The Multi-disciplinary Diabetes Centre : A Model of Care for the Future (or the Past) ?

1
The Multi-disciplinary Diabetes Centre
A Model of Care for the Future (or the
Past) ?

• Dennis Yue
• Director of Diabetes, Royal Prince Alfred
  Hospital
• Kellion Professor of Endocrinology, University of
  Sydney

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Conference in China
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The Burden and Complexity of Diabetes
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Different Models of Diabetes Care
Diabetic Clinic Care Diabetes Centre Diabetic Clinic Care Annual Complications Screening
Complications Screening in 12 months ()
Eyes review 88 100 86
 Lipids Measurement 72 96 92
 Microalbuminuria 56 94 72
Target Achieved ()
Cholesterol lt 4mmol/L 24 24 27
BP 26 35 28
HbA1c within 1 of normal range 29 44 41
ANDIAB Survey Cheung NW et al Diabet Med 2008
25(8) 974-8
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We Must Have A Centre !
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A Multi-disciplinary Diabetes Centre
Family Doctor
Podiatrist
Dietitian
Person with Diabetes
Researcher
Specialist
Secretaries
Diabetes Nurse / Educator
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What We Need Is Not A Diabetes Education Centre
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A Multi-disciplinary Diabetes Centre(Education
is Integrated with Clinical Service and Care is
Shared)
Hoskins PL Diab Med 1993 10(1) 81-6
Overland J et al Diabetes Res Clin Pract 1999
44(2) 123-8
Constantino M et al Med J Aust 1991 155(8)
515-8
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One Stop Complications Assessment
McGill M et al Diabet Med 1993 10(4) 366-70
McGill M et al Diabetes Care 1989 12(8)
599-600
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Standardised Data Capture
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Younger Onset of Type 2 Diabetes Increases Risk
of Retinopathy
Wong J et al Diabetes Care 2008 10 1985-90
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Beyond ONTARGET (Deterioration of renal
function while on combined ACE-I and A2 Receptor
Blocker Treatment )
Hypertension (BP lt 160/100)
Hypertension (BP gt 160/100 )
J Wong et al Diabetes Obesity and Metabolism
2010
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Ambulatory Stabilisation of Diabetes Commencing
Insulin Therapy
Hoskins PL et al Med J Aust 1993 158(3)
148-9
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Telephone Stabilisation
Genev NM et al Diabet Med 1990 (1) 920-1
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Changing Pattern of Treatment of Type 1 Diabetes
More Use of Carbohydrate Counting and Insulin
Pump
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Continuity of Care in a Multi-disciplinary Setting
Patient 1
Patient 2
Visit 1
Visit 2
Visit 3
Visit 4
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Standardised Format of Letters(Documentation and
Education)
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Infrastructure Support
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Monitoring By A Senior Nurse After Visits

• Daily team clinical meeting
• All patients medical record reviewed possible
  mistakes identified and appropriately questioned
• Standardises party line message and upskill staff
• Collects data

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The High Risk Diabetic Foot ClinicA Co-ordinator
Who Knows Everything
McGill M et al Intern Med J 2005 35(8)
451-6
Nube VL et al The Diabetic Foot Journal 2008
11, 187-193
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Benefits of Multi-disciplinary Foot Clinics
(RPAH) Prevalence and Level of Amputation
McGill M et al Intern Med J 2005 35(8)
451-6
Nube VL et al The Diabetic Foot Journal 2008
11, 187-193
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How Does Telemedicine Work?
High Risk Foot Clinics

• Medical Data

McGill M Constantino M et al Practical
Diabetes 2000 17(7) 235-238.
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Clinical Trials
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Why is the Multi-disciplinary Diabetes Centre a
Better Model for a Chronic and Complex Disease ?

