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Disease Management

Diabetes is fast becoming a global epidemic -- a silent killer afflicting increasingly younger people and eating away at the governments' coffers, writes Dr JULIANA CHAN

In Hong Kong, approximately 10,000 people die every year. Most of these are from natural causes or accidents, but 10 of every 30 deaths that occur here daily are due to stroke, heart disease or kidney disease -- up to 50 percent of which are related to diabetes.

In Hong Kong, the average age of a diabetic person is approximately 50. An average non-diabetic person of the same age can expect to live to 75 or more. The presence of diabetes, however, cuts a person's life expectancy by between 10 to 15 years.

Asians particularly at risk

The World Health Organisation estimates that in the year 2000, about 171 million people around the world had diabetes. Startlingly, more than two thirds of those were in Asia. India, China, U.S., Japan, and Pakistan topped the global list of sufferers. In China alone, there are believed to be at least 18 million people with diabetes -- equivalent to the entire population of Australia -- and this figure is expected to increase to 40 million by 2025.

The epidemic of diabetes and obesity is particularly evident in non-Caucasians, including Chinese populations, who undergo rapid changes in lifestyles characterised by high fat, high sugar and high salt diet with reduced physical activity and increased psychosocial stress.

Due to Hong Kong's highly efficient and competitive lifestyle, people here have too many food choices, too little time for exercise and generally too much stress. As a result, Hong Kong has one of the highest rates of diabetes in the world, affecting one in every eight people. This percentage increases from 1 to 2 percent in people under 35 to more than 25 percent in those aged 65 or above.

In the 45-55 age group, 6-10 percent of people can expect to develop diabetes and half remain undiagnosed. Men are more likely to be affected than women before they reach the age of 50, when the situation reverses, possibly due to the onset of menopause. In general, 30-50 percent of diabetic complications develop silently and slowly, but strike suddenly.

The major challenge in fighting diabetes is its silent and slow encroachment nature, coupled with a general tendency for people, doctors and patients alike to be complacent about it.

High blood glucose, high blood pressure and abnormal blood fat levels go hand in hand and are the main risk factors for heart disease, stroke and kidney failure. On average, 50-90 percent of diabetic patients have coexisting high blood pressure and abnormal blood fat levels. Besides, diabetic patients develop small blood vessel disease causing damage to the kidneys, eyes and nerves. All these risk factors and complications are silent and deadly, but if detected early and managed effectively, they will greatly reduce the risks of major illnesses such as blindness and kidney failure.

Hence, upon diagnosis, all diabetic people should undergo a comprehensive assessment to evaluate their profiles of risk factors and complications. Based on this clinical profile, doctors will be in a better position to advise on disease severity and types of therapy such as diet, exercise, tablets, insulin and medications for other conditions.

Equally important, these risk factors should be periodically monitored to ensure that target values are attained and that treatment regimens are appropriate. Patients must also learn about the disease and how lifestyle modification can help to prevent further deterioration. Here, patient self-management is an integral part of disease management.

Disease management 

Disease management is a multidisciplinary, systemic approach to manage patients with chronic conditions such as diabetes, asthma, heart disease, and depression. Disease management programs address a disease or condition through prevention, proactive, evidence based interventions, and patient self management. Through this approach, it helps patients and their physicians to better adhere to the recognised standard of care and prevent avoidable utilisation of expensive medical resources. Proponents of disease management believe that, when effectively designed and implemented, it offers substantial promise to improve health outcomes and, thereby reducing overall costs.

In fact, there is now indisputable evidence confirming that the risk of all-diabetes related complications can be reduced by 25-75 percent if treatment targets are attained and appropriate drugs are given to these patients under a disease management program.

For diabetes, a typical disease management program will include risk stratification, patient education that facilitates self-management, aggressive screening for complications, early interventions, appropriate speciality referral, practice of clinical guidelines and evidence based treatment protocols. The program is conducted by a co-ordinated professional team that involves medical specialists (endocrinologists), diabetes nurses, dieticians, podiatrists, and physical trainers.

One of the reasons for the generally sub-standard quality of diabetes care in the Hong Kong community is partly related to the complexity of the protocol. Compared to a solo practice, a Diabetes Centre operated by a multidisciplinary team can provide a more conducive environment for patients to learn how to manage their diabetes through information sharing, peer influence and mutual support.

Based on a study conducted by the Chinese University of Hong Kong, only 8 out of 91 diabetic people (8.8 percent) managed according to a structured care protocol in a Diabetes Centre died after 7 years. By contrast, 20 out of 81 (24.7 percent) diabetic people who received usual (random) care from a typical HA hospital clinic died during the same period. These findings are in agreement with several international studies showing the benefits of a multidisciplinary and holistic team approach compared to the traditional doctor-patient relationship in a solo-practice setting.

Cost to businesses

Apart from improving clinical outcomes, there is culminating evidence that an effective disease management program can save health expenditure in the long run. In a recent article published in McKinsey Quarterly, it has been predicted that in a few years, the average Fortune 500 company may be spending as much on health benefits as it earns in profits. One of the most important reasons for this growth in health care spending is due to the near epidemic of diabetes among its employees.

Many companies are now adopting a more strategic and integrated approach by partnering with preferred health care providers which deliver high quality disease management programs as well as encouraging their employees to take advantages of these health care packages through good and reliable information.

Financing diabetes care

In a typical HA regional hospital with 1,000-1,500 beds, a medical ward admits on average 30-50 patients a day, 30-50 percent of them have diabetes-related diseases, such as heart failure, heart attack, stroke, kidney failure and severe infections. The average treatment costs for these severe diseases range from HK$100,000 to more than HK$500,000, leaving aside the costs due to unemployment, sick days and personal suffering. Given the size of the population and the increasingly young onset of diabetes, the financial implications of this burgeoning epidemic are obvious even to non experts.

Due to limited resources and the government budget deficit, the current HA system is already overloaded with overwhelming demand of patients with chronic diseases. There is an obvious need to deliver a quality disease management model in the private sector. In most developed countries such as the U.S. and Europe, 8-16 percent of their gross domestic productivity (GDP) is spent on health care. In Hong Kong, given the low tax system, only 4-6 percent of our GDP is spent on health care. There is still scope for expanding the market by getting people to invest in their health. This can only be achieved through education, self-awareness, and informed choice.

Against this background, Qualigenics Diabetes Center was established in 2002 under an academic-industrial collaboration between the Chinese University of Hong Kong and GenRx Healthcare Ltd. (a subsidiary of HK Resources International Ltd., developer of Discovery Bay). This business model is the first in its kind in Hong Kong. By adopting a "one-stop" disease management model, the center provides an option in the private health sector to meet the growing demand of people with diabetes and other chronic diseases.

For more information on diabetes and disease management, visit www.qualigenics.com

Dr Juliana CN Chan is Professor in the Department of Medicine and Therapeutics at the Chinese University of Hong Kong.

Professor Peter CY Tong, Associate Professor, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, The Prince of Wales Hospital, Shatin, and Dr Norman Chan, Clinical Director, Qualigenics Diabetes Centre, also contributed to this article.