Download optimal diaBetes Care in Ch - International Diabetes Federation

Health Delivery
Integrated efforts
optimal diabetes
Ming-xia Yuan and Shen-yuan Yuan
The prevalence of diabetes is estimated to be 11.6%
in the Chinese adult population, which represents
up to 113.9 million Chinese adults with diabetes
or a third of the world’s diabetes population. The
prevalence of diabetes is higher in older age groups,
in urban residents and in persons living in economically developed regions. Among people with
diabetes, only 25.8% received treatment for diabetes and only 39.7% of those treated had adequate
glycaemic control.1,2 These numbers suggest that
China has overtaken India as the epicentre of the
global diabetes epidemic.3
relatively untapped resource pool. Once organised,
GPs could deliver better care for a broader base of
people living with diabetes in China. There is a
growing realisation that integrated efforts between
specialists and GPs may be the ideal way to ensure
optimal outcomes of management for diabetes.
The study
This ongoing BRIDGES supported project is
implementing and evaluating a community-hospital
integrated management system for type 2 diabetes
in Beijing, China. The quality and efforts of the
community-hospital integrated model for diabetes
Worldwide censuses have shown an increasing role care will be assessed by analysing group changes in
of general practitioners (GPs) in diabetes care.4 the primary outcome: principally the proportion
While the role of GPs in diabetes care should and of participants reaching optimal control of blood
must be increased in China, an urgent issue is glucose, blood pressure and lipids, as well as clinical
whether the quality of diabetes care will be com- outcomes, such as the incidence and progress of
promised as care shifts from the specialist to the diabetes-related microvascular complications.
primary level. Due to the relatively short history of
GP practice in China, and overall GP inexperience Current data
with diabetes management, people with diabetes It is well established that intensive glycaemic
choose specialist care over primary care. However, control, blood pressure (BP), lipid management
GPs from the local healthcare community remain a and aspirin usage in people with diabetes reduce
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June 2014 • Volume 59 • Special Issue
health delivery
key for
care in China
the risk of microvascular and macrovascular
complications.5 However, translation of these
interventions to real-life settings remains a
major challenge in China. In the 2006 nationwide
Diabcare-China surveys,6 only 26.8% of patients
with type 2 diabetes reached HbA1c ≤6.5%
(International Diabetes Federation criteria) and
41.1% of people with diabetes reached an HbA1c
<7% (American Diabetes Association criteria).
The proportion of patients with “poor control”
(HbA1c >8%) was 28.3%. In addition, only 22.4%
of patients achieved a BP goal of below 130/80
mmHg and the proportion of patients achieving
high density lipoprotein (HDL) levels >1.1 mmol/L
and triglyceride (TG) levels <1.5 mmol/L was
60.9% and 40.7% respectively.
The quality of diabetes management in Beijing
is similar to data collected nationwide. National
reports from community centres show diabetes
care status is even worse with approximately 10%
of people with type 2 diabetes having achieved
an HbA1c ≤6.5%. More importantly, only 2.7% of
people with diabetes obtained optimal glycaemic,
June 2014 • Volume 59 • Special Issue
blood pressure, and serum lipid control in
Shanghai,7,8 the largest city (by population) in
the world. It is evident that more intensive care is
required for people living with diabetes in China.
More specifically, the following issues require
attention:
■G
Ps need further expert guidance, including training on updated diabetes guidelines in practice.
■ Preventive measures are required for controlling
multiple risk factors associated with diabetes.
■P
roactive systems for surveillance and support are
needed to enhance current diabetes management.
General practitioner training
Training for community GPs is provided by tertiary
hospital specialists and developed by the project’s principal investigators along with an Expert
Committee. The Expert Committee consists of ten
experts from relevant professional fields including
Endocrinology, Cardiology, and Ophthalmology as
well as 20 endocrinologists from tertiary hospitals.
Training modules include group training class,
interactive workshops and specialist outpatient
services in the community. Specialists assist GPs in
DiabetesVoice 37
Health Delivery
clinical practice twice per week for the entire trial.
A total of 150 GPs are participating in the training
programme. Specialists supervise a specific community and a fixed number of GPs, who in turn
are responsible for a fixed number of participants.
All levels of the trial organisation are linked via a
web-based electronic monitoring platform, allowing participant records (such as HbA1c data) to be
shared quickly and easily. The web-based platform
also facilitates the rapid flow of information and
professional feedback from specialists to GPs and
patient participants.
participants with type 2 diabetes. Five urban districts were chosen over suburban regions because
the urban economic conditions offer a sufficiently
stronger medical infrastructure to carry out the
study. Participants were randomised into either the
intensive-care group or the control group.
