Diabetes care in the Malaysia primary care setting, MDES 2014

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Overview of chronic disease management in primary care in Malaysia with latest preliminary data from the National Diabetes Registry

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Diabetes care in the Malaysia primary care setting, MDES 2014

  1. 1. Diabetes Care in the Malaysia Primary Care Setting Feisul Idzwan Mustapha, MBBS, MPH, AM(M) Public Health Physician Disease Control Division Ministry of Health, Malaysia MDES Conference 2014 26 April 2014 Hotel Summit USJ Ministry of Health Malaysia
  2. 2. Population of Malaysia • 2000: 23.3 mil • 2010: 28.3 mil • Life expectancy: • Total pop : 70.83 (2000), 73.79 (2011). • Male: 71.05 • Female: 76.73 • Average annual population growth • 1996 to 2000: 2.65% • 2000 to2010: 2.0% • Fertility rate : • 2000: 3.0% • 2010: 2.6% 2
  3. 3. BurdenofDiabetesinMalaysia:Trends&Projections by2020(Adultsage18yearsandabove) 0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 5,000,000 0 5 10 15 20 25 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Estimatedpopulation Prevalence(%) Year Est. population, 2006 Est. population, 2011 Prevalence projection, 2006 Prevalence projection, 2011 3 Sources: NHMS I (1986), NHMS II (1996), NHMS III (2006) and NHMS 2011
  4. 4. National Strategic Plan for Non-Communicable Diseases (NSP-NCD) 2010-2014 • Presented and approved by the Cabinet on 17 December 2010. • Provides the framework for strengthening NCD prevention & control program in Malaysia. • Adopts the “whole-of-government” and “whole-of-society approach”. • Diabetes & obesity are used as the entry points. Seven Strategies: 1. Prevention and Promotion 2. Clinical Management 3. Increasing Patient Compliance 4. Action with NGOs, Professional Bodies & Other Stakeholders 5. Monitoring, Research and Surveillance 6. Capacity Building 7. Policy and Regulatory interventions 4
  5. 5. Multi-disciplinary care team (in health clinics) Post-basic training for paramedics Clinical practice guidelines Quality improvement programs Clinical information systems Patient resource centres Community empowerment StrengtheningChronic Disease Management at the primary care level 5
  6. 6. NationalDiabetesRegistry • Web-based application. • Went live on 1 January 2011. • Supports the implementation of the annual “Diabetes Clinical Audit” amongst Type 2 Diabetes patients in MOH Health Clinics. • First report, “NDR Report, Volume 1, 2009- 2012” was published in August 2013, available at the MOH website http://www.moh.gov.my/index.php/pages/view/115. 6
  7. 7. Number of Active Registered Patients; as of 28 Feb 2014 State Number of active patients Johor 117,363 Kedah 52,271 Kelantan 35,556 Melaka 54,725 N.Sembilan 67,950 Pahang 52,196 Perak 90,512 Perlis 16,384 P.Pinang 45,852 Sabah 15,643 Sarawak 70,642 Selangor 130,148 Terengganu 28,292 WPKL 42,287 WP Labuan 1,534 WP Putrajaya 2,983 Malaysia 824,338 7
