6/Aug/2008 in Queen’s town

1. Outcomes of Japanese Disease Management for Metabolic Syndrome Medical WG in APAN Queen’s town Naoki Nakashima, M.D., Ph.D. Department of Medical Informatics Kyushu University Hospital 6/Aug/2008 in Queen’s town

2. Cared Not Cared Family doctors Pre-Diabetes 3million 4 million 10 million 130 million citizen in Japan 1million Specialist Doctors Diabetes Mellitus Increase of Medical Cost Acute and Chronic Diabetic Complications Dropout Background of the project Problems Patients QOL Medical cost １．Continuously increasing patients and complications ２．Low hospitalization rate of patients (51%) ３．Shortage of specialist Drs. (=3,300）for diabetes

3. Japanese Government started“ Particular Health Check-up System (PHCS = Tokutei Kenshin)”from April 2008 • All of 40～74yo Japanese citizen (56 million) will have to take standard health examination • List of basic examination • Questionnaire (weight change, smoking, exercise) • A physical examination • Height, Weight (BMI), Waist, Blood Pressure • Blood/Urine chemistry • TG, HDL-C, LDL-C, GOT, GPT, γ-GTP, Fasting Blood glucose HbA1c, Hemoglobin, glucosuria • Moderate and high risk groups are required to receive standard healthcare counseling

4. Flow from health check-up to healthcare counseling Moderate risk group High risk group Low risk group 75.1％ 13.4％ 11.5％ Information provide Intervention 1 Face to face counseling (once) Intervention 2 Follow up (e-mail, phone)

5. Yearly Work Flow of PHCS as a Disease Management Arrangement of Health Check-up Planning next year Data analysis Plan Analysis Start ! For patients of Life Style Diseases strong Support for high risk group Daily Health counseling and Support Encourage to attend a clinic Annual Health Check-up Dunning of Health Check-up Intervention 2 Assessment Dunning of Health counseling Information Provided for all Motivation Support for moderate and high risk groups Stratification Data Accumulation And Stratification Arrangement of Health counseling Navigation system of counseling Health counseling Intervention 1

6. Stratification Logic in PHCS Grouping for Healthcare counseling Waist and Obesity *Risk Factors ①Blood Glucose： Fasting ≧ 100 mg/dl HbA1c ≧ 5.2 % Under medication ②Lipidemia： Triglyceride ≧ 150 mg/dl HDL-cholesterol<40 mg/dl Under madication ③BP： Systoric ≧ 130 mmHg Diastoric ≧ 85 mmHg Under medication ④Smoking history：　 + *④ is counted if there is one point at least in ①～③. ≧2 Big Waist 　　　　　　　　　　　（M≧85cm, F≧90cm) Strong Support Group 1 0 ≧3 65-74y.o. Normal Waist Obese 　　　　　　　（M<85cm, F<90cm) 　　　　　　　　 （BMI≧25） 1, 2 Motivation Support Group 0 Normal Waist Normal Weight 　　　　　（M<85cm, F<90cm) 　　　　　　　 　　 （BMI<25） Information provided Group Number of Risk Factors*

7. Expected Privacy Problem of PHCS ・Insurers will have economical penalties from 5year later, if they can not achieve outcomes the government sets. ・Insurer has close relationship to each company in Japan. ・Companies may start discrimination of obese employees with PHCS data (employment, salary, career, duty, etc). ・We should make a strict law which prohibits illegal use of privacy data by insurers ASAP.

8. Carna Consortium Members Diabetes Specialist Doctors Saiseikai Kumamoto Hospital Kyushu Electronic Power Co. and group（QIC，　QBS） Tokio Marine & Nichido Fire Insurance Co. Kyushu University Assented by Fukuoka Prefecture Medical Association Fukuoka City Medical Association Funded by • 2003-2005 Japan Science and Technology Agency • (Ministry of Education, Culture, Sports, Science and Technology ) • Ministry of Economy, Trade and Industry • Ministry of Economy, Trade and Industry • Ministry of Economy, Trade and Industry • 2008 Japan Science and Technology Agency • Ministry of Health, Labour and Welfare • 2008 Ministry of Education, Culture, Sports, Science and Technology The Authorization document from Fukuoka Prefecture Medical Association

9. IT system developed by Carna for PHCS Navi system for group meeting Navi system for follow up counseling Booking system Navi system for indigivual meeting Management System for follow up counseling Evaluation and reporting system Data management system develped Under developed

