exists in private sector e.g. private GP may choose to refer to public / private, ED / GOPC etc.

Question 21

When should I refer?

Answer 21

According to HK Reference Framework for Diabetes:

Immediate referral to hospital / Initiation of Insulin

• Acutely ill
• Heavy ketouria
• Blood glucose >=25
• DKA
• Diabetic hyperosmolar non-ketotic syndrome (HONK)

Referral to specialists

• Young patients (<30) with diabetes
• Suggestive of endocrinopathies
• Heavy proteinuria / Haematuria in absence of other complications
• Presence of complications
• Pregnant women