  8. 8. GlycaemicControl:PercentageofT2DM Patientswith HbA1c<6.5%,2009to 2013 2009 2010 2011 2012 2013 Johor 14.0 18.3 14.4 17.5 16.3 Kedah 8.5 12.8 12.3 15.8 17.0 Kelantan 8.7 9.2 12.5 11.3 16.2 Melaka 18.4 15.3 16.9 21.7 23.9 Negeri Sembilan 13.9 19.6 17.8 19.7 20.0 Pahang 13.4 19.9 13.4 15.1 16.4 Perak 14.5 16.3 13.9 18.1 21.6 Perlis 30.6 24.3 26.1 27.9 25.6 Pulau Pinang 12.3 18.5 19.3 16.5 18.7 Sabah 22.6 19.6 25.9 28.5 34.5 Sarawak 7.8 3.6 6.4 7.0 7.4 Selangor 15.8 25.2 15.1 18.4 21.3 Terengganu 19.9 20.5 17.9 16.2 17.1 WP Kuala Lumpur 12.6 27.9 17.9 24.3 30.0 WP Labuan n.a. 30.8 23.1 53.5 41.4 WP Putrajaya 15.6 26.2 15.1 29.6 32.4 Malaysia 13.3 17.2 15.6 18.1 19.8 8
  9. 9. DiabetesClinical Audit (2013) Variable Targets Total no. of tests (n) Meeting Target (%) Mean 95% CI HbA1c < 6.5 % 91,944 25.6 8.1 8.1 - 8.1 BP: Systolic < 130 mmHg 106,842 47.6 135.1 135.0 - 135.2 BP: Diastolic < 80 mmHg 106,828 69.2 77.7 77.6 - 77.8 Blood Pressure < 130 / 80 mmHg 106,809 41.2 Total cholesterol < 4.5 mmol/l 91,214 29.0 5.2 5.1 - 5.2 TG ≤ 1.7 mmol/l 90,593 61.8 1.8 1.8 - 1.8 HDL ≥ 1.1 mmol/l 67,354 66.6 1.3 1.3 - 1.3 LDL ≤ 2.6 mmol/l 67,090 37.3 3.1 3.1 - 3.1 BMI < 23 kg/m2 96,954 16.4 27.4 27.4 - 27.4 Waist circumference < 90 cm (Male) 31,790 33.7 94.0 93.9 - 94.1 < 80 cm (Female) 50,008 14.4 90.7 90.6 - 90.8 Total 115,254 Patients 9
  10. 10. DiabetesClinical Audit (2013) Complications Present Absent Not known n % n % n % Retinopathy 8,640 7.50% 89,118 77.32% 17,488 15.17% Ischaemic Heart Disease 6,133 5.32% 94,448 81.95% 14,665 12.72% Cerebrovascular Disease 1,519 1.32% 99,490 86.32% 14,237 12.35% Nephropathy 10,476 9.09% 90,693 78.69% 14,077 12.21% Diabetic Foot Ulcer 1,470 1.28% 101,211 87.82% 12,565 10.90% Amputation 726 0.63% 102,034 88.53% 12,486 10.83% Concomitant Co- Morbidity Yes No Not known n % n % n % Hypertension 83,765 72.68% 25,898 22.47% 5,583 4.84% Dyslipidaemia 69,157 60.00% 38,145 33.10% 7,944 6.89% 10
  11. 11. Anti-Diabetics 2009 2010 2011 2012 2013 Metformin 81.7% 85.7% 82.3% 82.2% 80.9% Sulphonylureas 65.2% 62.9% 59.5% 56.6% 53.0% Alpha-glucosidase inhibitors 4.7% 5.9% 6.5% 4.8% 4.2% Insulin 12.0% 11.9% 17.1% 21.3% 23.2% Monotherapy (OHA) 33.6% 34.1% 27.8% 27.3% 27.4% >= 2 OHA 51.1% 51.7% 48.7% 45.5% 42.3% OHA + insulin 8.8% 8.9% 13.2% 16.2% 17.9% Diet only 3.4% 2.3% 6.4% 5.9% 7.1% DiabetesClinical Audit (2009-2013) 11
  12. 12. Anti-Hypertensives 2009 2010 2011 2012 2013 ACE-Inhibitors 46.55% 48.18% 47.54% 48.72% 49.70% ARB 2.69% 3.61% 3.93% 4.14% 4.84% Beta-blockers 26.70% 26.36% 25.86% 24.49% 23.43% Ca Channel Blockers 26.49% 28.19% 33.35% 38.16% 41.37% Diuretics 16.63% 17.39% 19.56% 20.36% 20.28% Alpha-Blockers 4.33% 3.55% 3.89% 3.82% 3.64% Centrally Acting 0.43% 0.50% 0.43% 0.23% 0.25% Others 0.70% 0.41% 0.54% 0.70% 0.34% DiabetesClinical Audit (2009-2013) 12
  13. 13. Management of NCDs (including diabetes): 7 basic principles • Screening • Register • Clinical management • Complications • Rehabilitation • Defaulter tracing • Selfcare – Patient’s empowerment 13
  14. 14. Initiativesto Improve Clinical Outcome • The formation of Diabetes Team which consists of Diabetes Educator, Medical Officer, Family Medicine Specialist (FMS), Nutritionist and Pharmacist in every clinic as appropriate to their burden of diabetes patients. • FMS or senior Medical Officer in the clinic to do regular audits on green book. • Intensify and more frequent supervision especially by FMS of clinical staff to ensure compliance to CPGs and related guidelines. • Regular training and CMEs on diabetes care for all clinic staffs, and the state office to monitor the numbers of training sessions conducted. • Availability of module for health education for patients and a set of pre- and post-test for patients, as published by Disease Control Division, MOH. • The usage of the Diabetes Conversation Map. • Further development of a Peer Support Group. • Personalized care by Medical Officer in clinics with low to moderate burden of loads, as appropriate in the individual clinic settings. 14
