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Hospital-based integrated diabetes care management: An overview
Diabetes Research and Clinical Practice 106S2 (2014) S323–S327
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Hospital-based integrated diabetes care management: An overview Jeng-Fu Kuoa , Shih-Te Tua, *, Shang-Ren Hsua , I-Chieh Maoa , Yan-Chi Lib , Guan-Yi Linb , Jia-Yu Tianb , Ya-You Syub , Wen-Hui Chenb , Chia-Ching Hsub , Bai-Ling Syub , Tzu-Ying Wub , Yi-Wen Chob a b
Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Taiwan, ROC Diabetes Education Center, Lukang Christian Hospital, Taiwan, ROC
ARTICLE INFO
ABSTRACT
Keywords: Diabetes Share care Education
To provide continuous, accessible, and quality care, a diabetes share-care program has been in place in Taiwan for several years. Lukang Christian Hospital, a member of the diabetes share-care network, endeavors to provide “patient-centered” care aimed at increasing care quality and reducing diabetic complications. Information technology has been employed by the hospital for monitoring care quality and analyzing costeffectiveness. Structured health-care programs have also been developed to ensure the completeness of diabetes care and to encourage self-management of individuals at high risk for diabetes. The implementation of these strategies has led to progressive improvement in quality measures and spawned novel and creative ways to deliver care services. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Diabetes has been a top-ranking cause of death in Taiwan in recent years. From 2000 to 2009, the country’s total diabetes population has increased more than 70%, with a 35% increase in the standardized prevalence rate [1]. Recognizing the importance of disease prevention, the Taiwanese government has been promoting diabetes prevention and control programs [2] that encourage the target population to control diet, lose weight, and monitor blood sugar. In 1996, a diabetes share-care program was established to improve outpatient diabetes care at health institutions. The program emphasized patient self-care, multidisciplinary services, and an integrated care network to provide continuous, accessible, and quality care for diabetes. In 2001, the Bureau of National Health Insurance introduced the “National Health Insurance Diabetes Treatment Reimbursement Improvement Program” under the framework of diabetes share-care. Since its implementation, the program has brought about improvements in care quality, hospitalization rate, and medical expenditure for enrolled patients [3,4].
Here, we introduce the diabetes care management program at Lukang Christian Hospital in Taiwan, which is a participating institution in the share-care program. The hospital was founded in 2004 and has more than 30 clinical specialty and subspecialty departments and receives approximately 1500 patient visits daily. Its diabetes management team includes 9 diabetes specialist physicians, 4 nurse educators, and 5 dietitians.
2. Materials and methods Various public pronouncements and screening services for the metabolic syndrome were launched by the hospital to educate the public about the importance of a healthy lifestyle in preventing diabetes. Diabetic patients were enrolled for case management, which provided individualized health education and taught problem-solving skills aimed at reducing diabetes complications. Several strategies were developed to increase patient enrollment in the diabetes share-care program. A patient support group was formed in 2004 to reinforce patients’ motivation for self-care. Collaborative goalsetting, emotional support, and sharing of experiences were
* Corresponding author. Tel.: +886-4-7779595; fax: +886-4-7768296. E-mail address: [email protected] (S.-T. Tu). 0168-8227© 2014 Elsevier Ireland Ltd. All rights reserved.
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Table 1 Diabetes care quality indicators Criterion
Percentage 2011 (n = 2,006 a )
2012 (n = 2,248 a )
2013 (n = 2,598 a )
96.92
Accountability A1C
1 time/yr
99.40
99.33
LDL
1 time/yr
96.31
96.84
94.34
Nephropathy b
1 time/yr
89.38
87.72
81.06
Foot examination
1 time/yr
100
99.91
99.92
Fundus examination c
1 time/yr
88.93
86.43
75.92
Smoking cessation counseling
1 time/yr
36.41%
27.27
28.08
26.32
26.42
23.75
A1C < 7.0%
38.98%
45.91%
47.96%
A1C > 9.0%
12.86%
10.28%
9.70%
BP < 140/90 mmHg
74.88%
70.77%
68.44%
LDL < 100 mg/dL
58.08%
57.16%
62.12%
Insulin injection rate Quality
BP, blood pressure; LDL, LDL-cholesterol. a The number of cases enrolled in the diabetes share-care network. b Spot urine albumin-to-creatinine ratio as an indicator of urine albumin excretion was used for nephropathy screening. c Non-mydriatic retinal photography was used for retinopathy screening. facilitated through communicative interactions within the patient group.
