MULTIDISCIPLINARY CARE & FAMILY SUPPORT

FOR DIABETIC PATIENTS

Pradana Soewondo
Division of Metabolism & Endocrinology
Department of Internal Medicine
Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo Hospital
 EVIDENCE-BASED CASE REPORT:
MULTIDISCIPLINE CARE FOR DIABETIC PATIENTS

Benedicta M Suwita*, Deriyan Sukmawidjaja*, Evan Regar*, Liana

Srisawitri*, Wynne O Lionika*,Yashinta*, Dewi Friska**
*Faculty of Medicine, Universitas Indonesia
** Family Medicine Division, Community Medicine Department,
Faculty of Medicine, Universitas Indonesia
OUTLINE
CASE ILLUSTRATION
INTRODUCTION
EBCR
CLINICAL QUESTION
LITERATURE SEARCH
CRITICAL APPRAISAL
DISCUSSION
TAKE HOME MESSAGES
 HISTORY OF ILLNESS
CASE
Polyuria (+)
Mrs.Z, 68 yo
polydipsy (+)

Diagnosed type 2 DM
Tingling sensation (-)
Polyuria (+) Chest pain (-)
polydipsy (+) Dyspnea (-)
Polyphagy (-) Slurred speech (-)
Decrease of BW (-) Blurred vision Delayed wound healing
(+) (-)

BW loss: 10 kg

5 years ago 1 year ago Present

2009 2013 2014
Metformin + Glimepiride Uncontrolled Insulin 10 U 28 U
Blood glucose
Primary care Internist
CASE
Family’s pedigree
CASE
Mrs.Z routinely visited both doctors (GP & internist);
both never talked to each other

Diet recommendation: no sweets & less rice

Physical activities recommendation: forgotten

Perception about illness: not too worried because

there’s no ominous symptoms; pretty much satisfied
with recent FBG result though uncontrolled

She was a caregiver of her husband (T2DM); no one ever

accompanied her to hospital
CASE
Physical
Lab Result
Examination

BP 130/80 mmHg Fasting BG

BMI 29,3 kg/m2 (obese) Oct 2013 580 mg/dl
Waist/ hip circumference 89/ 97 cm Jan 2014 350 mg/dl
Apr 2014 240 mg/dl

Eye: shadow test (+/+)

Paresthesia on hands and feet HbA1c 7.5
(glove and stocks pattern)

Apr 2014
Other PE normal Chol 210 mg/dl / HDL 40 mg/dl
LDL 160 mg/dl
PROBLEMS
She hoped that her blood sugar level may be
Medical Conditions controlled.

• Metabolic syndrome
She was slightly bored taking her medication every
• DM type II, uncontrolled day, but was still motivated to consume it daily.
• Diabetic neuropathy
• Diabetic cataract
She believed that the only way to achieve
• Susp. Diabetic retinopathy. target was by taking medication.

Both doctors never discussed about her

problems.

None of her family member ever accompanied

her for medical visit.
INTRODUCTION
Increasing number; multiple ilnesses

CHRONIC Highest medical costs

DISEASE 27% adults with chronic disease 65% total medical
costs

Conventional care: often focus on one main disease

NEW
INTERVENTION?
THE COMPREHENSIVE INDIVIDUALIZED STRATEGY

DSME : Diet, exercise,

lifestyle,
change

Inzucchi et al. Diabetes Care

2012;35:1364–79
 CLINICAL GUIDELINES EMPHASISE THE IMPORTANCE OF THE
INDIVIDUALISATION OF THERAPEUTIC OPTIONS FOR T2DM

Focus on the needs, values,

and preferences of the
Individualise
patient, making all treatment
blood glucose goals.1
decisions, where possible, with
them.1,2

Assess the response to Use combination therapy

metformin monotherapy at with complementary
3 to 6 months, and intensify by mechanisms of action,
adding a second oral agent if the including drugs which
patient has not reached their target the underlying
goal.1 pathophysiology of T2DM.3

1. Adopted from Inzucchi SE, et al. Diabetes Care 2012;35:1364–79; 2. Adopted from Strain D, et al. Diabetes Res Clin Pract 2014;
http://dx.doi.org/10.1016/j.diabres.2014.05.005(Article in Press); 3. Adopted from Garber AJ, et al. Endocr Pract 2013; 19(2):327–36
 MULTIDISCIPLINARY APPROACH
Medical benefit
Physician Patient’s
compliance

MULTIDISCIPLINARY
CARE Non-medical benefit
Other
Nurse health
worker Cost-effective
(dietician)

So WY, Chan JCN. The Role of the Multidisciplinary Team. In: Holt R, Cockram C, Flyvbjerg A, Goldstein B, editors. Textbook of
Diabetes. 4th ed. West Sussex: Blackwell Publishing Ltd; 2010.
Shortus TD et al. Multidisciplinary care plans for diabetes: how are they used? Med J Aust 2007; 187 (2):
78-81.
 STRATEGIES FOR IMPROVING DM CARE
A patient-centered communication style that incorporates patient prefer- ences,
assesses literacy and numeracy, and addresses cultural barriers to care should be
used. B