  15. 15. Overview of a Peer Support Group • Patients becomes a trainer / facilitator, training his/her fellow colleagues with the same disease. • MOH responsible for developing the training modules, conduct training and develop the implementation guidelines. • Successful implementation of a Peer Support Group Program has been shown to: • Help patients understand their disease better; • Help patients achieve good disease control; and • Reduce rates of referral to hospitals due to complications. • Rationale – patients are more likely to accept advise from their peers or people living with the same condition. 15
  16. 16. Implementation in KK Padang Rengas, Kuala Kangsar, Perak 16 Workshop Name Description Items needed I’m a diabetes: is it the end of the world? Discussion on: What is diabetes? Why me? How do I get better? Use of medications Diabetes learning poster & slides Samples of medications (including insulins) Food for thoughts- what will be my food? What can I eat Do I need to stop sugar - Is sugar the culprit Food models, posters Complication of diabetes: Foot to Care Practical tips to care for your foot (actual examining foot and hygiene tips) Pail, water and sponge Old newspaper Complication of diabetes: Blind as a bat Practical walking with covered eye (experience as a blind and amputated patients) Wheelchair Blindfold cloth Crutches
  17. 17. Practical session 1: I’m a diabetes: is it the end of the world? 17
  18. 18. Practical Session 2: Food for thoughts - what will be my food? 18 Practical tips from their peers on how they manage their diet in day-to-day living
  19. 19. Practical Session 3: Complication of diabetes: Foot to Care 19
  20. 20. Practical Session 4: Complication of diabetes: Blind as a bat 20 Patients will experience having certain types of diabetes- related complications
  21. 21. Challenges: 1. The prevalence of diabetes has increased 31.0% in 5 years, from 11.6% in 2006 to the current 15.2%. • Mostly contributed by increase of “undiagnosed”. • Increase in prevalence occurring across all age-groups. 2. Increasing challenge in providing satisfactory quality of care to patients with diabetes. • Number of patients in MOH health clinics will continue to increase. • Referrals for specialists management will also continue to increase due to late diagnosis and sub-optimal control. • Need to address “patient-related factors” i.e. patient empowerment. 21
  22. 22. Opportunities… 22 Chronic Disease Management under 1Care Family doctor Choice of provider Quality Assurance No payment at Point of Care Emphasis on prevention Trained Primary Health Care Physicians Continuity of care Performance standards Proposed structural reforms to integrate public and private healthcare sectors…
  23. 23. Thank you dr.feisul@moh.gov.my Facebook: Feisul Mustapha 23

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