3. Results 3.1. Diabetes care quality indicators The Diabetes Quality Improvement Program and the American Diabetes Association Provider Recognition Program measurement criteria were adopted and modified as quality indicators. See Table 1.
3.2. Diabetes care approaches at Lukang Christian Hospital 3.2.1. Quality improvement strategies The hospital employed a dedicated computerized information system to systematically record patient data, initial visit data, telephone interview records, clinic visit results, followup visit data, and other necessary information. Information regarding health education, telephone interview, and followup results are communicated to the patient’s physician by the case manager through the online messaging application built into the system. By informing the physician of the patient’s current condition, problems encountered, response to treatment, treatment course, and suggestions for treatment modification, the physician may clarify problematic issues, make optimal treatment planning, and increase drug compliance and treatment adherence, thus helping patients acquire the greatest treatment benefit. Glycemic control is the shared responsibility between the care team and the patients. It is important to not only teach and inform the patients, but also be receptive to their feedback, such as their feelings toward glucose monitoring and insulin injection. As a result, a series of in-service
educational programs was developed for the hospital staff to clarify their concepts of diabetes care and nutrition and to cultivate empathy toward the patients. As a qualified institution for diabetes health promotion and training of medical personnel, Lukang Christian Hospital has provided training courses for its hospital staff. From October 2012 to September 2013, 13 courses for the education of certified diabetes educators were held in the hospital, with topics covering medical nutrition therapy, subcutaneous insulin injection technique, self-monitoring of blood glucose, and management of diabetic complications. The instructors consisted of 3 physicians, 2 nurses, and 3 dietitians. At the end of the course program, 2 trainees were certified as diabetes educators and 3 physicians (1 nephrologist, 1 cardiologist, and 1 neurologist) were qualified to participate in the diabetes share-care network. 3.2.2. Periodontal disease screening According to the consensus report of the Joint European Federation of Periodontology and American Academy of Periodontology Workshop on Periodontitis and Systemic Disease [5], patients with type 1, type 2, and gestational diabetes should, as part of their initial evaluation, receive a thorough oral examination, which includes a comprehensive periodontal examination. Our hospital has incorporated periodontal examination into its diabetes care plan since August 2012. Among the patients enrolled in the diabetes share-care program, 1295 (59%) received periodontal examination from August 2012 to October 2013. Of these, 657 (68.01%) had a Community Periodontal Index of Treatment Needs (CPITN) [6] of 2 and 181 (18.74%) had a CPITN of 4 (deep periodontal pockets 6 mm). Patients were given oral hygiene instruction or suggestions for subsequent dental treatment after examination (Table 2, Fig. 1).
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Table 2 Periodontal examination of diabetes mellitus share-care program History: Had received periodontal treatment: Have oral health examination every 6 months:
Yes Yes
No No
Community Periodontal Index of Treatment Needs: a < 17 … > 14; < 13 … > 23; < 24 … > 27 < 47 … > 44; < 43 … > 33; < 34 … > 37 Suggestions: Periodontal healthy and dental visit every 6 months Oral hygiene instruction and dental visit every 6 months Oral hygiene instruction and calculus removal Oral hygiene instruction and calculus removal and complex treatment Plans: The conditions have been reviewed with the patient, and the subsequent dental treatment has been suggested. Patient agreed Patient wanted to be treated at other facilities The numbers indicate the location of the teeth: < 17 > 14, upper right second molar to upper right first premolar; < 13 > 23, upper right canine to upper left canine; < 24 > 27, upper left first premolar to upper left second molar; < 47 > 44, lower right second molar to lower right first premolar; < 43 > 33, lower right canine to lower left canine; < 34 > 37, lower left first premolar to lower left second molar. CPITN scores are written on the ellipses.
a
Annual examination in DM share care program
i Periodontal examination
i Community Periodontal Index of Treatment Needs (CPITN) > 2 Yes
i
Subsequent dental treatment
i No Oral hygiene instruction
Fig. 1. Flow chart of screening for periodontal disease in diabetes.
