Human Evolution - APAN

Disease Management for
Diabetes Mellitus in Japan
Naoki Nakashima, M.D.,
M.D., Ph.D.
Department of Medical Informatics
Kyushu University Hospital
7/20/2006 in APAN Singapore
Human Evolution 1
?Diabetes?
The disease in which
there is apparent high glucose
in the blood.
Number of Diabetes Patients (million) in the World and Increase
Ratio in 2025 (Diabetes Voice, 2003.6 P. Zimmet )
2
Background of the project
Pre-Diabetes
130 millions citizen
in Japan
9 millions
Not
d
Care
4 millions
d
Care
Not Specialist
Doctors
3millions
1million
Diabetes Mellitus
Specialist
Doctors
Increase of
Medical Cost
Acute and
Chronic Diabetic
Complications
Dropped Out
We will start “ Specified Examination for
Health Program” from April 2008

All of 40～74yo Japanese citizen (50million) will
have to get standardized health examination
List of Basic Examination
Questionnaire (mention later)
A physical measurement and examination

Height, Weight (BMI), Waist, Blood Pressure

Blood chemistry
TG, HDLHDL-C, LDLLDL-C, GOT, GPT, γ-GTP, Cre,
Cre, Blood
glucose (fasting or postprandial), HbA1c, Uric acid
3
Stratification and
Specified Instruction about Healthcare
Count Risk Factors
Grouping for
Health
Instruction
Waist and Obesity
①　Blood Glucose：
Fasting ≧110mg/dl
Big Waist
Postprandial≧140mg/dl
（M≧85cm, F≧90cm)
HbA1c≧5.5%
Under medication
②　Lipidemia：
TG≧150mg/dl
Normal Waist
Obese
HDL-Chol<40mg/dl
（M<85cm, F<90cm)
Under madication
（BMI≧25）
③　BP： Systoric≧130mmHg
Diastoric≧85mg/dl
Under medication
Normal Waist
④　LDL-Chol：　≧120mg/dl
Normal Weight　⑤　Smoking history：　+
（M<85cm, F<90cm)
⑥　Uric Acidemia：　≧7.0mg/dl （BMI<25）
≧2
Aggressive
Support
0, 1
≧3
1, 2
0
Motivation
Support
≧4
1, 2, 3
Information
provide
0
Number of Risks
Specified Examination for Health
（Questionnaire）
Question
Answer
１．Gain your weight over 10kg from 20 years old?
Yes/No
２．Keeping exercise for 30 min with sweating more
than two days a week for one year at least?
Yes/No
３．Walking or similar exercise for one hour or more in
daily life?
Yes/No
４．Walking faster compared with same generation and
same gender?
Yes/No
５．Are you smoking?
Yes/No
Judgment
Yes: 1 point
1 point
by all “No”
Yes: 1 point
Total Score　＊　points
4
Adjustment of health instruction level
by the score of questionnaire
Tentative Grouping by Physical and Blood Examinations
Score of Questionnaire
Points
３
Information
Provide
Motivation
Support
To Motivation
Support
To Aggressive
Support
Aggressive
Support
２
１
To Information
Provide
０
To Motivation
Support
Encouragement to attend a clinic/hospital
The Result of Physical and Blood Examination was:
１）Blood Glucose
a Fasting
b Postprandial
c HbA1c
≧126mg/dl　or
≧180mg/dl　or
≧　6.1 %
２）Lipidemia a TG
b HDL-Chol
≧150mg/dl　or
＜40mg/dl
３）BP
≧140mmHg　or
≧90mg/dl
a Systoric
b Diastoric
４）Uric Acidemia
≧8.0mg/dl
５）LDL-Chol
≧140mg/dl
5
What do “Specified Examination for Health and Relations”
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 of the latter
high ages as a penalty
Target number is about 50 million (45% of the
population) in Japan.
It intends to make the results of health examination
standardized electronic data.
Standardized electronic data of
health examination

Code of medical institutes and healthcare instructors, JLAC10, HL7
HL7

Insurers have to accumulate annual data of health examination as
long as the member keeps membership. If the member moves to
other insure, the former insures have to transfer the data to the
the next
insure to keep life long data.

Insures can accumulate data more effectively by the achievement of
onon-line reimbursement, which will be achieved at 100% in 2011.

