Diabetes Care in the Malaysia Primary Care Setting

Feisul Idzwan Mustapha, MBBS, MPH, AM(M)Public Health Physician

Disease Control DivisionMinistry of Health, Malaysia

MDES Conference 201426 April 2014

Hotel Summit USJ

Ministry of Health Malaysia

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%

• .

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Burden of Diabetes in Malaysia: Trends & Projections by 2020 (Adults age 18 years and above)

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 20200

5

10

15

20

25

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

Est. population, 2006 Est. population, 2011 Prevalence projection, 2006 Prevalence projection, 2011

Year

Prev

alen

ce (%

)

Estim

ated

pop

ulati

on

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Sources: NHMS I (1986), NHMS II (1996), NHMS III (2006) and NHMS 2011

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

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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

Strengthening Chronic Disease Management at the primary care level

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National Diabetes Registry

• 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.

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Number of Active Registered Patients; as of 28 Feb 2014

State Number of active patientsJohor 117,363Kedah 52,271Kelantan 35,556Melaka 54,725N.Sembilan 67,950Pahang 52,196Perak 90,512Perlis 16,384P.Pinang 45,852Sabah 15,643Sarawak 70,642Selangor 130,148Terengganu 28,292WPKL 42,287WP Labuan 1,534WP Putrajaya 2,983Malaysia 824,338

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Glycaemic Control: Percentage of T2DM Patients with HbA1c <6.5%, 2009 to 2013

2009 2010 2011 2012 2013Johor 14.0 18.3 14.4 17.5 16.3Kedah 8.5 12.8 12.3 15.8 17.0Kelantan 8.7 9.2 12.5 11.3 16.2Melaka 18.4 15.3 16.9 21.7 23.9Negeri Sembilan 13.9 19.6 17.8 19.7 20.0Pahang 13.4 19.9 13.4 15.1 16.4Perak 14.5 16.3 13.9 18.1 21.6Perlis 30.6 24.3 26.1 27.9 25.6Pulau Pinang 12.3 18.5 19.3 16.5 18.7Sabah 22.6 19.6 25.9 28.5 34.5Sarawak 7.8 3.6 6.4 7.0 7.4Selangor 15.8 25.2 15.1 18.4 21.3Terengganu 19.9 20.5 17.9 16.2 17.1WP Kuala Lumpur 12.6 27.9 17.9 24.3 30.0WP Labuan n.a. 30.8 23.1 53.5 41.4WP Putrajaya 15.6 26.2 15.1 29.6 32.4Malaysia 13.3 17.2 15.6 18.1 19.8

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Diabetes Clinical 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 - 8.1BP: Systolic < 130 mmHg 106,842 47.6 135.1 135.0 - 135.2BP: Diastolic < 80 mmHg 106,828 69.2 77.7 77.6 - 77.8

Blood Pressure < 130 / 80 mmHg 106,809 41.2Total cholesterol < 4.5 mmol/l 91,214 29.0 5.2 5.1 - 5.2TG ≤ 1.7 mmol/l 90,593 61.8 1.8 1.8 - 1.8HDL ≥ 1.1 mmol/l 67,354 66.6 1.3 1.3 - 1.3LDL ≤ 2.6 mmol/l 67,090 37.3 3.1 3.1 - 3.1BMI < 23 kg/m2 96,954 16.4 27.4 27.4 - 27.4Waist 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

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Diabetes Clinical Audit (2013)

Complications Present Absent Not knownn % 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 knownn % 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%

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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%

Diabetes Clinical Audit (2009-2013)

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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%

Diabetes Clinical Audit (2009-2013)

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Management of NCDs (including diabetes): 7 basic principles

• Screening• Register• Clinical management• Complications• Rehabilitation• Defaulter tracing• Selfcare – Patient’s

empowerment13

Initiatives to 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

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.

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Implementation in KK Padang Rengas, Kuala Kangsar, Perak

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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 eatDo 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 spongeOld newspaper

Complication of diabetes: Blind as a bat

Practical walking with covered eye (experience as a blind and amputated patients)

WheelchairBlindfold clothCrutches

Practical session 1:I’m a diabetes: is it the end of the world?

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Practical Session 2:Food for thoughts - what will be my food?

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Practical tips from their peers on how they manage their diet in day-to-day living

Practical Session 3:Complication of diabetes: Foot to Care

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Practical Session 4:Complication of diabetes: Blind as a bat

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Patients will experience having certain types of diabetes-related complications

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

Opportunities…

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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…

Thank you

dr.feisul@moh.gov.myFacebook: Feisul Mustapha

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