3.2.3. Health promotion reduces diabetes risk Among the hospital’s employees, those with the metabolic syndrome were identified and health promotion plans were formulated according to the recommendations of American Diabetes Association’s Standards of Care [7]. For those at high risk of developing type 2 diabetes, structured programs that emphasize lifestyle changes – including moderate weight loss (7% of body weight), regular physical activity (150 minutes per week), and dietary modification (reduced caloric and fat intake) – were recommended. From October 2012 to September 2013, 336 employees (62 men, 274 women) at risk for diabetes were identified. Lifestyle modification counseling was provided for the 37 employees (13 men, 24 women) with hyperglycemia (fasting blood glucose 100 mg/dL). After intervention, 9 men (69.23%) and 17 women (70.8%) achieved a reduction of blood glucose levels. For the 55 employees (22 men, 33 women) with hypertension
(blood pressure 130/80 mmHg), lifestyle counseling included weight reduction, sodium restriction, moderation of alcohol intake, and increased physical activity. After intervention, 14 men (63.64%) and 26 women (78.79%) achieved a reduction in blood pressure. For the 88 employees (20 men, 68 women) with hyperlipidemia (total cholesterol 200 mg/dL), intervention included medical nutrition therapy, increased physical activity, weight reduction, and smoking cessation. After intervention, 18 men (90%) and 44 women (64.71%) achieved a reduction in cholesterol levels. For the 90 employees (13 men, 77 women) with abdominal obesity (waist circumference 90 cm for men, 80 cm for women), lifestyle and dietary counseling was given. After intervention, 11 men (84.62%) and 50 women (64.94%) achieved weight reductions. Ongoing education and support via telephone communication have been given to those who failed to achieve or maintain improvement. 3.2.4. Diabetes patient support group The majority of our diabetic patients were elderly, with an average age of 60–69 years. Patient group activities were conducted periodically to help these patients develop and maintain healthy behaviors, improve life quality, and achieve better glycemic control. From January to September 2013, the hospital has held 25 educational courses, attended by a total of 103 patients. Educational materials such as the STENO tool and MAP were used creatively in workshop settings for small groups to help address patients’ real-life concerns regarding diabetes self-management. The structured curricula of interactive courses were designed from the patient’s standpoint, employing self-care tools developed by our diabetes educators (e.g., insulin rotary disk; Fig. 2) to increase motivation for self-care. Personal approach strategies were developed to
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Fig. 2 – Insulin rotary disc. • Patients adjust their insulin dosage every 3 days according to the suggestion displayed by the insulin rotary disk when the dial is aligned with the average of the fasting glucose values measured in the past 3 days. • The disk also suggests the timing and frequency of self-monitoring of blood glucose. The reverse side of the disk shows symptoms and diabetic complications liable to occur if diabetes is not adequately controlled. © Copyright Changhua Christian hospital; reproduced with permission. help patients identify psychosocial issues, share experiences, and clarify misconceptions about their illness. Educational materials for different language and literacy levels were used to help patients improve self-care ability, overcome reluctance to accept insulin therapy, and understand the importance of glycemic control for the prevention of complications [8]. Patients were also given reinforcement through follow-up telephone interviews, and individualized plans were formulated with focus on insulin injection, blood glucose monitoring, and self-care problem-solving. To maintain effective diabetes self-management over the long term, patients were given reminders for follow-up visits and tests, and ongoing education, medication management, and behavioral goal setting were included as part of our diabetes self-management education. The patient support group had 103 participants. Among them, 98 adhered to the program. After joining the group, participants’ average HbA1c (A1C) levels declined from 10.09% to 7.76%. The number of participants who exercised regularly increased from 14 to 54. At baseline, 97 patients had a body mass index (BMI) > 24, with an average BMI of 28.3 kg/m2 . After joining the group, 37 patients lost weight, with an average decrease in BMI of 0.2%. The number of patients in the group who performed self-monitoring of blood glucose increased from 32 to 70.