Treatment decisions should be timely and founded on evidence-based guide-

lines that are tailored to individual patient preferences, prognoses, and
comorbidities. B

Care should be aligned with components of the Chronic Care Model

(CCM) to ensure productive interactions between a prepared proactive
practice team and an informed activated patient. A

When feasible, care systems should support team-based care, community

involvement, patient registries, and decision support tools to meet patient needs. B

Diabetes Care 2015;38(Suppl. 1):S5–S7 | DOI: 10.2337/dc15-S004

 CHRONIC CARE MODEL
1 2 3
delivery system self-management
decision support
design support

4 5 6
clinical community
information resources and health systems
systems policies

“Collaborative, multidisciplinary teams are best suited to

provide care for people with chronic conditions such as
diabetes and to facilitate patients’ self-management.”

Diabetes Care 2015;38(Suppl. 1):S5–S7 | DOI: 10.2337/dc15-S004

 CHRONIC CARE MODEL (CCM)

Delivery system design

1 From reactive to a PROACTIVE 2
care delivery system Self-management
Planned support
Team-based approach

3 Decision support
Based on EBM
Effective care guidelines

Diabetes Care 2015;38(Suppl. 1):S5–S7 | DOI: 10.2337/dc15-S004

 CHRONIC CARE MODEL (CCM)

Clinical information
4 systems 5 Community resources
and policies
Registries which provide
patient-specific & population- Developing resources to
based support to the care team support healthy lifestyles

6 Health systems
Developing a quality-oriented
culture

Diabetes Care 2015;38(Suppl. 1):S5–S7 | DOI: 10.2337/dc15-S004

 KEY OBJECTIVES
Optimize provider & Support patient behavior
team behavior change
• Identify barriers to care • Systematic approach to:
(language, culture, • Healthy lifestyle changes
understanding) • Disease self-
• Use of evidence-based management
guidelines (medication, self BG
• Integrate management monitoring)
teams (nurses, • Prevention of diabetes
pharmacists, and other complications (active
providers) participation in
screening)
Diabetes self
A1c, BP, LDL management education
(DSME) improve
blood glucose control
Diabetes Care 2015;38(Suppl. 1):S5–S7 | DOI: 10.2337/dc15-S004
Change the care system
• Expand the role of
teams
• Implement more
intensive disease
management strategies
• Engage community
resources and public
policy that support
healthy lifestyles
• Remove financial
barriers
JKN?
CLINICAL QUESTION
P: Adult diabetic patients
I: Multidisciplinary care
C: Conventional care
O: Uncontrolled DM (HbA1c >7%)

In adult diabetic patients, can multidisciplinary care decrease the

number of uncontrolled diabetic patients compared to conventional
care?
LITERATURE SEARCH
Method
 ARTICLES
Katon W, Russo J, Lin EH, Schmittdiel J, Ciechanowski P, Ludman E, et al. Cost
1 effectiveness of a multicondition collaborative care intervention: a randomized controlled
trial. Arch Gen Psychiatry. 2012 May;69(5):506-14.

2 Pape GA, Hunt JS, Butler KL, Siemienczuk J, LeBlanc BH, Gillanders W, et al. Team-
based care approach to cholesterol management in diabetes mellitus: twoyear
cluster randomized controlled trial. Arch Intern Med. 2011; 12;171(16):1480-6.

Ko GT, Yeung CY, Leung WY, Chan KW, Chung CH, Fung LM, et al. Cost implication
3 of team-based structured versus usual care for type 2 diabetic patients with chronic
renal disease. Hong Kong Med J. 2011;17 (Suppl 6):9- 12.

4 Huang Y, Wei X, Wu T, Chen R, Guo A. Collaborative care for patients with depression
and diabetes mellitus: a systematic review and meta-analysis. BMC Psychiatry. 2013 Oct
14;13:260.
 EVIDENCE-BASED CASE REPORT: MULTIDISCIPLINE CARE FOR DIABETIC PATIENT RCT
Katon et al Pape et al Ko et al

Validity No double blind No double blind No double blind

No intention to treat Unknown baseline
analysis characteristics

Multidisciplinary Counselling Counselling Counselling &

care method (face-to-face & by (by phone) follow-up by trained
phone) nurses
HbA1c after 12 Intervention: 0.81 Intervention: 53.13% Intervention: 7.3±1.3%
mo achieved target Control: 8.0±1.6%
Control: 0.23 Control: 57.64% achieved (p <0.01)
target
Factors affecting results:
-Short trial duration
-Different patient’s characteristics

Suwita BM, Sukmawidjaja D, Regar E, Srisawitri L, Lionika WO,Yashinta, et al. Evidence-based case report: multidiscipline care
for diabetic patients. Presented at WONCA. 2014.
 CRITICAL APPRAISAL
Systematic Review
Katon et al

