The Brisbane South Complex Diabetes Service: an innovative ...€¦ · • The team improved...

The Brisbane South Complex Diabetes Service:The Brisbane South Complex Diabetes Service: ananinnovative model of care conquering outpatientinnovative model of care conquering outpatient

waiting listswaiting listsAnthony Russell MBBS (Hons) PhD FRACP

Director, Diabetes and Endocrinology, Princess Alexandra HospitalAssoc Prof, School of Medicine, UQ

Co-Chair Qld Statewide Diabetes Clinical NetworkMember Qld Clinical Senate Executive

Claire JacksonProfessor of General Practice and Primary Health Care, UQ

Anthony Russell MBBS (Hons) PhD FRACPDirector, Diabetes and Endocrinology, Princess Alexandra Hospital

Assoc Prof, School of Medicine, UQCo-Chair Qld Statewide Diabetes Clinical Network

Member Qld Clinical Senate Executive

Claire JacksonProfessor of General Practice and Primary Health Care, UQ

Background: The ProblemBackground: The Problem• Diabetes (T2DM) is an epidemic

– Prevalence 7.5%, Incidence – 1.5% per year– 156,000 Queenslanders– 50 Queenslanders diagnosed with diabetes each day– Reduces life expectancy by 10 years and responsible for 572 deaths in

Qld each year

• Good diabetic control reduces complications and costs to thehealth system– 35% of patients are not achieving therapeutic target guidelines

• Public hospital diabetic outpatients have long waiting lists andare not able to treat all these patients– Access block

• QHealth has limited resources

• Diabetes (T2DM) is an epidemic– Prevalence 7.5%, Incidence – 1.5% per year– 156,000 Queenslanders– 50 Queenslanders diagnosed with diabetes each day– Reduces life expectancy by 10 years and responsible for 572 deaths in

Qld each year

• Good diabetic control reduces complications and costs to thehealth system– 35% of patients are not achieving therapeutic target guidelines

• Public hospital diabetic outpatients have long waiting lists andare not able to treat all these patients– Access block

• QHealth has limited resources

Access block to specialist clinics…Access block to specialist clinics…

250

300

350

400Numbers on Waiting List

Category 1 patient not seen for2.3 months

Cat 2 – average wait to be seen11.2 months

Cat 3 – essentially not seen

0

50

100

150

200

250

2004 2005 2006 2007 2008 2009

total waiting list number diab new waiting list number endo new Waiting list - weight loss Bone Clinic

Category 1 patient not seen for2.3 months

Cat 2 – average wait to be seen11.2 months

Cat 3 – essentially not seen

ABF penalties: review to newratio

R:NAged Care 0 2.79 0.02632Alcohol and other drug 1.61 20.32 0 1.58Allergy 2.35 2.23 Yes 310 16 0.07289 1.2 4,896$ 2.36Audiology 0.40 0.55 0 0.03938Cardiac Surgey 1.79 3.4 0 0.05816 1.85Cardiology 2.85 1.11 Yes 4090 6424 0.05105 327.9 1,374,016$ 5.00Chemotherapy 1.00 18.92 0 0.23026Clinical Haematology 14.34 11.44 Yes 7379 1872 0.14474 271.0 1,135,416$ 11.68Clinical Measurement 0.81 0.47 Yes 8150 5866 0.03868 226.9 Excluded 0.69Cystic Fibrosis 97.13 0.23158Dementia 0.00 1.97 0 0.02632Dermatology 6.08 4.84 Yes 7086 1808 0.03526 63.8 267,148$ 6.23Diabetes 6.97 5.55 Yes 3319 850 0.04842 41.2 172,468$ 5.83

Clinic TypeFY 09/10 Required

(StatewideAverage) R:N

Exceeds RevenueReduction

Raw R:Nfor 7 mthsFY2011

Face toRequiredReview

ExcessReview

WAU -Review

WAUreductionR:N

Aged Care 0 2.79 0.02632Alcohol and other drug 1.61 20.32 0 1.58Allergy 2.35 2.23 Yes 310 16 0.07289 1.2 4,896$ 2.36Audiology 0.40 0.55 0 0.03938Cardiac Surgey 1.79 3.4 0 0.05816 1.85Cardiology 2.85 1.11 Yes 4090 6424 0.05105 327.9 1,374,016$ 5.00Chemotherapy 1.00 18.92 0 0.23026Clinical Haematology 14.34 11.44 Yes 7379 1872 0.14474 271.0 1,135,416$ 11.68Clinical Measurement 0.81 0.47 Yes 8150 5866 0.03868 226.9 Excluded 0.69Cystic Fibrosis 97.13 0.23158Dementia 0.00 1.97 0 0.02632Dermatology 6.08 4.84 Yes 7086 1808 0.03526 63.8 267,148$ 6.23Diabetes 6.97 5.55 Yes 3319 850 0.04842 41.2 172,468$ 5.83