4. Discussion In 2011, the Taiwan Association of Diabetes Educators conducted a nationwide diabetes-care quality survey that included 5,599 subjects treated at 120 Diabetes Health Promotion Institutions [9]. The survey found that 34.5% of subjects had an A1C level of < 7%, 68.4% had a blood pressure level lower than 140/90 mmHg, and 55.7% had a total cholesterol level of < 160 mg/dL or low-density lipoprotein cholesterol level of < 100 mg/dL. In comparison, our hospital has exceeded the national results in all of these quality measures. We believe the advantages of a continuously operating diabetes sharecare network, integrated care resources, and implementation
of a referral system in the hospital may be responsible for the high quality of care. In addition to the widely recognized comorbidities of diabetes, such as obesity, hypertension, and dyslipidemia, Lukang Christian Hospital also evaluated and addressed other comorbid conditions that may complicate diabetes management [7]. For example, current evidence suggests that periodontal disease adversely affects diabetes outcomes. We therefore incorporated periodontal examination into the diabetes care plan and offered annual screening for early detection and treatment of periodontal disease. To facilitate periodontal examination and increase patient cooperation, a dental screening station was established in close proximity to the diabetes outpatient clinic. By thus integrating and procuring the assistance of the dental service, which had been an underused resource at our hospital, we have set an example of interdisciplinary referral and coordinated patient services for other departments to follow. According to the 2014 American Diabetes Association’s Standards of Care, all patients should be advised not to smoke or use tobacco products [7]. Routine and thorough assessment of tobacco use is key to preventing smoking or encouraging smoking cessation. Our hospital has been providing smokingcessation outpatient service since 2010. In 2013, 211 smokers (including 37 diabetic patients) were treated at the smokingcessation clinic. Among the diabetic smokers, 43.0% successfully quit smoking after 3 months of treatment. All of our diabetes nurse educators were trained and qualified for smoking-cessation counseling, which has been incorporated into our diabetes care plan. However, the percentage of diabetic patients who received smoking-cessation counseling at least once a year has remained suboptimal; therefore, more effort is required in this area. In agreement with an analysis of perceived facilitators and barriers in diabetes care in the Netherlands [10], there are still barriers in our daily practice that need to be addressed. Multidisciplinary collaboration means that patients may need to visit multiple health-care professionals. The time spent waiting for appointments will not be appealing to the more
J.-F. Kuo et al. / Diabetes Research and Clinical Practice 106S2 (2014) S323–S327
demanding patients. In fact, time constraint may be the biggest obstacle for patients to commit themselves to the diabetes share-care program. A recent study by Changhua Christian Healthcare Diabetes e-Institute investigated the effectiveness of a share-care program assisted by telecare [11]. It demonstrated significant improvement in glycemic control for type 2 diabetes patients living in an underserved community. The addition of telecare may therefore be a viable way to provide more convenient services and increase patient satisfaction. The National Standards for Diabetes Self-Management Education and Support states that the diabetic patient is “the center of the diabetes education and support process”. In other words, the patients are the principal managers of their condition. They do the actual “hard work of managing their condition“, and the diabetes educator’s role, “first and foremost, is to make that work easier …” [8]. At Lukang Christian Hospital, these statements fully coincide with the aim of its diabetes care service.
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3. Tsai CL, Yeh LL, Yaung CL, Sheu WHH. Utilization of patients enrolled in the Shared Care Disease Management Program for Diabetes – an example from a regional teaching hospital. Formos J Endocrin Metab 2009;1:6–15. 4. Lee CP, Chu CI, Wu DA, Fu CC, Li JC, Wang YH, et al. Comparison of the diabetes regular care model and the “Diabetes Share Care Disease Management” model in eastern Taiwan. Tzu Chi Med J 2007;19:66–73. 5. Chapple IL, Genco R; working group 2 of the joint EFP/AAP workshop. Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and System Diseases. J Periodontol 2013;84(4 Suppl.):S106–12. 6. Ainamo J, Barmes D, Beagrie G, Cutress T, Martin J, SardoInfirri J. Development of the World Health Organization (WHO) community periodontal index of treatment needs (CPITN). Int Dent J 1982;32(3):281–91. 7. American Diabetes Association. Standards of medical care in diabetes – 2014. Diabetes Care 2014;37(Suppl 1):S14–80. 8. Haas L, Maryniuk M, Beck J, Cox CE, Duker P, Edwards L, et al. National standards for diabetes self-management
Conflict of interest The authors declare that they have no conflicts of interest.
education and support. Diabetes Care 2014;37(Suppl 1): S144–53. 9. Yu NC, Su HY, Chiou ST, Yeh MC, Yeh SW, Tzeng MS, et al. Trends of ABC control 2006–2011: A National Survey of
References 1. Jiang YD, Chang CH, Tai TY, Chen JF, Chuang LM. Incidence and prevalence rates of diabetes mellitus in Taiwan: analysis of the 2000–2009 Nationwide Health Insurance database. J Formos Med Assoc 2012;111(11):599–604. 2. Health Promotion Administration, Ministry of Health and Welfare. Diabetes prevention and future in Taiwan. http:// www.hpa.gov.tw/English/file/ContentFile/ 200803260528051093/Diabetes%20Prevention%20and%20 Future%20in%20Taiwan.pdf (accessed 10 October 2014).
