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
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
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
Increase capacityof GPs to managethese patients andreduce need forspecialist care
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
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
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
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
ICDMS PAH ICDMS PAH ICDMS PAH
% 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
ICDMS PAH ICDMS PAH ICDMS PAH
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
The Team !The Team !
Copyright © 2005 Accenture AllRights Reserved.
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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
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