Clinic TypeFY 09/10 Required

(StatewideAverage) R:N

Exceeds RevenueReduction

Raw R:Nfor 7 mthsFY2011

Face toRequiredReview

ExcessReview

WAU -Review

WAUreduction

T2DM: The Current Model of CareT2DM: The Current Model of CareEndocrinologist

GP

Educator

Psychologist

Podiatry

Dietitian • Removing focus of care

away from GP

• Specialist centre holds ontopatient.

• Is a solution to access blockto provide more staff indiabetes centres?– Are there enough DNEs to

cope with demand?– Are there enough specialists?

• Removing focus of careaway from GP

• Specialist centre holds ontopatient.

• Is a solution to access blockto provide more staff indiabetes centres?– Are there enough DNEs to

cope with demand?– Are there enough specialists?

What is the role of the diabetes centre?

1. Stay with the diabetes centre forever and GP says“We’ll leave the diabetic clinic to sort that out”?

2. Consultative - provide advice regardingmanagement plan and discharge back to GP/primary carer.

3. ? Carry-out the management plan until targetsreached. Once at target or best as we can get –should they be discharged back to GP whocontinues surveillance and management?

1. Stay with the diabetes centre forever and GP says“We’ll leave the diabetic clinic to sort that out”?

2. Consultative - provide advice regardingmanagement plan and discharge back to GP/primary carer.

3. ? Carry-out the management plan until targetsreached. Once at target or best as we can get –should they be discharged back to GP whocontinues surveillance and management?

Background: The literature tells us…Background: The literature tells us…

Wagner EH. Chronic disease management: What will it take to improve care forchronic illness? Effect Clin Pract.1998;1:2-4.

The proposed solutionThe proposed solutionGP

Endocrinologist

Dietitian

Educator

Podiatrist

Psychologist

Up-skilledUp-skilled

QHealth Innovation Grant:The Brisbane South Complex Diabetes Service

Issues with this model…Issues with this model…

• Can every GP be up-skilled to managecomplex diabetes?

• Are there enoughspecialists to get toevery practice?

• ? Beacon practice

GP

Endocrinologist

Dietitian

EducatorPodiatrist

Psychologist

Up-skilled

• Can every GP be up-skilled to managecomplex diabetes?

• Are there enoughspecialists to get toevery practice?

• ? Beacon practice

GP

Endocrinologist

Dietitian

EducatorPodiatrist

Psychologist

Up-skilled

QHealth Innovation Grant:The Brisbane South Complex Diabetes Service

Beacon practice model…Beacon practice model…

Psychologist Dietitian

Endocrinologist

Endocrinologist

GP

Hospital ClinicCommunity

Psychologist

Podiatrist Educator

Dietitian

GPUp-skilled

Endocrinologist

GP

GP

Which patients are we talking about?Which patients are we talking about?

Managing Chronic Disease

In summary, it is evident that there is an urgent need to identify practical and achievableapproaches to develop Australia’s health system to meet current and future demands for chronicdisease prevention and care. The development and implementation of the National ChronicDisease Strategy is critical to addressing this significant health challenge.

Level 170-80% Chronic disease population

Self management Support

Level 2High Risk

Disease / Care Management

Level 3High

ComplexityCare Coordination

Prevention Activities

Figure 1. Levels of health care for people with chronic disease





Level 2High Risk


Level 3High





Level 2High Risk


Level 3High




Increase capacityof GPs to managethese patients andreduce need forspecialist care





Level 2High Risk


Level 3High








Level 2High Risk


Level 3High





Level 2High Risk


Level 3High




Increase capacityof GPs to managethese patients andreduce need forspecialist care

Flow on effect ofimproving otherGPs knowledge tomanage Level 1and 2 patients

MethodsMethods• Subjects

– patients referred to Princess Alexandra Hospital Dept of Diabetes andEndocrinology – ie with complex diabetes that have been referred to aspecialist

– All new and review patients within postcode area had care transferredto Inala vs. 145 consecutive patients with T2DM seen at PAH

• Location– Managed at Inala Primary Care (UQ GP Superclinic prototype)