Diabetes Health Promotion Institutes in Taiwan. Diabetes Res Clin Pract 2013;99(2):112–9. 10. Raaijmakers LG, Hamers FJ, Martens MK, Bagchus C, de Vries NK, Kremers SP. Perceived facilitators and barriers in diabetes care: a qualitative study among health care professionals in the Netherlands. BMC Fam Pract 2013; 14(1):114. 11. Liou JK, Soon MS, Chen CH, Huang TF, Chen YP, Yeh YP, et al. Shared care combined with telecare improves glycemic control of diabetic patients in a rural underserved community. Telemed J E Health 2014;20(2):175–8.
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Hospital-based integrated diabetes care management: An overview Jeng-Fu Kuoa , Shih-Te Tua, *, Shang-Ren Hsua , I-Chieh Maoa , Yan-Chi Lib , Guan-Yi Linb , Jia-Yu Tianb , Ya-You Syub , Wen-Hui Chenb , Chia-Ching Hsub , Bai-Ling Syub , Tzu-Ying Wub , Yi-Wen Chob a b
Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Taiwan, ROC Diabetes Education Center, Lukang Christian Hospital, Taiwan, ROC
ARTICLE INFO
ABSTRACT
Keywords: Diabetes Share care Education
To provide continuous, accessible, and quality care, a diabetes share-care program has been in place in Taiwan for several years. Lukang Christian Hospital, a member of the diabetes share-care network, endeavors to provide “patient-centered” care aimed at increasing care quality and reducing diabetic complications. Information technology has been employed by the hospital for monitoring care quality and analyzing costeffectiveness. Structured health-care programs have also been developed to ensure the completeness of diabetes care and to encourage self-management of individuals at high risk for diabetes. The implementation of these strategies has led to progressive improvement in quality measures and spawned novel and creative ways to deliver care services. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Diabetes has been a top-ranking cause of death in Taiwan in recent years. From 2000 to 2009, the country’s total diabetes population has increased more than 70%, with a 35% increase in the standardized prevalence rate [1]. Recognizing the importance of disease prevention, the Taiwanese government has been promoting diabetes prevention and control programs [2] that encourage the target population to control diet, lose weight, and monitor blood sugar. In 1996, a diabetes share-care program was established to improve outpatient diabetes care at health institutions. The program emphasized patient self-care, multidisciplinary services, and an integrated care network to provide continuous, accessible, and quality care for diabetes. In 2001, the Bureau of National Health Insurance introduced the “National Health Insurance Diabetes Treatment Reimbursement Improvement Program” under the framework of diabetes share-care. Since its implementation, the program has brought about improvements in care quality, hospitalization rate, and medical expenditure for enrolled patients [3,4].
Here, we introduce the diabetes care management program at Lukang Christian Hospital in Taiwan, which is a participating institution in the share-care program. The hospital was founded in 2004 and has more than 30 clinical specialty and subspecialty departments and receives approximately 1500 patient visits daily. Its diabetes management team includes 9 diabetes specialist physicians, 4 nurse educators, and 5 dietitians.
2. Materials and methods Various public pronouncements and screening services for the metabolic syndrome were launched by the hospital to educate the public about the importance of a healthy lifestyle in preventing diabetes. Diabetic patients were enrolled for case management, which provided individualized health education and taught problem-solving skills aimed at reducing diabetes complications. Several strategies were developed to increase patient enrollment in the diabetes share-care program. A patient support group was formed in 2004 to reinforce patients’ motivation for self-care. Collaborative goalsetting, emotional support, and sharing of experiences were
* Corresponding author. Tel.: +886-4-7779595; fax: +886-4-7768296. E-mail address: [email protected] (S.-T. Tu). 0168-8227© 2014 Elsevier Ireland Ltd. All rights reserved.