Japanese government, prefectures can accumulate the huge
anonymous data for statistical purpose.
6
Circulation of medical and insurance
information after 2011
Insurance info
（medical action info）
Medical
institutes
2011～
2011～
Medical info
(medical result info）
Insurance medical
fee paymentfund
2011～
2011～
Insurance info
（medical action info）
Citizens (patients)
2008～
2008～
Insurance info
（medical action info）
Insurers
(payers)
Healthcare info
（health exam result info）
To organize “National DB of Electronic Ｈealthcare Record (EHR)”
What is “Carna Project” ?
The Carna project is a newly developed Japanese
type 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.
7
1980’s＞　＞　2005　＞　future
USA
Classical　Disease
Classical　DiseaseManagement　Management　Model
Model
Recent　Disease
Recent　DiseaseManagement
Management Model
Model
Success cases
l in USA (e.g. AHW)
Change to Outsourcing of medical insurance
Start as a consultant for hospital
＜problem in the days＞　poor access and high dropped out　＜NEEDS＞　down medical cost paid by insurance companies
＞　＞　＞　2006　＞　＞　＞　MANAGED CARE
<Needs>
Establishment of “Japanese type”
Disease　Management Model in Japan
＜problem now＞　１．Deficit of specialists for diabetes　２．Need to down medical cost keeping quality
USA
USAClassical　Disease
Classical　DiseaseManagement　Model
Management　Model
Japan
USA
USARecent　Disease
Recent　DiseaseManagement　Model
Management　Model
Alteration of public medical insurance system creates
a new business for outsourcing of medical insurance
by local governments.
＜definition＞
＜definition＞
Adding
Addingto
toDisease
DiseaseManagement
Management
model
modelininUSA,
USA,itithas
hasbigger
bigger
incentive
for
doctors
incentive for doctorsand
andpatients.
patients.
＊private insurance company also need disease
management as in USA
Coupon incentive
Unique
UniqueininJapanese
Japanesetype
typeDisease　Management
Disease　Management
○Edutainment（education
○Edutainment（education++entertainment）
entertainment）
○Support
system
of
Non-specialist
○Support system of Non-specialistby
byspecialist
specialist
by
bycritical
criticalpathway
pathwaysystem
system
by effort pointing
system
Summary of CARNA Project
Secondary, Tertiary Prevention
①Provide Care Plan, Outcome Management
（Relational Critical Pathway）
②Question to Find Complications Earlier
③Question to Check knowledge・Education
④Push to Go to Clinic・Avoid to Drop Out
⑤Quick Report of HbA1c to Patient
⑥Provide and Manage the CARNA Points
Service Providers
CARNA office
＝Service＝
Restaurants
Relational Critical
Pathway
Points
Tourism Co.
Mail
Gymnasium
Phone
Private
Insurance Co.
Out Bound Call Center
Primary Prevention
⑦Group Education by Video Lectures
⑧Individual “Target” to Get the Points
Edutainment
Service
Coupon
Service
Clinics
Patients
Primary Dr.
（Company Dr.）
Team Care
DM
Dentist
Kidney Ophthalmologist
Specialists
Individuals
Strengthen Relationship
Public Health
Insurance
Company
Local
Government
8
Summary of CARNA Project
Service Providers
CARNA office
＝Service＝
Restaurants
Secondary, Tertiary Prevention
①Provide Care Plan, Outcome Management
（Relational Critical Pathway）
②Question to Find Complications Earlier
③Question to Check knowledge・Education
④Push to Go to Clinic・Avoid to Drop Out
⑤Quick Report of HbA1c to Patient
⑥Provide and Manage the CARNA Points
Points
Relational Critical
Pathway
Tourism Co.
Mail
Gymnasium
Phone⑥
Provide and Manage the CARNA Points
Private
Insurance Co.
Out Bound Call Center
Primary Prevention
⑦Group Education by Video Lectures
