A Japanese model of disease management for diabetes mellitus from primary to tertiary prevention

1. A Japanese model of disease management for diabetes mellitus from primary to tertiary prevention Naoki Nakashima, M.D., Ph.D. Department of Medical Informatics Kyushu University Hospital APAN-Hawaii 24/January/2008 in Honolulu

2. Cared Not Cared Family doctors Pre-Diabetes 3millions 4 millions 10 millions 130 millions 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 will start“ Particular Health Check-up System (PHCS = Tokutei Kenshin)”from April 2008 • All of 40～74yo Japanese citizen (56 million) will have to take standardized health examination • List of basic examination • Questionnaire (weight change, smoking, exercise) • A physical examination • Height, Weight (BMI), Waist, Blood Pressure • Blood chemistry • TG, HDL-C, LDL-C, GOT, GPT, γ-GTP, Cre, Blood glucose (fasting or postprandial), HbA1c, Uric acid • Moderate and high risk groups are required to receive standard health instruction

4. Yearly Work Flow of Particular Health Check-Up System Arrangement of Health Check-up Planning next year Data analysis Plan Analysis Start ! Affected by Life Style Diseases Aggressive Support Daily Health Instruction and Support Encourage to attend a clinic Health Check-up Dunning of Health Check-up Assessment Dunning of Health Instruction Information Provided Motivation Support Stratification Data Accumulation And Stratification Arrangement of Health Instruction Navigation system of Instruction Health Instruction Intervention

5. Stratification Logic for Particular Health Check-up and Healthcare Instruction system Grouping for Healthcare Instruction 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) Aggressive 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*

6. Decision line to attend a clinic/hospital The Result of Physical and Blood Examination was: １）Blood Glucose a Fasting ≧126mg/dlor b HbA1c ≧6.1 % ２）Lipidemia a TG ≧300mg/dlor b HDL-Chol ＜35mg/dl ３）BP a Systoric ≧140mmHgor b Diastoric ≧90mg/dl ４）LDL-Chol ≧140mg/dl

7. Rate of stratification group by the “Particular Health Check-up and Healthcare Instruction Program” estimated by Ministry of Health, Labor and Welfare information provided motivation support aggressive support total (low risk group) (moderate risk group) (high risk group) Male： ６５．７ １５．５ １８．８ 　１００％ Female： ８４．０ １１．５ 　４．５　 　１００％ Total： ７５．１ １３．４ １１．５ 　１００％

8. What does “Specified Examination for Health and Relations” mean? • Including healthcare instruction and encouragement of medication, in addition to health examination • Insurers’ duty, which is based on the law • Cost is depend on insurers • If insurers neglect their duties, they have to pay bigger shares of the support for medical cost of the latter high ages as a penalty • Target number is about 56 million (45% of the population) in Japan. • It intends to make the results of health examination by standardized electronic data.

9. DTD of HL7 CDA-R2 L3

10. To organize “National DB of Electronic Health Record (EHR)” Circulation of medical and insurance information after 2011 Reimbursement info （medical action info） Medical institutes Insurance medical fee payment fund 2011～ Medical info (medical result info） Reimbursement info （medical action info） 2011～ Reimbursement info （medical action info） Citizens (patients) Insurers (payers) 2008～ Healthcare info （health exam result info）

11. What is “Carna Project” ? The Carna project is a newly developed Japanese disease management for life style disease. It aim the primary and secondary/tertiary prevention of diabetes mellitus/complication through prior interventions by the call-center. Carna’s goal is to establish a high quality medical care system with reasonable cost.

12. 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 ) 2005Ministry of Economy, Trade and Industry 2006Ministry of Economy, Trade and Industry 2003- Kyushu Electronic Power Co. Total fund = 4 million US$ / 5years The Authorization document from Fukuoka Prefecture Medical Association

13. Carna project has highly regarded for; • Quality management -Standard guideline of medical/health care courses -Algorithm of all work flows in the call center -ICT • Appropriate matching of services to individuals -Patient profiling -Matching of member and health instructor • Adaptation to the Japanese political measure and medical system • Efficient and secure data management • Ethical considerations -Privacy policy