• Intervention – the model of care

• Analysis

• Subjects– patients referred to Princess Alexandra Hospital Dept of Diabetes and

Endocrinology – ie with complex diabetes that have been referred to aspecialist

– All new and review patients within postcode area had care transferredto Inala vs. 145 consecutive patients with T2DM seen at PAH

• Location– Managed at Inala Primary Care (UQ GP Superclinic prototype)

• Intervention – the model of care

• Analysis

EducationEducation• Designed 8 week education programme to ‘advanced

skill’ GPs– Now 26 hr module available online through UQ Masters of

Medicine (General Practice)– To produce an up-skilled GP – called a “clinical fellow”

• Other GP’s in area and training of practice nurses– Breakfast and learn – monthly– Dinner meeting – monthly– Visit larger GP practices at lunch-time for case based

discussions (4 sessions)

• Designed 8 week education programme to ‘advancedskill’ GPs– Now 26 hr module available online through UQ Masters of

Medicine (General Practice)– To produce an up-skilled GP – called a “clinical fellow”

• Other GP’s in area and training of practice nurses– Breakfast and learn – monthly– Dinner meeting – monthly– Visit larger GP practices at lunch-time for case based

discussions (4 sessions)

Eligible patients referred to PAHEndocrinology OPD

Lipidsglucose NutritionBloodpressure

Retinopathyscreening

Patient selfmanagement

ICDMS Step 1

ICDMS Step

Renal

ICDMS Step 2

ICDMS Step 4

ICDMSModel of CareEligible patients referred to PAH

Endocrinology OPD

Footcare

BloodPsychologist

3

Clinic day – assessment and development of a management plan. Protocol driven referral to Allied Health, as indicated.

ICDMS Step 5

ICDMS Model of Care

Referral

Assessment

Treatment

Maintenance

• Assessment & screening by ICDMS care coordinator as per protocol,

ICDMS undertakes acute diabetes management as indicated in the management plan and informed by evidence basedprotocol s.1) Care to be provided within ICDMS; and2) Actions recommended to be implemented by referring GP.

Patient s discharged from ICDMS to receive follow up call at 6 weeks, 3 & 9 months as per protocol.• Patient provided with their shared care plan• Letter with copy of Patients Management Plan sent to the Patients “usual GP”

Figure 2 – Model of Care / Study Intervention

Review patient as indicated in the management plan.Discharge to referring GP following resolution of acute exacerbation .Link Patient into appropriate community support programs .

Eligible patients referred to PAHEndocrinology OPD

Lipidsglucose NutritionBloodpressure

Retinopathyscreening

Patient selfmanagement

ICDMS Step 1

ICDMS Step

Renal

ICDMS Step 2

ICDMS Step 4

ICDMSModel of CareEligible patients referred to PAH

Endocrinology OPD

Footcare

BloodPsychologist

3

Clinic day – assessment and development of a management plan. Protocol driven referral to Allied Health, as indicated.

ICDMS Step 5

ICDMS Model of Care

Referral

Assessment

Treatment

Maintenance

• Assessment & screening by ICDMS care coordinator as per protocol,

ICDMS undertakes acute diabetes management as indicated in the management plan and informed by evidence basedprotocol s.1) Care to be provided within ICDMS; and2) Actions recommended to be implemented by referring GP.

Patient s discharged from ICDMS to receive follow up call at 6 weeks, 3 & 9 months as per protocol.• Patient provided with their shared care plan• Letter with copy of Patients Management Plan sent to the Patients “usual GP”

Figure 2 – Model of Care / Study Intervention

Review patient as indicated in the management plan.Discharge to referring GP following resolution of acute exacerbation .Link Patient into appropriate community support programs .

Methods: OutcomesMethods: Outcomes• Treatment targets

– HbA1c, Blood pressure, Lipids, Weight according to NationalGuidelines.

• Principles of best practice management– Number of patients on aspirin, on statin if abnormal lipids, on ACE-

/AIIRB if microalbuminuria, have had appropriate foot, urine andeye screening

• Access– Attendance– Occasions of service and activity mix– Number of patients waiting on OPD wait list

• Qualitative assessment of the “big losers”

• Treatment targets– HbA1c, Blood pressure, Lipids, Weight according to National

Guidelines.