⑧Individual “Target” to Get the Points
Edutainment
Service
Coupon
Service
Clinics
Patients
Primary Dr.
（Company Dr.）
Individuals
Strengthen Relationship
Team Care
DM
Dentist
Public Health
Insurance
Company
Local
Government
Kidney Ophthalmologist
Specialists
Provide and Manage the CARNA Points
・Nothing happen by my efforts on diet and exercise （patient）
You got 2200 points！！
Visit clinic
Evaluation
by Dr
JAN
FEB
MAR
100
100
point
point
100
100
point
point
Improvement
HbA1c
100
point
APR
MAY
JUN
JUL
100
100
100
100
point
point
point
point
100
100
100
100
100
point
point
point
point
point
AUG
SEP
OCT
NOV
DEC
100
100
100
point
point
100
point
100
100
100
100
point
point
point
point
point
As like as “millage system” in flight companies, patient can
exchange the accumulated points with coupons of various
healthy service or item.
Point system
9
CARNA　ARGORISM
Summary
Comment list
Summary
sheets
（12 items）
stratification
Question
at regsitration
(clinic）
Question
at registration
（patient）
RCP overview
Rapid report
Comment list
Rapid report
(HbA1c）
Interval
question
（patient）
Comment
Sheets for
exam result
Template of
Letter to
Specialist Dr
RCP
Visiting day’s
Check
and
record
sheet
Letter to
Specialist Dr
Message
from
CARNA
office
Education sheets
Coupon
catalog
Document
for
education
Constant
question
Relational Critical Pathway
We decide the phase of Diabetes Mellitus as the
progression of complication. We have a system to make
appropriate RCP for individual patient with 2,880 pattern
Constant questions（５)
Retinopathy（３）
nephropathy（４）
Basic Sheet
（insulin +／-）
（Interval of visit at clinic (３) ）
Neuropathy（２）
Diabetes foot（２）
Atherosclerosis（２）
10
Structure of RCP
糖尿病クリニカルパス（網膜症なし・腎症2期・神経障害なし・足病変なし・動脈硬化なし）：日めくり式パス
ID　00000000　患者氏名　西田　大介　・34 才　性別　男　・女　※生活動作F、知識・教育Kに関してはオプションシートを参照してください。
診察医　中島　直樹
診察医（　中島　直樹　）
年
月
日（
OC
）
VC
時刻内容/アクション
動
生
作
活
F
アウトカム
H01 身体所見、神経系、眼所見、皮膚、下肢、口腔が異常がない
H02 高血糖、低血糖がない
F01 食事療法ができている
知
識
・
教
育
K
OUTCOME
F02 運動療法ができている
F03 薬物療法の管理ができている
K01 服薬（内服薬・インスリン）について理解できている
K05 生活（フットケア、禁煙、飲酒、民間療法）の注意点について理解できている
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生化学検査（ミニマムセット：中性脂肪，総コレステロール，HDLコレステロール，尿
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素窒素，クレアチニン，尿酸，AST，ALT，γ-GTP）
01 血糖値（空腹時・食後）
02 HbA1c（グリコアルブミン）
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04 胸腹部単純X線　※青項目施行不可の場合は、専門医に検査受診
05 心電図（非負荷）　□
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06 尿中アルブミン
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07 尿中蛋白定量
08 振動覚域検査・アキレス腱反射
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10 PWV・ABI　11 頸部血管エコー　□
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12 足部診察
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①神経伝達速度②心電図R波間隔変動③振動覚閾値検査：専門医検査
（※08に異常があった場合のみ2ヵ月後）
TASK
13 口腔内診察
14 腹部エコー　15 眼科受診
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16 糖尿病専門医もしくは腎臓専門医受診（栄養指導含む：塩分・タンパク）
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17 歯科受診
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18 内服薬確認
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19 教育シート評価
20 運動指導　（適宜）
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21 食事指導　（適宜）
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22 生活習慣病指導管理料記載、あるいは特定疾患指導管理料記載
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23 在宅自己注射指導管理料記載
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24 自己測定記載？検討中
25 針加算記載？検討中
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01 感覚障害がない（感覚鈍麻・知覚過敏など）
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01 振動覚低下がない[適正値：≧10]