14. ①Services with Critical Pathways Coupon Summary of Carna Project 　　　　　＜＜Serviceｓ＞＞ Primary Prevention ①Life style instruction program (Critical pathways for 5 action stage for self-care) ②Data Management and Analysis ③Individual “Target” to Get Carna Points Service Providers Carna Office Restaurants Points Critical Pathway Tourism Co. + Secondary, Tertiary Prevention ④Provide Care Plan, Outcome Management 　（Relational Critical Pathway for Diabetes） ⑤Question to Find Complications Earlier ⑥Question to Check knowledge・Education ⑦Push to go to Clinic・Avoid to Drop Out ⑧Quick Report of HbA1c to Patient Mail Gymnasium Phone Private Insurance Co. Outbound Call Center Edutainment Service Service Clinics Patients Individuals Family Drs. （Company Drs.） Strengthen Relationship Public Health Insurance Company Team Care DM Dentist Ophthalmologist Kidney Local Government Specialists

15. PRIMARY PREVENTION Life Style Instruction Programwith Critical Pathways for 5 stages We have developed 5 kinds of critical pathway (CP) for 5 stages. We decided the specific outcomes in each CP (outcome oriented CP). ＊The CP for upper stage can be applied by achievement of outcomes (goal) in each CP. We continue same intervention until we get outcomes in each CP Precontemplation Requirement for apply Condition of escape Outcomes for goal Contemplation Requirement for apply Condition of escape Outcomes for goal Preparation Requirement for apply Condition of escape Outcomes for goal Action Requirement for apply Condition of escape Outcomes for goal Maintain Requirement for apply Condition of escape Outcomes for goal

16. Coupon Summary of Carna Project 　　　　　＜＜Serviceｓ＞＞ Primary Prevention ①Life style instruction program (Critical pathways for 5 action stage for self-care) ②Data Management and Analysis ③Individual “Target” to Get Carna Points Service Providers Carna Office Restaurants Points Critical Pathway Tourism Co. + Secondary, Tertiary Prevention ④Provide Care Plan, Outcome Management 　（Relational Critical Pathway for Diabetes） ⑤Question to Find Complications Earlier ⑥Question to Check knowledge・Education ⑦Push to go to Clinic・Avoid to Drop Out ⑧Quick Report of HbA1c to Patient Mail Gymnasium ③Provide the Carna Points Phone Private Insurance Co. Outbound Call Center Edutainment Service Service Clinics Patients Individuals Family Drs. （Company Drs.） Strengthen Relationship Public Health Insurance Company Team Care DM Dentist Ophthalmologist Kidney Local Government Specialists

17. JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Constant answer to e-mail 100 point 100 point 100 point 100 point 100 point 100 point 100 point 100 point 100 point 100 point Achievement to the target line 100 point 100 point 100 point 100 point 100 point 100 point 100 point Improvement of Body weight 100 point 100 point 100 point 100 point 100 point We Provide and Manage the Carna Points （patient）Nothing happen by my efforts on diet and exercise・・・ You got 2200 points！！ As like as “mileage system” in flight companies, patient can exchange the accumulated points with coupons of various healthy service or item. Point system

18. Coupon SECONDARY/TERTIARY PREVENTION Summary of CARNA Project 　　　　　＜＜Serviceｓ＞＞ Primary Prevention ①Life style instruction program (Critical pathways for 5 action stage for self-care) ②Data Management and Analysis ③Individual “Target” to Get Carna Points Service Providers CARNA office Restaurants Points ④Provide Care Plan, Outcome Management 　　（Relational Critical Pathway） Relational Critical Pathway Tourism Co. + Secondary, Tertiary Prevention ④Provide Care Plan, Outcome Management 　（Relational Critical Pathway for Diabetes） ⑤Question to Find Complications Earlier ⑥Question to Check knowledge・Education ⑦Push to go to Clinic・Avoid to Drop Out ⑧Quick Report of HbA1c to Patient Mail Gymnasium Phone Private Insurance Co. Out Bound Call Center Edutainment Service Service Clinics Patients Individuals Primary Dr. （Company Dr.） Strengthen Relationship Public Health Insurance Company Team Care DM Dentist Ophthalmologist Kidney Local Government Specialists