• A more stable system than one dependent on
  rotating doctors
• Complement better the skill of allied health
  professionals and doctors therefore a broader
  range of expertise
• Better stratification and triaging of patients
• Facilitate communication
• Better facilities for service between visits
• More flexibility internally (diversified staff
  skills and training) and externally (referring
  doctors pick what they want)
• Can be as good as an excellent doctor and can
  serve more people

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The Power of Computer
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The Under Water Volcano Theory of GDM
Ethnic Susceptibility to GDM is a Function of
Ethnic Difference in Age of Onset of Type 2
Diabetes
Ross GP et al Diabet Med 13(8) 748-52
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Long-term Efficacy Of Metformin Treatment In
Non-obese Individuals With Type 2 Diabetes
Ong CR et al Diabetes Care 2006 29(11)
2361-4
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Metabolic Syndrome in Type 1 Diabetes
McGill M et al J Diabetes Complications 2008
22(1) 18-23
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Strong Family History Predicts A Younger Age Of
Onset For Subjects Diagnosed With Type 2 Diabetes
Molyneaux L et al Diabetes Obesity and
Metabolism 2004 6 187-94
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A Transplant of Diabetes Centre to Rural Area
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Overseas Collaborations
Fiji and Kirabati
China
Liu DP et al Diabetes Res Clin Pract 2002 56(2)
125-31
Wong, J et al Journal of Diabetes and
Complications 2008 22 389-394
Hoskins PL et al Diabetes Res Clin Pract 1987
3(5) 257-67
Hoskins PL et al diabetes Res Clin Pract 1987
3(5) 257-67
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Training and Exchange ProgramsNational and
International
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Clinical Research and Basic Science Research
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Biomedical Research on Diabetic Complications
Brooks B et al Diabetes Care 1999 22(10)
1722-7
Brooks B et al Diabet Med 2001 18(5) 374-80
Brooks B et al J Clin Endocrinol Metab 1994
79(6) 1681-5
Brooks BA et al Diabetes Obes Metab 2008
10(9) 739-46
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Skin Biopsy to Assess Small Fibre Diabetic
Neuropathy
Sorensen L et al Diabetes Care 2006 22(3)
261-5
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Magnetic Resonance Spectroscopy in the Study of
Diabetic Neuropathic Pain
Sorensen L et al Diabetes Care 2008 31(5)
980-1
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Relationship Between Age of Diabetes Onset and
Mitochondrial DNA Content
No comps
r0.7p0.0002
Comps
r-0.04p0.8
Wong J et al Diabetologia 2009 52(9) 1953-61
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Wound Fluid MMP-9 and TIMP-1 Levels Predict Poor
Wound Healing
Liu Y- Diabetes Care 2009 32(1) 117-9
Xu, L et al Diabetes Care 200730(2)378-80
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The Relationship of Monocyte Surface Markers with
Diabetes and Retinopathy
Min D et al American Diabetes Association
Meeting 2010
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Research in a Multi-disciplinary Setting Less
linear than thematic
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The Interactive Multi-disciplinaryTeam
Doctor
Doctor
Nurse
Dietitian
Dietitian
Nurse
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What is an Interactive Team ?
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Weekly Training Sessions
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The Nurses and Other Allied Health Professionals

• A wider horizon
• On the job training according to ambition and
  skills
• Better rewarded
• More demanding (The Nuremberg Principle)
• The seven most senior nurses have worked at the
  Diabetes Centre for a total of 160 years

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Professional Development and Achievements

• Allied health professionals were 1st author in
  more than 70 publications in international peer
  reviewed journals
• 3 PhD, 4 MSc, 1 MPH
• Two employees of the month (Information
  Technology and High Risk Foot Clinic)
• 1 statistician to an international peer review
  journal
• Lilly Award (The Unsung Heroes)
• Best High Risk Foot Podiatrist (NSW) Award
• Chairperson of the NSW Health Telemedicine
  Committee
• The first two Nurse Practitioners in diabetes in
  NSW
• 3 Associate Professors
• 1 IDF Senior Vice-President
• 2 Board Members of JDRF
• Other Grants and Awards
• 12 babies !!!

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The Doctors

• Take responsibility
• Contribute to leadership and vision
• Training of staff
• Do the things that allied health professionals
  cannot do, according to a sliding scale

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The Diabetes Centre Model of CareRoyal Prince
Alfred Hospital
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The Italian Way
If you never never go, you will never never know
Rome was burnt in one day in AD 64
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A Model in Danger of Evolutionary Extinction
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Number Of Patient Services Per Year
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Cost and Output (2008)

1. About one-third self generated (clinical trials,
   clinical services, training of health
   professionals, grants)
2. Our current capacity can see about 23 of known
   cases in our area.

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National Health Care Reform

• Focus diabetes treatment at the Primary Care
  Level
• Diagnostic Related Groups used to evaluate
  efficiency of hospital and determine funding
• Where does Diabetes Centre sit on this ?

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Organization of the Diabetes Movement
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Thanks for the Family !
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A Chance Meeting