10. ICT system (1) for data management system for health check-up and healthcare counseling Appropriate information according to each result of health check-up Data upload by HL7, Csv or input by hand Automatic stratification Down loadable Down loadable HL7 CDA data Secure Internet browsing

11. ICT system (2) for navigation of health counseling • Quality management of counseling • Automatic providing of information • Management of Personalized plan • Education tool of instructor • Using many animation for education • *All data are accumulated as HL7CDA

12. Verification study of PHCS in 2007 by the Carna (results of stratification)

13. Effects of Intervention on Loss of Weightin verification study in 2007

14. Effects of Intervention on Loss of Waistin verification study in 2007

15. Effects of Intervention on blood examinationin verification study in 2007 （indicator of diabetes mellitus） Blood sugar n Change by intervention p value (mg/dl) All 175 +0.24 ± 1.0 0.812 Lowrisk 94 - 1.3 ± 0.65 0.054 Moderate risk16 - 0.5 ± 2.22 0.825 High risk46 - 1.2 ± 1.31 0.350 Having medication19 +12.0 ± 7.53 0.130 ＨｂＡ１ｃ (%) n Change by intervention p value (％) All144 -0.03 ± 0.28 0.231 Low risk74 -0.03 ± 0.35 0.437 Moderate risk15 +0.04 ± 0.10 0.679 High risk38 -0.14 ± 0.05 0.004 Having medication17 +0.11 ± 0.13 0.419

16. Effects of Intervention on blood examinationin verification study in 2007 （indicator of dyslipidemia） Triglyceride n Change by intervention (mg/dl) p value All144 -15.2 ± 7.16 0.036 Low risk74 -3.91 ± 6.16 0.528 Moderate risk15-24.4 ± 23.2 0.311 High risk38-32.8 ± 20.8 0.124 Having medication17 -16.5 ± 19.7 0.413 ＨＤＬcholesterol n Change by intervention (mg/dl) p value All175 +2.71 ± 0.72 <0.001 Low risk94 +3.70 ± 0.82 <0.001 Moderate risk 16 +4.25 ± 1.95 0.046 High risk46 +0.90 ± 1.73 0.606 Having medication19 +0.90 ± 2.70 0.744 ＬＤＬcholesterol n Change by intervention (mg/dl) p value All 155 +2.27 ± 1.80 0.209 Low risk 83 +0.90 ± 1.96 0.648 Moderate risk 15 +5.75 ± 6.84 0.415 High risk 40 +2.15 ± 4.39 0.627 Having medication 17 +6.13 ± 6.16 0.335

17. Effects of Intervention on blood examinationin verification study in 2007 （indicator of liver function） ＧＯＴ n Change by intervention (IU) p value All 144 -1.41 ± 1.04 0.176 Low risk 74 +0.07 ± 0.65 0.918 Moderate risk 15 -0.93 ± 0.86 0.296 High risk 38 -3.95 ± 3.61 0.281 Having medication 17 -2.59 ± 1.85 0.181 ＧＰＴ n Change by intervention (IU) p value All 144 -3.12 ± 1.17 0.009 Low risk 74 +0.41 ± 0.95 0.672 Moderate risk 15 -1.20 ± 2.35 0.617 High risk 38 -9.90 ± 3.22 0.004 Having medication 17 -5.50 ± 4.21 0.253 ｒＧＴＰ n Change by intervention (IU) p value All175 -13.0 ± 4.32 0.003 Low risk 94 - 1.9 ± 1.38 0.160 Moderate risk 16 - 1.0 ± 4.81 0.838 High risk 46 -25.6 ± 11.6 0.032 Having medication 19 +47.7 ± 25.6 0.079

18. Conclusion In Japan, the new health check-up system followed by healthcare counseling, which has been enforced in April 2008, and the online reimbursement of medical fee, which will be achieved in 2011, will change the circulation and accumulation of health and medical information. We need to establish secure and patient-centeredsocial system for the alterations. As a model of the social system, we presented a newly developed Japanese disease management for diabetes mellitus “Carna”. If you have any questions, call to Carna office, +81-92-263-4385 Or carna@med.kyushu-u.ac.jp

19. Please send all presentation files to nnaoki@med.kyushu-u.ac.jp If you have any questions, call to Carna office, +81-92-263-4385 Or carna@med.kyushu-u.ac.jp