• Principles of best practice management– Number of patients on aspirin, on statin if abnormal lipids, on ACE-

/AIIRB if microalbuminuria, have had appropriate foot, urine andeye screening

• Access– Attendance– Occasions of service and activity mix– Number of patients waiting on OPD wait list

• Qualitative assessment of the “big losers”

Project Manager 1 x FTE

Clinical Fellows x 2 & GP Registrar 1 session/week

Endocrinologist 0.1 x FTE

Diabetic Educator/Case Manager 2 (1) x FTE

Staff: previous and now (BSCDS)Staff: previous and now (BSCDS)

Diabetic Educator/Case Manager 2 (1) x FTE

Dietitian 0.5 x FTE

Podiatrist 0.5 (0.1)x FTE

Psychologist 0.5 x FTE

AO 1 x FTE

Data Manager 1 x FTE

What patients are we dealing with?What patients are we dealing with?ICDMSn=183

PAHn=145

Sex (% female) 55% 36%*

Age (yr) 59.4±13.4 62.9±11.6*

Weight (kg) 91.2±26.4 91.5±22.5

BMI (kg/m2) 33.4±8.3 31.8±6.3BMI (kg/m2) 33.4±8.3 31.8±6.3

Born in Australia (%) 43.8 60Education - % not complete Yr 12 ordegree 51% 40%*

Duration Diabetes (yrs) 12.8±9.7 13.7±10.2

Diabetes complications (%)

microalbuminuria 63 59neuropathy 31 56*

previous amputation 2 9*foot ulcer 5 6

Clinical Activity

Control ICDMS

Total number of OOS 448 1553

% patients discharged from service 12.9% 37.2%

1553

Doctor visits (mean per patient) 1.81 4.32

Allied Health (mean per patient)

Diabetes Nurse Educator 0.33 2.36

Dietitian 0.41 0.94

Podiatrist 1.86 1.74

Psychologist 0.21 0.67

Did Not Attend (DNA) RatesDid Not Attend (DNA) Rates

Health Professional DNA Rate %

Clinical Fellows 9.1

Diabetes Educator 18

Dietitian 23.2Dietitian 23.2

Podiatrist 7.8

Psychologist 17.8

PAH DNA rate for doctor is between 30-40%

Outcome Data: ClinicalOutcome Data: ClinicalBaseline 6 months 12 months

ICDMS PAH ICDMS PAH ICDMS PAH

HbA1c (%) 8.6±1.9* 7.9±1.9 7.5±1.3^ 7.6±1.5 7.7±1.7^ 7.5±1.4

Blood Pressure

Systolic (mmHg) 130±16* 140±20 130±15* 140±17 128±17* 138±15Systolic (mmHg) 130±16* 140±20 130±15* 140±17 128±17* 138±15

Diastolic (mmHg) 72±11 77±11 70±10 77±13 69±11 76±11

Lipids

Chol (mmol/l) 4.3±1.1* 4.2±1.1 3.8±0.9*^ 4.1±1.1 3.8±1*^ 4.1±1.3

Tg (mmol/l) 2.3±4.1 1.9±1.5 1.8±1 1.8±1.7 1.8±1.2 1.9±2.1

LDL (mmol/l) 2.4±0.8 2.3±0.9 1.9±0.7^ 2.1±0.8^ 1.9±0.8^ 2.1±.8^

HDL (mmol/l) 1.1±0.4 1.1±0.3 1.1±0.6 1.1±0.4 1.1±0.4 1.2±0.4^

*Significant difference between groups^Significant difference over time within group

Outcome Data: ProcessOutcome Data: Processmarkersmarkers

Baseline 6 months 12 months


% Insulin 50.9* 56.6 69*^ 58 73*^ 57

Insulin Dose (units) 36 40 63 42 71 45

ACE/ARB (%) 74.6 81.4 82 90ACE/ARB (%) 74.6 81.4 82 90

per protocol (%) 88 92.4 99.2 95

Statin (%) 71 72 88.4 81.8

per protocol (%) 81 82 99.2 91.7

Aspirin(%) 53.3 63.5 71.5 64

per protocol (%) 68.6 68.3 97.7 71.1

Outcome Data: SafetyOutcome Data: SafetyindicatorsindicatorsBaseline 6 months 12 months