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J.-F. Kuo et al. / Diabetes Research and Clinical Practice 106S2 (2014) S323–S327
Table 1 Diabetes care quality indicators Criterion
Percentage 2011 (n = 2,006 a )
2012 (n = 2,248 a )
2013 (n = 2,598 a )
96.92
Accountability A1C
1 time/yr
99.40
99.33
LDL
1 time/yr
96.31
96.84
94.34
Nephropathy b
1 time/yr
89.38
87.72
81.06
Foot examination
1 time/yr
100
99.91
99.92
Fundus examination c
1 time/yr
88.93
86.43
75.92
Smoking cessation counseling
1 time/yr
36.41%
27.27
28.08
26.32
26.42
23.75
A1C < 7.0%
38.98%
45.91%
47.96%
A1C > 9.0%
12.86%
10.28%
9.70%
BP < 140/90 mmHg
74.88%
70.77%
68.44%
LDL < 100 mg/dL
58.08%
57.16%
62.12%
Insulin injection rate Quality
BP, blood pressure; LDL, LDL-cholesterol. a The number of cases enrolled in the diabetes share-care network. b Spot urine albumin-to-creatinine ratio as an indicator of urine albumin excretion was used for nephropathy screening. c Non-mydriatic retinal photography was used for retinopathy screening. facilitated through communicative interactions within the patient group.
3. Results 3.1. Diabetes care quality indicators The Diabetes Quality Improvement Program and the American Diabetes Association Provider Recognition Program measurement criteria were adopted and modified as quality indicators. See Table 1.
3.2. Diabetes care approaches at Lukang Christian Hospital 3.2.1. Quality improvement strategies The hospital employed a dedicated computerized information system to systematically record patient data, initial visit data, telephone interview records, clinic visit results, followup visit data, and other necessary information. Information regarding health education, telephone interview, and followup results are communicated to the patient’s physician by the case manager through the online messaging application built into the system. By informing the physician of the patient’s current condition, problems encountered, response to treatment, treatment course, and suggestions for treatment modification, the physician may clarify problematic issues, make optimal treatment planning, and increase drug compliance and treatment adherence, thus helping patients acquire the greatest treatment benefit. Glycemic control is the shared responsibility between the care team and the patients. It is important to not only teach and inform the patients, but also be receptive to their feedback, such as their feelings toward glucose monitoring and insulin injection. As a result, a series of in-service
educational programs was developed for the hospital staff to clarify their concepts of diabetes care and nutrition and to cultivate empathy toward the patients. As a qualified institution for diabetes health promotion and training of medical personnel, Lukang Christian Hospital has provided training courses for its hospital staff. From October 2012 to September 2013, 13 courses for the education of certified diabetes educators were held in the hospital, with topics covering medical nutrition therapy, subcutaneous insulin injection technique, self-monitoring of blood glucose, and management of diabetic complications. The instructors consisted of 3 physicians, 2 nurses, and 3 dietitians. At the end of the course program, 2 trainees were certified as diabetes educators and 3 physicians (1 nephrologist, 1 cardiologist, and 1 neurologist) were qualified to participate in the diabetes share-care network. 3.2.2. Periodontal disease screening According to the consensus report of the Joint European Federation of Periodontology and American Academy of Periodontology Workshop on Periodontitis and Systemic Disease [5], patients with type 1, type 2, and gestational diabetes should, as part of their initial evaluation, receive a thorough oral examination, which includes a comprehensive periodontal examination. Our hospital has incorporated periodontal examination into its diabetes care plan since August 2012. Among the patients enrolled in the diabetes share-care program, 1295 (59%) received periodontal examination from August 2012 to October 2013. Of these, 657 (68.01%) had a Community Periodontal Index of Treatment Needs (CPITN) [6] of 2 and 181 (18.74%) had a CPITN of 4 (deep periodontal pockets 6 mm). Patients were given oral hygiene instruction or suggestions for subsequent dental treatment after examination (Table 2, Fig. 1).
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Table 2 Periodontal examination of diabetes mellitus share-care program History: Had received periodontal treatment: Have oral health examination every 6 months:
Yes Yes
No No
Community Periodontal Index of Treatment Needs: a < 17 … > 14; < 13 … > 23; < 24 … > 27 < 47 … > 44; < 43 … > 33; < 34 … > 37 Suggestions: Periodontal healthy and dental visit every 6 months Oral hygiene instruction and dental visit every 6 months Oral hygiene instruction and calculus removal Oral hygiene instruction and calculus removal and complex treatment Plans: The conditions have been reviewed with the patient, and the subsequent dental treatment has been suggested. Patient agreed Patient wanted to be treated at other facilities The numbers indicate the location of the teeth: < 17 > 14, upper right second molar to upper right first premolar; < 13 > 23, upper right canine to upper left canine; < 24 > 27, upper left first premolar to upper left second molar; < 47 > 44, lower right second molar to lower right first premolar; < 43 > 33, lower right canine to lower left canine; < 34 > 37, lower left first premolar to lower left second molar. CPITN scores are written on the ellipses.
a
Annual examination in DM share care program
i Periodontal examination
i Community Periodontal Index of Treatment Needs (CPITN) > 2 Yes
i
Subsequent dental treatment
i No Oral hygiene instruction
Fig. 1. Flow chart of screening for periodontal disease in diabetes.
