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The Multi-disciplinary Diabetes Centre : A Model of Care for the Future (or the Past) ?

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) ?

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  1. 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

  2. Conference in China

  3. The Burden and Complexity of Diabetes

  4. Different Models of Diabetes Care ANDIAB Survey : Cheung NW et al : Diabet Med 2008 ; 25(8) : 974-8

  5. We Must Have A Centre !

  6. A Multi-disciplinary Diabetes Centre Family Doctor Podiatrist Dietitian Person with Diabetes Researcher Specialist Secretaries Diabetes Nurse / Educator

  7. What We Need Is Not A Diabetes Education Centre

  8. Referring Doctor 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

  9. One Stop Complications Assessment McGill M et al : Diabet Med 1993 ; 10(4) : 366-70 McGill M et al :Diabetes Care : 1989 ; 12(8) : 599-600

  10. Standardised Data Capture

  11. Younger Onset of Type 2 Diabetes Increases Risk of Retinopathy Wong J et al : Diabetes Care 2008; 10 : 1985-90

  12. Beyond ONTARGET :(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

  13. Ambulatory Stabilisation of Diabetes : Commencing Insulin Therapy Hoskins PL et al : Med J Aust 1993 ; 158(3) : 148-9

  14. Telephone Stabilisation Genev NM et al Diabet Med 1990 ; (1) : 920-1

  15. Changing Pattern of Treatment of Type 1 Diabetes :More Use of Carbohydrate Counting and Insulin Pump

  16. Continuity of Care in a Multi-disciplinary Setting Patient 1 Patient 2 Visit 1 Visit 2 Visit 3 Visit 4

  17. Standardised Format of Letters(Documentation and Education)

  18. Infrastructure Support

  19. Monitoring By A Senior Nurse After Visits • Daily team clinical meeting • All patients’ medical record reviewed ; possible mistakes identified and appropriately questioned • Standardises party line message and upskill staff • Collects data

  20. The High Risk Diabetic Foot ClinicA 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

  21. 2 =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

  22. E-mail How Does Telemedicine Work? High Risk Foot Clinics • Medical Data McGill M & Constantino M et al : Practical Diabetes 2000 ; 17(7) : 235-238.

  23. Clinical Trials

  24. 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

  25. The Power of Computer

  26. The Under Water Volcano Theory of GDM 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

  27. 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

  28. Metabolic Syndrome in Type 1 Diabetes McGill M et al : J Diabetes Complications 2008 ; 22(1) : 18-23

  29. 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

  30. A Transplant of Diabetes Centre to Rural Area

  31. Overseas Collaborations 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

  32. Training and Exchange ProgramsNational and International

  33. Clinical Research and Basic Science Research

  34. Biomedical Research on Diabetic Complications 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

  35. Skin Biopsy to Assess Small Fibre Diabetic Neuropathy Sorensen L et al : Diabetes Care 2006 ; 22(3) : 261-5

  36. D. 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

  37. 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

  38. MMP-9 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

  39. The Relationship of Monocyte Surface Markers with Diabetes and Retinopathy Min D et al : American Diabetes Association Meeting 2010

  40. Research in a Multi-disciplinary Setting :Less linear than thematic

  41. The Interactive Multi-disciplinaryTeam Doctor Doctor Nurse Dietitian Dietitian Nurse

  42. What is an Interactive Team ?

  43. Weekly Training Sessions

  44. The Nurses and Other Allied Health Professionals • 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

  45. Professional Development and Achievements • 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 !!!

  46. The Doctors • Take responsibility • Contribute to leadership and vision • Training of staff • Do the things that allied health professionals cannot do, according to a sliding scale

  47. The Diabetes Centre Model of CareRoyal Prince Alfred Hospital

  48. The Italian Way If you never never go, you will never never know Rome was burnt in one day in AD 64

  49. A Model in Danger of Evolutionary Extinction

  50. Number Of Patient Services Per Year

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