Overview of chronic disease management in primary care in Malaysia with latest preliminary data from the National Diabetes Registry

1. Diabetes Care in the Malaysia
Primary Care Setting
Feisul Idzwan Mustapha, MBBS, MPH, AM(M)
Public Health Physician
Disease Control Division
Ministry of Health, Malaysia
MDES Conference 2014
26 April 2014
Hotel Summit USJ
Ministry of Health
Malaysia

2. 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%
2

3. BurdenofDiabetesinMalaysia:Trends&Projections
by2020(Adultsage18yearsandabove)
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
0
5
10
15
20
25
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Estimatedpopulation
Prevalence(%)
Year
Est. population, 2006 Est. population, 2011 Prevalence projection, 2006 Prevalence projection, 2011
3
Sources: NHMS I (1986), NHMS II (1996), NHMS III (2006) and NHMS 2011

4. 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
4

5. 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
StrengtheningChronic Disease
Management at the primary care level
5

6. NationalDiabetesRegistry
• 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.
6

7. Number of Active Registered
Patients; as of 28 Feb 2014
State Number of active patients
Johor 117,363
Kedah 52,271
Kelantan 35,556
Melaka 54,725
N.Sembilan 67,950
Pahang 52,196
Perak 90,512
Perlis 16,384
P.Pinang 45,852
Sabah 15,643
Sarawak 70,642
Selangor 130,148
Terengganu 28,292
WPKL 42,287
WP Labuan 1,534
WP Putrajaya 2,983
Malaysia 824,338
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8. GlycaemicControl:PercentageofT2DM Patientswith
HbA1c<6.5%,2009to 2013
2009 2010 2011 2012 2013
Johor 14.0 18.3 14.4 17.5 16.3
Kedah 8.5 12.8 12.3 15.8 17.0
Kelantan 8.7 9.2 12.5 11.3 16.2
Melaka 18.4 15.3 16.9 21.7 23.9
Negeri Sembilan 13.9 19.6 17.8 19.7 20.0
Pahang 13.4 19.9 13.4 15.1 16.4
Perak 14.5 16.3 13.9 18.1 21.6
Perlis 30.6 24.3 26.1 27.9 25.6
Pulau Pinang 12.3 18.5 19.3 16.5 18.7
Sabah 22.6 19.6 25.9 28.5 34.5
Sarawak 7.8 3.6 6.4 7.0 7.4
Selangor 15.8 25.2 15.1 18.4 21.3
Terengganu 19.9 20.5 17.9 16.2 17.1
WP Kuala Lumpur 12.6 27.9 17.9 24.3 30.0
WP Labuan n.a. 30.8 23.1 53.5 41.4
WP Putrajaya 15.6 26.2 15.1 29.6 32.4
Malaysia 13.3 17.2 15.6 18.1 19.8
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9. DiabetesClinical 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 - 8.1
BP: Systolic < 130 mmHg 106,842 47.6 135.1 135.0 - 135.2
BP: Diastolic < 80 mmHg 106,828 69.2 77.7 77.6 - 77.8
Blood Pressure < 130 / 80 mmHg 106,809 41.2
Total cholesterol < 4.5 mmol/l 91,214 29.0 5.2 5.1 - 5.2
TG ≤ 1.7 mmol/l 90,593 61.8 1.8 1.8 - 1.8
HDL ≥ 1.1 mmol/l 67,354 66.6 1.3 1.3 - 1.3
LDL ≤ 2.6 mmol/l 67,090 37.3 3.1 3.1 - 3.1
BMI < 23 kg/m2 96,954 16.4 27.4 27.4 - 27.4
Waist
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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10. DiabetesClinical Audit (2013)
Complications
Present Absent Not known
n % 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 known
n % 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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11. 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%
DiabetesClinical Audit (2009-2013)
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12. 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%
DiabetesClinical Audit (2009-2013)
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13. Management of NCDs (including
diabetes): 7 basic principles
• Screening
• Register
• Clinical management
• Complications
• Rehabilitation
• Defaulter tracing
• Selfcare – Patient’s
empowerment
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14. Initiativesto 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.
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15. 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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16. 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 eat
Do 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 sponge
Old newspaper
Complication of diabetes: Blind
as a bat
Practical walking with covered eye
(experience as a blind and amputated
patients)
Wheelchair
Blindfold cloth
Crutches

17. Practical session 1:
I’m a diabetes: is it the end of the world?
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18. Practical Session 2:
Food for thoughts - what will be my food?
18
Practical tips
from their
peers on how
they manage
their diet in
day-to-day
living

19. Practical Session 3:
Complication of diabetes: Foot to Care
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20. Practical Session 4:
Complication of diabetes: Blind as a bat
20
Patients will
experience
having certain
types of
diabetes-
related
complications

21. 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.
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22. 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…

23. Thank you
dr.feisul@moh.gov.my
Facebook: Feisul Mustapha
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