3.2.3. Health promotion reduces diabetes risk Among the hospital’s employees, those with the metabolic syndrome were identified and health promotion plans were formulated according to the recommendations of American Diabetes Association’s Standards of Care [7]. For those at high risk of developing type 2 diabetes, structured programs that emphasize lifestyle changes – including moderate weight loss (7% of body weight), regular physical activity (150 minutes per week), and dietary modification (reduced caloric and fat intake) – were recommended. From October 2012 to September 2013, 336 employees (62 men, 274 women) at risk for diabetes were identified. Lifestyle modification counseling was provided for the 37 employees (13 men, 24 women) with hyperglycemia (fasting blood glucose 100 mg/dL). After intervention, 9 men (69.23%) and 17 women (70.8%) achieved a reduction of blood glucose levels. For the 55 employees (22 men, 33 women) with hypertension
(blood pressure 130/80 mmHg), lifestyle counseling included weight reduction, sodium restriction, moderation of alcohol intake, and increased physical activity. After intervention, 14 men (63.64%) and 26 women (78.79%) achieved a reduction in blood pressure. For the 88 employees (20 men, 68 women) with hyperlipidemia (total cholesterol 200 mg/dL), intervention included medical nutrition therapy, increased physical activity, weight reduction, and smoking cessation. After intervention, 18 men (90%) and 44 women (64.71%) achieved a reduction in cholesterol levels. For the 90 employees (13 men, 77 women) with abdominal obesity (waist circumference 90 cm for men, 80 cm for women), lifestyle and dietary counseling was given. After intervention, 11 men (84.62%) and 50 women (64.94%) achieved weight reductions. Ongoing education and support via telephone communication have been given to those who failed to achieve or maintain improvement. 3.2.4. Diabetes patient support group The majority of our diabetic patients were elderly, with an average age of 60–69 years. Patient group activities were conducted periodically to help these patients develop and maintain healthy behaviors, improve life quality, and achieve better glycemic control. From January to September 2013, the hospital has held 25 educational courses, attended by a total of 103 patients. Educational materials such as the STENO tool and MAP were used creatively in workshop settings for small groups to help address patients’ real-life concerns regarding diabetes self-management. The structured curricula of interactive courses were designed from the patient’s standpoint, employing self-care tools developed by our diabetes educators (e.g., insulin rotary disk; Fig. 2) to increase motivation for self-care. Personal approach strategies were developed to
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Fig. 2 – Insulin rotary disc. • Patients adjust their insulin dosage every 3 days according to the suggestion displayed by the insulin rotary disk when the dial is aligned with the average of the fasting glucose values measured in the past 3 days. • The disk also suggests the timing and frequency of self-monitoring of blood glucose. The reverse side of the disk shows symptoms and diabetic complications liable to occur if diabetes is not adequately controlled. © Copyright Changhua Christian hospital; reproduced with permission. help patients identify psychosocial issues, share experiences, and clarify misconceptions about their illness. Educational materials for different language and literacy levels were used to help patients improve self-care ability, overcome reluctance to accept insulin therapy, and understand the importance of glycemic control for the prevention of complications [8]. Patients were also given reinforcement through follow-up telephone interviews, and individualized plans were formulated with focus on insulin injection, blood glucose monitoring, and self-care problem-solving. To maintain effective diabetes self-management over the long term, patients were given reminders for follow-up visits and tests, and ongoing education, medication management, and behavioral goal setting were included as part of our diabetes self-management education. The patient support group had 103 participants. Among them, 98 adhered to the program. After joining the group, participants’ average HbA1c (A1C) levels declined from 10.09% to 7.76%. The number of participants who exercised regularly increased from 14 to 54. At baseline, 97 patients had a body mass index (BMI) > 24, with an average BMI of 28.3 kg/m2 . After joining the group, 37 patients lost weight, with an average decrease in BMI of 0.2%. The number of patients in the group who performed self-monitoring of blood glucose increased from 32 to 70.