Discharged (%) 31 8

Ongoing (%) 54 77

Lost to follow up (%) 15 15Lost to follow up (%) 15 15

Died (n) 1 4

Hypos (%)daily 1.2 1 1

monthly 18.9 17 14

rarely/never 69.2 69 83

weekly 10.7 13 2

Assistance required (%) 4 2 5.2 4.3

Percent achieving HbA1c ≤ 7%Percent achieving HbA1c ≤ 7%

Percent achieving SBP ≤ 130Percent achieving SBP ≤ 130mmHgmmHg

Percent achieving LDL ≤ 2.5Percent achieving LDL ≤ 2.5mmolmmol/L/L

Percent achieving A1c/BP/LDLPercent achieving A1c/BP/LDLtargetstargets

HbA1c<7%, BP <130 mmHg, LDL < 2.5 mmol/l

Why does it work ?Why does it work ?Take from ‘The Big Losers’Take from ‘The Big Losers’

The Service: accessible, welcoming, team-basedThe Team The relationship of the team members with patients enabled:• Patients' to feel that the team really understood their problems• That they could "talk openly about even little issues" with team members• Patients to be treated as a person and not a number• Patients felt comfortable returning for appointments, and once referred back to

their GPs could also contact the service if they needed additional input or advice.• Most importantly, patients liked seeing the same team members, esp DNEImplications• The team improved patients' knowledge and understanding of type 2 diabetes.• Moved some patients from denial to accepting they had diabetes - - - significant to

engage patients in their own health care.• Team builds patients' confidence to effectively manage diabetes in an on-going

way

The Service: accessible, welcoming, team-basedThe Team The relationship of the team members with patients enabled:• Patients' to feel that the team really understood their problems• That they could "talk openly about even little issues" with team members• Patients to be treated as a person and not a number• Patients felt comfortable returning for appointments, and once referred back to

their GPs could also contact the service if they needed additional input or advice.• Most importantly, patients liked seeing the same team members, esp DNEImplications• The team improved patients' knowledge and understanding of type 2 diabetes.• Moved some patients from denial to accepting they had diabetes - - - significant to

engage patients in their own health care.• Team builds patients' confidence to effectively manage diabetes in an on-going

way

Effect on waiting listWaiting List - by clinic

0

50

100

150

200

250

300

350

400

450

JAN

FEB

MA

RA

PR

MA

YJU

NJU

LA

UG

SE

PT

OC

TN

OV

DE

CJA

NFE

BM

AR

AP

RM

AY

JUN

JUL

AU

GS

EP

TO

CT

NO

VD

EC

JAN

FEB

MA

RA

PR

MA

YJU

NJU

LA

UG

SE

PT

OC

TN

OV

DE

CJA

NFE

BM

AR

AP

RM

AY

JUN

JUL

AU

GS

EP

TO

CT

NO

VD

EC

JAN

FEB

MA

RA

PR

MA

YJU

NJU

LA

UG

SE

PT

OC

TN

OV

DE

CJA

NFE

BM

AR

AP

RM

AY

JUN

JUL

AU

GS

EP

TO

CT

NO

VD

EC

JAN

FEB

MA

RA

PR

MA

YJU

N

2004 2005 2006 2007 2008 2009 2010

Date

Num

ber p

atie

nts

Diabetes Endocrine Weight Loss Bone Thyroid

Waiting List - by clinic

0

50

100

150

200

250

300

350

400

450

JAN

FEB

MA

RA

PR

MA

YJU

NJU

LA

UG

SE

PT

OC

TN

OV

DE

CJA

NFE

BM

AR

AP

RM

AY

JUN

JUL

AU

GS

EP

TO

CT

NO

VD

EC

JAN

FEB

MA

RA

PR

MA

YJU

NJU

LA

UG

SE

PT

OC

TN

OV

DE

CJA

NFE

BM

AR

AP

RM

AY

JUN

JUL

AU

GS

EP

TO

CT

NO

VD

EC

JAN

FEB

MA

RA

PR

MA

YJU

NJU

LA

UG

SE

PT

OC

TN

OV

DE

CJA

NFE

BM

AR

AP

RM

AY

JUN

JUL

AU

GS

EP

TO

CT

NO

VD

EC

JAN

FEB

MA

RA

PR

MA

YJU

N

2004 2005 2006 2007 2008 2009 2010

Date

Num

ber p

atie

nts

Diabetes Endocrine Weight Loss Bone Thyroid

Effect on PAH waiting listsEffect on PAH waiting lists

250

300

350

400

Numbers on Waiting List

0

50

100

150

200

250

2004 2005 2006 2007 2008 2009

total waiting list number diab new waiting list number endo new Waiting list - weight loss Bone Clinic

Efficiency 2010/2011 OOS• PAH

– 1921 occasions of service (OOS) this year– Delivered by 15 doctor sessions per week– ie 128 OOS per doctor over 12 months

