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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. Conference in China. The Burden and Complexity of Diabetes .

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The multi disciplinary diabetes centre a model of care for the future or the past l.jpg

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


Conference in china l.jpg
Conference in China Model of Care for the Future (or the Past) ?


The burden and complexity of diabetes l.jpg
The Burden and Complexity of Diabetes Model of Care for the Future (or the Past) ?


Different models of diabetes care l.jpg
Different Models of Diabetes Care Model of Care for the Future (or the Past) ?

ANDIAB Survey : Cheung NW et al : Diabet Med 2008 ; 25(8) : 974-8


We must have a centre l.jpg
We Must Have A Centre ! Model of Care for the Future (or the Past) ?


A multi disciplinary diabetes centre l.jpg
A Multi-disciplinary Diabetes Centre Model of Care for the Future (or the Past) ?

Family Doctor

Podiatrist

Dietitian

Person with

Diabetes

Researcher

Specialist

Secretaries

Diabetes Nurse

/ Educator


What we need is not a diabetes education centre l.jpg
What We Need Is Not A Diabetes Education Centre Model of Care for the Future (or the Past) ?


Slide8 l.jpg

Referring Doctor Model of Care for the Future (or the Past) ?

Pregnancy

Clinic

Waiting time

6 months

High Risk

Foot Clinic

Waiting time

0 to 2 weeks

Complications and

Metabolic Management

(Type 1 & 2)

Acute Intervention

Clinic

Follow-Up Clinic

Review Clinic

Within

4 months

Referring Doctor

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


One stop complications assessment l.jpg
One Stop Complications Assessment Model of Care for the Future (or the Past) ?

McGill M et al : Diabet Med 1993 ; 10(4) : 366-70

McGill M et al :Diabetes Care : 1989 ; 12(8) : 599-600


Standardised data capture l.jpg
Standardised Data Capture Model of Care for the Future (or the Past) ?


Younger onset of type 2 diabetes increases risk of retinopathy l.jpg
Younger Onset of Type 2 Diabetes Increases Risk of Retinopathy

Wong J et al : Diabetes Care 2008; 10 : 1985-90


Slide12 l.jpg
Beyond ONTARGET : Retinopathy(Deterioration of renal function while on combined ACE-I and A2 Receptor Blocker Treatment )

Hypertension (BP < 160/100)

Hypertension (BP > 160/100 )

J Wong et al : Diabetes Obesity and Metabolism 2010


Ambulatory stabilisation of diabetes commencing insulin therapy l.jpg
Ambulatory Stabilisation of Diabetes : Commencing Insulin Therapy

Hoskins PL et al : Med J Aust 1993 ; 158(3) : 148-9


Telephone stabilisation l.jpg
Telephone Stabilisation Therapy

Genev NM et al Diabet Med 1990 ; (1) : 920-1


Changing pattern of treatment of type 1 diabetes more use of carbohydrate counting and insulin pump l.jpg
Changing Pattern of Treatment of Type 1 Diabetes : TherapyMore Use of Carbohydrate Counting and Insulin Pump


Continuity of care in a multi disciplinary setting l.jpg
Continuity of Care in a Multi-disciplinary Setting Therapy

Patient 1

Patient 2

Visit 1

Visit 2

Visit 3

Visit 4


Standardised format of letters documentation and education l.jpg
Standardised Format of Letters Therapy(Documentation and Education)



Monitoring by a senior nurse after visits l.jpg
Monitoring By A Senior Nurse After Visits Therapy

  • Daily team clinical meeting

    • All patients’ medical record reviewed ; possible mistakes identified and appropriately questioned

    • Standardises party line message and upskill staff

    • Collects data


The high risk diabetic foot clinic a co ordinator who knows everything l.jpg
The High Risk Diabetic Foot Clinic TherapyA 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


Benefits of multi disciplinary foot clinics rpah prevalence and level of amputation l.jpg

Therapy2 =14.6; P=0.001

90

Clinic

80

No Clinic

70

60

Percentage of Amputations (%)

50

40

30

20

10

0

Above Knee

Distal

Below Knee

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


How does telemedicine work l.jpg

E-mail Therapy

How Does Telemedicine Work?

High Risk

Foot Clinics

  • Medical Data

McGill M & Constantino M et al : Practical Diabetes 2000 ; 17(7) : 235-238.



Why is the multi disciplinary diabetes centre a better model for a chronic and complex disease l.jpg
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


The power of computer l.jpg
The Power of Computer for a Chronic and Complex Disease ?