Validity Inconsistency shown from different

studies

Importance HbA1c mean difference (collaborative

group)
-0.13 (95% CI = -0.46 - 0.19; p = 0.08)

Factors affecting results:

-Different methods of multidisciplinary care used in each
study
-Different trial duration

Suwita BM, Sukmawidjaja D, Regar E, Srisawitri L, Lionika WO,Yashinta, et al. Evidence-based case report: multidiscipline care
for diabetic patients. Presented at WONCA. 2014.
DISCUSSION
Multidisciplinary care tends to be beneficial for diabetic patients
Applicable to our patients
Varies greatly depends on healthcare availability; which one is the most
effective and efficient way?
Obstacles: external factors? Family?
None of above studies encompassed patients’ family’s role

Next question:
Does family play any role in helping multidisciplinary care for diabetic
(chronic illness) patients?
 FAMILY SUPPORT
More than half of diabetic patients involved family members in daily disease management
tasks (taking medications, monitoring blood glucose). (Rosland et al, 2006)

Half of chronically-ill patients accompanied by family members into the exam room key
support for patient-provider communication. (Rosland et al, 2011)

Chronically-ill patients who got better family support had better self- management
regimen adherence, better control of their chronic conditions, lower hospitalization rates,
and greater satisfaction with their medical care.
(DiMatteo, 2004; Gallant, 2003; Lett et al, 2005; Zhang et al, 2007; Strom et al, 2011)

Rosland AM, Heisler M, Janevic MR, Connell CM, Langa KM, Kerr EA, et al. Current and Potential Support for Chronic Disease Management in
the United States: The Perspective of Family and Friends of Chronically Ill Adults. Fam Syst Health. 2013; 31(2):119-31.
 FAMILY SUPPORT

• Only 44% (100 million) adults involved in their

Survey in the family’s chronic illness management.
US • Mostly felt obliged by privacy concerns & lack of
patient’s health information.

A meta-analytical • Accompanied patient visits were significantly

longer health care providers engaged in
review (US) more biomedical information giving.

• Family support early diagnosing &

Study in HK intervening diabetes-related complications,
cost-effective
Rosland AM, Heisler M, Janevic MR, Connell CM, Langa KM, Kerr EA, et al. Current and Potential Support for Chronic Disease Management in the United States: The
Perspective of Family and Friends of Chronically Ill Adults. Fam Syst Health. 2013; 31(2):119-31.
Wolff JL, Roter DL. Family Presence in Routine Medical Visits: A Meta-Analytical Review. Soc Sci Med. 2011; 72(6):823-31
Nan HR, Au A, Lam A, Sum R, Yap M. Effect of family support intervention in patients with diabetic retinopathy and with depressive symptoms dwelling in community in
hongkong: a randomized controlled trial. Diabetes Research and Clinical Practice. Vol 106. 2014.p.106-107.
 Next question:
Does Asian family have better participation compared to western one?
 ASIAN FAMILY INVOLVEMENT
IN MANAGING CHRONIC DISEASES
• Chinese families are involved in interpreting symptoms
and constructing disease management better
US (Asian) outcome.
• Family roles in T2DM fundamental to effective
management and quality of life

• Rely greatly on their family for disease management

UK (South Asian) improved diabetes outcomes.

• Family support important protective factor in

patients with chronic conditions.
• 6195 participants
Hongkong • Life stress, total of chronic conditions & satisfaction
with family support 43% of the variance in PHQ-9
(depressive symptoms)
Chesla CA, Kwan CML, Chun KM. Cultural and Family Challenges to Managing Type 2 Diabetes in Immigrant Chinese Americans. Diabetes Care. 2009; 32:1812–6
Singh H, Cinnirella HM, Bradley C. Support systems for and barriers to diabetes management in South Asians and Whites in UK: qualitative study of patient’s perpectives.
BMJ Open 2012;2:e001459. doi:10.1136/bmjopen-2012- 001459 .
Nan et al. BMC Psychiatry 2012, 12:198
 ASIAN FAMILY INVOLVEMENT
IN MANAGING CHRONIC DISEASES

HOWEVER

Barriers:
Diabetes disturbs family harmony
Dietary recommendations disrupt cultural food beliefs and practices
Disease management requirements disrupt established family role
responsibilities

Chesla CA, Kwan CML, Chun KM. Cultural and Family Challenges to Managing Type 2 Diabetes in Immigrant Chinese
Americans. Diabetes Care. 2009; 32:1812–6
TAKE HOME MESSAGES
Multidisciplinary care & family involvement in managing DM patients
(chronic disease) may be beneficial to improve medical outcome.

Chronic care model (CCM) may be adapted and may result in more
comprehensive care and cost-effective.

Further research needed to help determining the most effective way

to deliver this system.

Further studies needed to overcome barriers for multidisciplinary care

implementation and to increase family involvement.
THE COMPREHENSIVE INDIVIDUALIZED STRATEGY

DSME : Diet, exercise,

lifestyle,
change

Inzucchi et al. Diabetes Care

2012;35:1364–79
THANK YOU