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01 アキレス腱反射の消失がない
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01 自律神経障害がない（起立性低血圧・発汗障害・勃起障害など）
01 足病変がない（足背動脈の拍動低下・消失・壊疽・潰瘍・胼胝形成・浮腫）
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01 口腔内異常がない（齲歯・歯周病の症状・歯牙脱落・舌・口腔内感染症の症状）
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01 口渇・多飲・多尿・体重減少・易疲労がない
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02 血糖（空腹時）[適正値：80≦血糖＜130]または（食後）[適正値：140≦血糖＜180]
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02 HbA1c[適正値：＜6.5%]
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ASSESEMENT
患 03 尿中アルブミン[適正値：30～300mg/g・Cre]
者 03 尿中蛋白定量
状
03 血清クレアチニン[適正値：≦1.0]
態
脂質[適正値：＜200（TC），＜120（LDL）]
H
03
03
03
03
03
03
03
03
6
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04
05
生活（フットケア、禁煙、飲酒、民間療法）の注意点について理解できている
01
糖尿病網膜症がない
糖尿病腎症がない
糖尿病神経障害がない
糖尿病足病変がない
動脈硬化性疾患がない
01
01
01
（単位：ヶ月目）
03
5
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01
C01 合併症がない
03
4
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□
03
合
併
症
C
K04 運動（運動療法）について理解できている
09
3
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□
02
K02 疾患（糖尿病）について理解できている
K03 食事（食事療法）について理解できている
検
査
・
処
置
T
2
□
03
01
H03 合併症の検査所見がない
03
1
食事療法ができている
運動療法ができている（実測値を記入）
薬物療法の管理ができている
服薬（内服薬・インスリン）について理解できている
疾患（糖尿病）について理解できている
食事（食事療法）について理解できている
運動（運動療法）について理解できている
01
02
※動脈硬化がある場合[適正値：＜180（TC)，＜100（LDL）]
脂質[適正値：＜150（TG）]（空腹時の時のみ測定）
収縮期血圧[適正値：≦130mmHg]
拡張期血圧[適正値：≦80mmHg]
胸腹部単純X線で異常がない　心電図（非負荷）で異常がない　PWV・ABIで異常がない
頸部血管エコーで異常がない
腹部エコーで異常がない（脂肪肝など）
肥満がない[適正値：BMI≦25]
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ASSESEMENT
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基本シート：インスリン　（無・　有）
合併症に変化があればご記入ください
HbA1c（％）
腎症
０（無）
○　インスリン
無（現状）　→
○　腎症
2期（現状）　→
○　網膜症
無（現状）　→
5以下
No１（２期）
6
7
No２（３期）
○　神経障害
無（現状）　→
8
Condition of
網膜症０（無）
N ３（４期） 9
No１
（単純網膜症）
０（無）
No２
（増殖前網膜症）
足病変 ○　足病変
COMPLICATION
No１（有）
０（無）
先々月
○　動脈硬化症
無（現状）　→
No１（有）
神経障害
無（現状）　→
No１（有）
０（無）
動脈硬化症
先月
【教育・指導管理】
【事務局よりお知らせ】
※3ヶ月目より腎症2期オプションシート
追加
【共有情報・その他】
【薬剤処方】
©Saiseikai Kumamoto Hospital　（コード番号；2005/02/19）
The Six Factors of Disease Management in Carna
Identification
Assessment
Stratification
Intervention
Members of insurance
Introduction from primary doctors
Questionnaire
Data from health exam
Data from primary doctors
Age, Sex,
HbA1c, Complications, Therapy,
Characters, Self-efficacy
Continuous
Reassessment
Phone call, mail,
E-mail, Web,
From primary doctors,
Critical pathways
Measurement
HbA1c, Complications, Therapy, Self-efficacy, Behavior, Medical cost
11
Carna’s Basic Strategy for Disease Management
Promote Communication
Between Patient & Dr
Standard Medical
Process
Avoid a Lawsuit
Keep medication
Avoid drop out
Improved patient
satisfaction
Relational Critical Pathway
based on guideline of each chronic disease
Effective redistribution of
Medical Costs
Prevention of
Complication
Future Directions
Primary prevention
Secondary prevention
Regional development
Tokyo
Kumamoto
Pref.
Secondary/
e
r
n
u
l
o
i
i
a
s
a
F
s
D m
e
t P
r
r
h
p
a
t
D e
O s
e H
D I
H C A
CARNA in 2006
e
p
o
r
e
c
n
a
c
t
s
o
P
Tertiary Prevention of
Diabetes Mellitus
In Fukuoka
Prefecture
Disease
Development
12
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
reconstruct a secure and patient-centered social system.
As a model of a part of the social system, we presented a
Japanese style disease management for diabetes mellitus.
If you have any questions, call to Carna office, +81-92-642-6459
[email protected]
13

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