19. Coupon SECONDARY/TERTIARY PREVENTION Summary of CARNA Project 　　　　　＜＜Serviceｓ＞＞ Primary Prevention ①Life style instruction program (Critical pathways for 5 action stage for self-care) ②Data Management and Analysis ③Individual “Target” to Get Carna Points Service Providers CARNA office Restaurants Points Relational Critical Pathway ⑤⑥⑦Call Center Service (Phone Call Question to Find Complications Earlier) Tourism Co. + Secondary, Tertiary Prevention ④Provide Care Plan, Outcome Management 　（Relational Critical Pathway for Diabetes） ⑤Question to Find Complications Earlier ⑥Question to Check knowledge・Education ⑦Push to go to Clinic・Avoid to Drop Out ⑧Quick Report of HbA1c to Patient Mail Gymnasium Phone Private Insurance Co. Out Bound Call Center Edutainment Service Service Clinics Patients Individuals Primary Dr. （Company Dr.） Strengthen Relationship Public Health Insurance Company Team Care DM Dentist Ophthalmologist Kidney Local Government Specialists

20. Coupon SECONDARY/TERTIARY PREVENTION Summary of CARNA Project 　　　　　＜＜Serviceｓ＞＞ Primary Prevention ①Life style instruction program (Critical pathways for 5 action stage for self-care) ②Data Management and Analysis ③Individual “Target” to Get Carna Points Service Providers CARNA office Restaurants Points Relational Critical Pathway Tourism Co. + Secondary, Tertiary Prevention ④Provide Care Plan, Outcome Management 　（Relational Critical Pathway for Diabetes） ⑤Question to Find Complications Earlier ⑥Question to Check knowledge・Education ⑦Push to go to Clinic・Avoid to Drop Out ⑧Quick Report of HbA1c to Patient Mail ⑧Quick Report of HbA1c to Patent Gymnasium Phone Private Insurance Co. Out Bound Call Center Edutainment Service Service Clinics Patients Individuals Primary Dr. （Company Dr.） Strengthen Relationship Public Health Insurance Company Team Care DM Dentist Ophthalmologist Kidney Local Government Specialists

21. Carna’s two programs of disease management Primary prevention program Secondary/tertiary prevention program for diabetes mellitus Diagnosis of Diabetes Mellitus medication prevention health promotion association Family doctors Specialists doctors Secondary/tertiary prevention without cooperation of family doctors (DM light service) Health promotion for healthy people Intervention by an initial health instruction and repeated instructions Secondary/tertiary prevention with cooperation of family doctors (DM regular service) Service for clinics (outsourcing of lifestyle management fee in medical payment) Service for insurers (outsourcing of Tokutei Kenshin)

22. Schedule of Carna’s Diabetes Project Final formation of the diabteic project Verified test from 2006 Verified test from 2005 Primary prevention （Capitalized from 2008） Secondary/tertiary prevention （Capitalized from 2010） We will start capitalization from primary prevention at first and extend the target to secondary/tertiary prevention later. Information provided Classic Diabetes program ・Management of Critical path ・Support of hospitalization ・Support to find early complication ・Data Management of diabetes indicator ・Support of education ・Intensive program for DM ・Consultation program Motivation support Aggressive support Encouragement of hospitalization Business target; clinics Business target; insurers

23. Primary prevention Post ope of cancer Depression IHD Heart Failure COPD Asthma Disease kinds Future Directions in 2008 Data management = 100,000 people Health instruction = 2,000 people Regional development Tokyo Kumamoto Pref. Secondary/ Tertiary Prevention of Diabetes Mellitus In Fukuoka Prefecture Carna in 2008

24. Effect of Face to Face Healthcare Instruction on the Healthcare Instruction Group (Motivation Support + Aggressive support) by an e-mail questionnaire (%) Group of Healthcare instruction Group of non-healthcare instruction 100 80 60 40 20 0 102 Stress Smoking Soft drink Eating out Night eating Quick eating Skip breakfast Sleeping well Daily exercise Persisting present lifestyle Smoking number Walking for 1 hour Eating before sleep Daily alcohol taking Want to improve present lifestyle Feel better by sleeping Exercise twice/a week Eating more than same generation Faster walking than same generation Improved at least one item Method to release stress

25. Conclusion The bill to reorganize the public medical insurance, which will be enforced in 2008, and the project of 100% online reimbursement, which will be achieved in 2011, will change the circumstances of circulation and accumulation of medical, healthcare and insurance 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, +81-92-642-6459 Or carna@med.kyushu-u.ac.jp