• BSCDS– 1365 OOS this year– Delivered by 4 doctor sessions per week– ie 341 OOS per doctor over 12 months

• New : Review ratio (July 2011 to Feb 2012)– PAH – 1:7.9– BSCDS – 1:4.8

• PAH– 1921 occasions of service (OOS) this year– Delivered by 15 doctor sessions per week– ie 128 OOS per doctor over 12 months

• BSCDS– 1365 OOS this year– Delivered by 4 doctor sessions per week– ie 341 OOS per doctor over 12 months

• New : Review ratio (July 2011 to Feb 2012)– PAH – 1:7.9– BSCDS – 1:4.8

Cost BenefitCost Benefit• Cost per outpatient visit:

– PAH - $774– ICDMS - $150 (seen 2-3x more often)

– Costs in both settings inclusive of all clinical andadministrative costs, infrastructure, IT, Medicareand state health costings exclusive of pathology.

• Cost per outpatient visit:– PAH - $774– ICDMS - $150 (seen 2-3x more often)

– Costs in both settings inclusive of all clinical andadministrative costs, infrastructure, IT, Medicareand state health costings exclusive of pathology.

SummarySummary• This model of care, consisting of the general practitioner

delivering specialist level of care in the community supportedby a multi-disciplinary team including an endocrinologist, isachieving significant improvement in disease outcomes andprocesses of care.

• It has the potential to be expanded to other rural and remotecenters across the state:– interest already in Gympie, UQ GP superclinics, Redlands, Ipswich– Adapt to fit the setting – eg physician in the practice. Inala indigenous

health and Cloncurry.

• Prototype has recurrent funding through PAH

• This model of care, consisting of the general practitionerdelivering specialist level of care in the community supportedby a multi-disciplinary team including an endocrinologist, isachieving significant improvement in disease outcomes andprocesses of care.

• It has the potential to be expanded to other rural and remotecenters across the state:– interest already in Gympie, UQ GP superclinics, Redlands, Ipswich– Adapt to fit the setting – eg physician in the practice. Inala indigenous

health and Cloncurry.

• Prototype has recurrent funding through PAH

DiscussionDiscussion• Formally consider the pro/cons of this care

model vs. increasing resources in tertiary referralhospitals– Patient outcomes, cost-benefit and efficiency– Synergy with Commonwealth reform initiatives– Potential to extend model to other complex chronic

diseases to both better manage patients and allowtertiary services to concentrate on tertiary-levelproblems

• Cardiac disease, particularly heart failure• Chronic kidney disease• Chronic respiratory disease

• Formally consider the pro/cons of this caremodel vs. increasing resources in tertiary referralhospitals– Patient outcomes, cost-benefit and efficiency– Synergy with Commonwealth reform initiatives– Potential to extend model to other complex chronic

diseases to both better manage patients and allowtertiary services to concentrate on tertiary-levelproblems

• Cardiac disease, particularly heart failure• Chronic kidney disease• Chronic respiratory disease

Tertiary:PrimaryTertiary:Primary Care RelationshipCare Relationship

The Next Step with CREQuestions:• Can the model be expanded into other centres?

– Is IPC unique?– Is it specific to current personnel?

• What are the core components of the model?– GP training programme– Care co-ordinator – (DNE)– Delivered in community– Co-consultation (Case conference with patient)

• How measure the power of this?

• Cost analysis

• What happens long term to the patient?

Questions:• Can the model be expanded into other centres?

– Is IPC unique?– Is it specific to current personnel?

• What are the core components of the model?– GP training programme– Care co-ordinator – (DNE)– Delivered in community– Co-consultation (Case conference with patient)

• How measure the power of this?

• Cost analysis

• What happens long term to the patient?

Design of Diabetes Arm

• Test the model in 3-4 other centres– Metropolitan, ?rural

• Design?– Problem has been control– Ideally need randomization at point of receiving

the referral at tertiary hospital/diabetes centre

• Test the model in 3-4 other centres– Metropolitan, ?rural

• Design?– Problem has been control– Ideally need randomization at point of receiving

the referral at tertiary hospital/diabetes centre

Trial: Outcomes• Clinical:

– Baseline, 6 and 12 months– Ideally also long term outcomes at 24 months and 36 months so know

what happens after discharge and predictors of success on discharge.If deterioration in control after discharge – Ix why – GP vs patient