The under water volcano theory of gdm l.jpg
The Under Water Volcano Theory of GDM for a Chronic and Complex Disease ?

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


Long term efficacy of metformin treatment in non obese individuals with type 2 diabetes l.jpg
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


Metabolic syndrome in type 1 diabetes l.jpg
Metabolic Syndrome in Type 1 Diabetes Individuals With Type 2 Diabetes

McGill M et al : J Diabetes Complications 2008 ; 22(1) : 18-23


Slide29 l.jpg

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


A transplant of diabetes centre to rural area l.jpg
A Transplant of Diabetes Centre to Rural Area Subjects Diagnosed With Type 2 Diabetes


Overseas collaborations l.jpg
Overseas Collaborations Subjects Diagnosed With Type 2 Diabetes

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


Training and exchange programs national and international l.jpg
Training and Exchange Programs Subjects Diagnosed With Type 2 DiabetesNational and International


Clinical research and basic science research l.jpg
Clinical Research and Basic Science Research Subjects Diagnosed With Type 2 Diabetes


Biomedical research on diabetic complications l.jpg
Biomedical Research on Diabetic Complications Subjects Diagnosed With Type 2 Diabetes

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


Skin biopsy to assess small fibre diabetic neuropathy l.jpg
Skin Biopsy to Assess Small Fibre Diabetic Neuropathy Subjects Diagnosed With Type 2 Diabetes

Sorensen L et al : Diabetes Care 2006 ; 22(3) : 261-5


Magnetic resonance spectroscopy in the study of diabetic neuropathic pain l.jpg

D. Subjects Diagnosed With Type 2 Diabetes

B.

C.

NAA

Cr/PCr

mI

Cho

Gluc

Glx/GABA

Magnetic Resonance Spectroscopy in the Study of Diabetic Neuropathic Pain

Sorensen L et al : Diabetes Care 2008 ; 31(5) : 980-1


Relationship between age of diabetes onset and mitochondrial dna content l.jpg
Relationship Between Age of Diabetes Onset and Mitochondrial DNA Content

No comps

r=0.7:p=0.0002

Comps

r=-0.04:p=0.8

Wong J et al Diabetologia 2009 ; 52(9) : 1953-61


Wound fluid mmp 9 and timp 1 levels predict poor wound healing l.jpg

MMP-9 Mitochondrial DNA Content

Ratio of MMP-9/TIMP-1

*

Healed

Unhealed

Healed

Unhealed

**

MMP-9/TIMP-1 (x100)

MMP-9 (μg/ml)

*

*

pro-MMP-9/TIMP-1 act-MMP-9/TIMP-1

pro-MMP-9 act-MMP-9

* p<0.05, ** p<0.01 different from healed within 12 weeks

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 2007;30(2):378-80


The relationship of monocyte surface markers with diabetes and retinopathy l.jpg
The Relationship of Monocyte Surface Markers with Diabetes and Retinopathy

Min D et al : American Diabetes Association Meeting 2010


Research in a multi disciplinary setting less linear than thematic l.jpg
Research in a Multi-disciplinary Setting : and RetinopathyLess linear than thematic


The interactive multi disciplinaryteam l.jpg
The Interactive Multi-disciplinaryTeam and Retinopathy

Doctor

Doctor

Nurse

Dietitian

Dietitian

Nurse



Weekly training sessions l.jpg
Weekly Training Sessions and Retinopathy


The nurses and other allied health professionals l.jpg
The Nurses and Other Allied Health Professionals and Retinopathy

  • 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


Professional development and achievements l.jpg
Professional Development and Achievements and Retinopathy

  • 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 !!!


The doctors l.jpg
The Doctors and Retinopathy

  • Take responsibility

  • Contribute to leadership and vision

  • Training of staff

  • Do the things that allied health professionals cannot do, according to a sliding scale


The diabetes centre model of care royal prince alfred hospital l.jpg
The Diabetes Centre Model of Care and RetinopathyRoyal Prince Alfred Hospital


The italian way l.jpg
The Italian Way and Retinopathy

If you never never go, you will never never know

Rome was burnt in one day in AD 64




Cost and output 2008 l.jpg
Cost and Output (2008) and Retinopathy

  • About one-third self generated (clinical trials, clinical services, training of health professionals, grants)

  • Our current capacity can see about 23% of known cases in our area.


National health care reform l.jpg
National Health Care Reform and Retinopathy

  • 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 ?



Thanks for the family l.jpg
Thanks for the Family ! and Retinopathy


A chance meeting l.jpg
A Chance Meeting and Retinopathy


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