4. Discussion In 2011, the Taiwan Association of Diabetes Educators conducted a nationwide diabetes-care quality survey that included 5,599 subjects treated at 120 Diabetes Health Promotion Institutions [9]. The survey found that 34.5% of subjects had an A1C level of < 7%, 68.4% had a blood pressure level lower than 140/90 mmHg, and 55.7% had a total cholesterol level of < 160 mg/dL or low-density lipoprotein cholesterol level of < 100 mg/dL. In comparison, our hospital has exceeded the national results in all of these quality measures. We believe the advantages of a continuously operating diabetes sharecare network, integrated care resources, and implementation
of a referral system in the hospital may be responsible for the high quality of care. In addition to the widely recognized comorbidities of diabetes, such as obesity, hypertension, and dyslipidemia, Lukang Christian Hospital also evaluated and addressed other comorbid conditions that may complicate diabetes management [7]. For example, current evidence suggests that periodontal disease adversely affects diabetes outcomes. We therefore incorporated periodontal examination into the diabetes care plan and offered annual screening for early detection and treatment of periodontal disease. To facilitate periodontal examination and increase patient cooperation, a dental screening station was established in close proximity to the diabetes outpatient clinic. By thus integrating and procuring the assistance of the dental service, which had been an underused resource at our hospital, we have set an example of interdisciplinary referral and coordinated patient services for other departments to follow. According to the 2014 American Diabetes Association’s Standards of Care, all patients should be advised not to smoke or use tobacco products [7]. Routine and thorough assessment of tobacco use is key to preventing smoking or encouraging smoking cessation. Our hospital has been providing smokingcessation outpatient service since 2010. In 2013, 211 smokers (including 37 diabetic patients) were treated at the smokingcessation clinic. Among the diabetic smokers, 43.0% successfully quit smoking after 3 months of treatment. All of our diabetes nurse educators were trained and qualified for smoking-cessation counseling, which has been incorporated into our diabetes care plan. However, the percentage of diabetic patients who received smoking-cessation counseling at least once a year has remained suboptimal; therefore, more effort is required in this area. In agreement with an analysis of perceived facilitators and barriers in diabetes care in the Netherlands [10], there are still barriers in our daily practice that need to be addressed. Multidisciplinary collaboration means that patients may need to visit multiple health-care professionals. The time spent waiting for appointments will not be appealing to the more
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demanding patients. In fact, time constraint may be the biggest obstacle for patients to commit themselves to the diabetes share-care program. A recent study by Changhua Christian Healthcare Diabetes e-Institute investigated the effectiveness of a share-care program assisted by telecare [11]. It demonstrated significant improvement in glycemic control for type 2 diabetes patients living in an underserved community. The addition of telecare may therefore be a viable way to provide more convenient services and increase patient satisfaction. The National Standards for Diabetes Self-Management Education and Support states that the diabetic patient is “the center of the diabetes education and support process”. In other words, the patients are the principal managers of their condition. They do the actual “hard work of managing their condition“, and the diabetes educator’s role, “first and foremost, is to make that work easier …” [8]. At Lukang Christian Hospital, these statements fully coincide with the aim of its diabetes care service.
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3. Tsai CL, Yeh LL, Yaung CL, Sheu WHH. Utilization of patients enrolled in the Shared Care Disease Management Program for Diabetes – an example from a regional teaching hospital. Formos J Endocrin Metab 2009;1:6–15. 4. Lee CP, Chu CI, Wu DA, Fu CC, Li JC, Wang YH, et al. Comparison of the diabetes regular care model and the “Diabetes Share Care Disease Management” model in eastern Taiwan. Tzu Chi Med J 2007;19:66–73. 5. Chapple IL, Genco R; working group 2 of the joint EFP/AAP workshop. Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and System Diseases. J Periodontol 2013;84(4 Suppl.):S106–12. 6. Ainamo J, Barmes D, Beagrie G, Cutress T, Martin J, SardoInfirri J. Development of the World Health Organization (WHO) community periodontal index of treatment needs (CPITN). Int Dent J 1982;32(3):281–91. 7. American Diabetes Association. Standards of medical care in diabetes – 2014. Diabetes Care 2014;37(Suppl 1):S14–80. 8. Haas L, Maryniuk M, Beck J, Cox CE, Duker P, Edwards L, et al. National standards for diabetes self-management
Conflict of interest The authors declare that they have no conflicts of interest.
education and support. Diabetes Care 2014;37(Suppl 1): S144–53. 9. Yu NC, Su HY, Chiou ST, Yeh MC, Yeh SW, Tzeng MS, et al. Trends of ABC control 2006–2011: A National Survey of
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