– HbA1c, lipids, BP, weight, eGFR, Ast, Alt– Development of complications – renal disease, retinopathy,

nephropathy, foot ulcers and CVDx/stroke– Medication – OHG, insulin, BP and lipid lowering drugs and anti-

platelet drugs– Safety

• Number of diabetes related hospitalizations and death• Hypoglycaemia

– How collect data?• eHR, study co-ordinator,• QHealth admission data (DRG)/patient self report

• Clinical:– Baseline, 6 and 12 months– Ideally also long term outcomes at 24 months and 36 months so know

what happens after discharge and predictors of success on discharge.If deterioration in control after discharge – Ix why – GP vs patient

– HbA1c, lipids, BP, weight, eGFR, Ast, Alt– Development of complications – renal disease, retinopathy,

nephropathy, foot ulcers and CVDx/stroke– Medication – OHG, insulin, BP and lipid lowering drugs and anti-

platelet drugs– Safety

• Number of diabetes related hospitalizations and death• Hypoglycaemia

– How collect data?• eHR, study co-ordinator,• QHealth admission data (DRG)/patient self report

Trial: Outcomes

• Process:– Complications screening completed– On statin if meet PBS criteria– On ACE/ARB if microalbuminuria

• Quality of life– SF36, depression scale– Medication adherance

• Process:– Complications screening completed– On statin if meet PBS criteria– On ACE/ARB if microalbuminuria

• Quality of life– SF36, depression scale– Medication adherance

Trial Outcomes

• Health resource utilisation and cost?– ?? True costs from PBS, Medicare

• Number occasions of service (bookingsystems)

• DNA rates (booking systems)• Effect on public wait list – referral waiting

times (Diab/Endo Dept)• Staff satisfaction

• Health resource utilisation and cost?– ?? True costs from PBS, Medicare

• Number occasions of service (bookingsystems)

• DNA rates (booking systems)• Effect on public wait list – referral waiting

times (Diab/Endo Dept)• Staff satisfaction

Power

Primary outcome:• Change in HbA1c

– 2 sided test with HbA1c 7.9 to 7.4 with SD of 1.9requires 227 patients (PAH baseline and 12 monthdata)

– HbA1c 8.6 to 7.7 with SD of 1.9 requires 70patients (Inala data)

Primary outcome:• Change in HbA1c

– 2 sided test with HbA1c 7.9 to 7.4 with SD of 1.9requires 227 patients (PAH baseline and 12 monthdata)

– HbA1c 8.6 to 7.7 with SD of 1.9 requires 70patients (Inala data)

• the work the model, the data collection, nextsteps in both analysis of this data and infurther testing the model?

• the work the model, the data collection, nextsteps in both analysis of this data and infurther testing the model?

What are the consequences ofWhat are the consequences ofachieving good metabolicachieving good metabolic

control in patients withcontrol in patients withdiabetes?diabetes?

What are the consequences ofWhat are the consequences ofachieving good metabolicachieving good metabolic

control in patients withcontrol in patients withdiabetes?diabetes?

Blood Pressure - < 130/80 mmHg

Cholesterol – LDL < 2.5 mmol/l

Blood sugar – assessed by HbA1c – aim <7%

Improved sugars reduces complicationsImproved sugars reduces complications

Presentation Title… benefit is exponentially gained

After median 8.5 years post-trial follow-up

Aggregate Endpoint 1997 2007

Any diabetes related endpoint RRR: 12% 9%P: 0.029 0.040

Microvascular disease RRR: 25% 24%P: 0.0099 0.001

Myocardial infarction RRR: 16% 15%P: 0.052 0.014

All-cause mortality RRR: 6% 13%P: 0.44 0.007

UKPDS 10 year follow up

After median 8.5 years post-trial follow-up

Aggregate Endpoint 1997 2007

Any diabetes related endpoint RRR: 12% 9%P: 0.029 0.040

Microvascular disease RRR: 25% 24%P: 0.0099 0.001

Myocardial infarction RRR: 16% 15%P: 0.052 0.014

All-cause mortality RRR: 6% 13%P: 0.44 0.007

RRR = Relative Risk Reduction, P = Log Rank NEJM 2008:359

1%reductionin HbA1c

= 37% 21% 21% 14%

Observational study of UKPDS data

LLESSONS FROM THEESSONS FROM THE UKPDSUKPDS

1%reductionin HbA1c

= 37% 21% 21% 14%

reduction inmicrovascularcomplications

reductionin diabetes-related deaths

reduction inany diabetes-relatedendpoint

reductionin myocardialinfarction

Stratton 2000

The STENO2 StudyThe STENO2 Study

N=160Follow up 7.8 years NNT / 10 years

You only need to intensively treat 4 people with diabetesover 10 years to prevent one person developing kidney