Trial management
To achieve good target control, management adjustment strategies on guidelines,9 continued to
be applied by a collaborative team consisting of
participating tertiary hospital specialists and the
programme’s community GPs. Further, to ensure
Patient recruitment
the integrity and quality of data collection, a superGreater Beijing is divided into two regions, one vision team consisting of four trained specialists has
urban and the other rural. Each of these regions been checking study progress and data records in
consists of eight districts. Out of five districts in the every community centre twice yearly. Data checks
urban region, 15 communities with their health- result in a quality score and ranking issued in recare centres were selected by a multi-stage random port form to corresponding researcher meetings.
sampling approach, resulting in a total of 4,080 The researcher meetings consist of 150 researchers
including the specialists and GPs. These are held
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June 2014 • Volume 59 • Special Issue
health delivery
every four months. The researcher meetings provide: updated follow-up data, summary of endpoint
events, lectures by the principal investigators, and
GP generated oral presentations.
Preliminary results
By analysis, 9.4% in the intensive-care group and
8.4% in the control group met all the HbA1c, BP,
and LDL-C target values at the baseline (p=0.35).
People with diabetes who were treated by community GPs in training showed a significant improvement after 18 months intervention (14.6% vs. 12%,
p=0.03) compared to the control group, as well as
a significant increase compared with the baseline.
Ming-xia Yuan and Shen-yuan Yuan
Ming-xia Yuan is Chief-Physician and Vice-Director
at the Department of Endocrinology, Beijing Tongren
Hospital, Capital Medical University, Beijing, China.
Shen-yuan Yuan is Professor at the Department of Endocrinology,
Beijing Tongren Hospital, Capital Medical University, Beijing, China.
BRIDGES project
Promotion of community-hospital integrated
model for diabetes management in Beijing
Acknowledgement
This project is supported by BRIDGES. BRIDGES is an
International Diabetes Federation programme supported
by an educational grant from Lilly Diabetes.
To date, the community-based care system has
proved to be an effective approach, although results will not be complete until the study ends in
December 2014.
Public health significance
Optimal target control of glycaemia, BP and lipids
should significantly reduce the risk of chronic complications, improve quality of life for people living
with diabetes and lessen the financial burden for
diabetes care. However, the challenge to maintain
continuous optimal diabetes management during
the long-term is considerable.
Sustainability plan
Results and experiences gained in this study will
be used on a wider scale in Beijing and in more
regions in China. Further exploration and followup studies across larger communities will continue
for the next five years, ten years or longer.
References
1. Ning G, Zhao W, Wang W, et al. Prevalence and control of diabetes in Chinese
adults. 2010 China Noncommunicable Disease Surveillance Group. JAMA 2013;
310: 948-59
2. Yang W, Lu J, Weng J, et al. Prevalence of diabetes among men and women
in China. N Engl J Med 2010; 362: 1090-101.
3. Hu FB. Globalization of Diabetes. The role of diet, lifestyle, and genes.
Diabetes Care 2011; 34: 1249-57.
4. G
oyder EC, Drucquer M, McNally PG, et al. Shifting of care for diabetes from
secondary to primary care, 1990-5: review of general practices. BMJ 1998; 316:
1505-6.
5. Stratton IM, Adler AI, Neil HAW, et al. Association of glycaemia with
macrovascular and microvascular complications of type 2 diabetes
(UKPDS 35): prospective observational study. BMJ 2000; 321: 405-12.
6. Pan C, Yang W, Jia W, et al. Management of Chinese patients with type 2 diabetes,
1998-2006: the Diabcare-China surveys. Curr Med Res Opin 2009; 25: 39-45.
7. Lu B, Yang Y, Song X, et al. Analysis of diabetes management in population-based
patients diagnosed with type 2 diabetes in the Shanghai downtown.
J Clin Intern Med 2008; 25: 466-8.
8. Yuan MX, Yuan SY, Fu HJ, et al. Current HbA1c status of type 2 diabetes in
Beijing communities and the related factors. Chin J Diabetes 2010; 18: 752-5.
9. Chinese Diabetes Society (CDS). China guideline for type 2 diabetes - 2010.
Chin J Diabetes Mellitus 2010; 2: 1-56.
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