disease, blindness or dying from a heart attack

N Engl J Med 2003; 348(5): 383-93

N=160Follow up 7.8 years NNT / 10 years

Nephropathy 4.1

Retinopathy 4.8

Neuropathy 3.3

Death due to CVD 3.8

Complications of diabetesComplications of diabetes

• The leading cause of kidney failure in theWestern world

• The leading cause of blindness

• Causes foot ulceration and amputation

• Significantly increases the risk of heart disease

• The leading cause of kidney failure in theWestern world

• The leading cause of blindness

• Causes foot ulceration and amputation

• Significantly increases the risk of heart disease

TheThe InalaInala Chronic Disease Management Project:Chronic Disease Management Project:

The Team– Deb Askew (UQ)– Jenny Doust (UQ)– Claire Jackson (Prof GP, UQ)– Clare Maher (Clinical Fellow, IPC)– Pat Matthews (QHealth)– John Prins (QHealth, Prof Endocrinology, UQ)– Ian Scott (QHealth)– Jane Tsai, Andrea Sanders, Matt Evans, Erin Lamb, Rebecca Mann,

Mellissa Conaughton, Rosine Warwick

• QHealth and CPIC– Innovation Funding Qld Govt Action Plan

The Team– Deb Askew (UQ)– Jenny Doust (UQ)– Claire Jackson (Prof GP, UQ)– Clare Maher (Clinical Fellow, IPC)– Pat Matthews (QHealth)– John Prins (QHealth, Prof Endocrinology, UQ)– Ian Scott (QHealth)– Jane Tsai, Andrea Sanders, Matt Evans, Erin Lamb, Rebecca Mann,

Mellissa Conaughton, Rosine Warwick

• QHealth and CPIC– Innovation Funding Qld Govt Action Plan

The overall aim is to improve the quality of life for people withcomplex T2DM by building the capacity of the primary care sectorand providing care in the community via a multi-disciplinary acuteand community sector partnership adopting principles of patientself-management

Aim of the ICDMSAim of the ICDMS

Inala CHCG/Practice

PAH

UQInformation Technology / Communications & HR

Key Performance Reporting and Management

Project and Change Management

Referral Assessment Treatment Review

Shared Approach Patient Centred Service Redesign

Intervention…Intervention…• Retinal screening

– Clinical Fellows x 2 (both Inala GPs) and DNE responsiblefor taking and reading photos for the service

• Foot care – high risk foot– Utilise the team - Up-skilled community podiatrist,

endocrinologist, Clinical Fellow– Easier access than to PAH– Aim to Prevent admissions and reduce length of stay– Using state protocol via another Innovation project

• Retinal screening– Clinical Fellows x 2 (both Inala GPs) and DNE responsible

for taking and reading photos for the service

• Foot care – high risk foot– Utilise the team - Up-skilled community podiatrist,

endocrinologist, Clinical Fellow– Easier access than to PAH– Aim to Prevent admissions and reduce length of stay– Using state protocol via another Innovation project

Copyright © 2005 Accenture AllRights Reserved.

53

Theme 1 THE NEW DIABETES SERVICE1.1 Convenient, easy to use, accessible1.2 Patient satisfaction with the service1.3 The multi-professional health care team1.4 Diabetes educators

Theme 2 PATIENTS’ ROLE IN DIABETESMANAGEMENT2.1 Adopting a routine2.2 Keeping records2.3 Patient as part of the team

Theme 3 PATIENTS’ MOTIVATION FOR IMPROVEDDIABETES MANAGEMENT3.1 The service/team3.2 Family reasons

Theme 1 THE NEW DIABETES SERVICE1.1 Convenient, easy to use, accessible1.2 Patient satisfaction with the service1.3 The multi-professional health care team1.4 Diabetes educators

Theme 2 PATIENTS’ ROLE IN DIABETESMANAGEMENT2.1 Adopting a routine2.2 Keeping records2.3 Patient as part of the team

Theme 3 PATIENTS’ MOTIVATION FOR IMPROVEDDIABETES MANAGEMENT3.1 The service/team3.2 Family reasons

The Brisbane South Complex Diabetes Service: an innovative ...€¦ · • The team improved...

Documents

Transcript of The Brisbane South Complex Diabetes Service: an innovative ...€¦ · • The team improved...