1

Disease Management for

Diabetes Mellitus in Japan

Naoki Nakashima, M.DNaoki Nakashima, M.D.,., Ph.D.Ph.D.Department of Medical InformaticsDepartment of Medical InformaticsKyushu University HospitalKyushu University Hospital

7/20/2006 in APAN Singapore

Human Evolution 　

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The disease in which there is apparent high glucose

in the blood.

?Diabetes?

Number of Diabetes Patients (million) in the World and Increase Number of Diabetes Patients (million) in the World and Increase Ratio in 2025 (Diabetes Voice, 2003.6 P. Ratio in 2025 (Diabetes Voice, 2003.6 P. ZimmetZimmet ))

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Background of the projectBackground of the project

Pre-DiabetesNot Cared

Specialist Doctors

Cared

130 millions citizenin Japan

9 millions 4 millions1million

Not SpecialistDoctors

Diabetes Mellitus

Dropped OutAcute and

Chronic Diabetic Complications

Increase of Increase of Medical CostMedical Cost

3millions

We will start We will start ““ Specified Examination for Specified Examination for Health ProgramHealth Program”” from April 2008from April 2008

All of 40All of 40～～74yo Japanese citizen (50million) will 74yo Japanese citizen (50million) will have to get standardized health examinationhave to get standardized health examinationList of Basic ExaminationList of Basic Examination

Questionnaire (mention later)Questionnaire (mention later)A physical measurement and examination A physical measurement and examination

Height, Weight (BMI), Waist, Blood PressureHeight, Weight (BMI), Waist, Blood Pressure

Blood chemistryBlood chemistryTG, HDLTG, HDL--C, LDLC, LDL--C, GOT, GPT, C, GOT, GPT, γγ--GTP, GTP, CreCre, Blood , Blood glucose (fasting or postprandial), HbA1c, Uric acidglucose (fasting or postprandial), HbA1c, Uric acid

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Stratification and Stratification and Specified Instruction about HealthcareSpecified Instruction about Healthcare

Big Waist　　　　　　　　　　　（M≧85cm, F≧90cm)

Normal Waist　　　　　　 Obese　　　　　　　（M<85cm, F<90cm)　　　　　　　　 （BMI≧25）

　　　　

Normal Waist Normal Weight　

　　　　　　（M<85cm, F<90cm)

　　　　　　　 　　 （BMI<25）

Waist and ObesityCount Risk Factors

①　Blood Glucose：Fasting ≧110mg/dlPostprandial≧140mg/dlHbA1c≧5.5%Under medication

②　Lipidemia：TG≧150mg/dlHDL-Chol<40mg/dlUnder madication

③　BP： Systoric≧130mmHgDiastoric≧85mg/dlUnder medication

④　LDL-Chol：　≧120mg/dl⑤　Smoking history：　+⑥　Uric Acidemia：　≧7.0mg/dl

Grouping for Health

Instruction

Aggressive Support

Motivation Support

Information provide

≧2

0, 1

≧3

1, 2

0

≧41, 2, 3

0

Number of Risks

Specified Examination for HealthSpecified Examination for Health（（QuestionnaireQuestionnaire））

１．Gain your weight over 10kg from 20 years old?

２．Keeping exercise for 30 min with sweating more than two days a week for one year at least?

３．Walking or similar exercise for one hour or more in daily life?

４．Walking faster compared with same generation and same gender?

５．Are you smoking?

Question Answer

Yes/No

Judgment

Yes: 1 point

1 point by all “No”

Total Score　　　 ＊　points

Yes/No

Yes/No

Yes/No

Yes/No Yes: 1 point

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Adjustment of health instruction level Adjustment of health instruction level by the score of questionnaireby the score of questionnaire

To Motivation To Motivation SupportSupport

To Information To Information ProvideProvide

００

１１

２２

To Aggressive To Aggressive SupportSupport

To Motivation To Motivation SupportSupport

３３

Aggressive Aggressive SupportSupport

Motivation Motivation SupportSupport

Information Information ProvideProvide

PointsPoints

Scor

e of

Que

stio

nnair

eTentative Grouping by Physical and Blood Examinations

Encouragement to attend a clinic/hospitalEncouragement to attend a clinic/hospital

The Result of Physical and Blood Examination was:

１）Blood Glucosea Fasting ≧126mg/dl　orb Postprandial ≧180mg/dl　orc HbA1c ≧　6.1 %

２）Lipidemia a TG ≧150mg/dl　orb HDL-Chol ＜40mg/dl

３）BP a Systoric ≧140mmHg　orb Diastoric ≧90mg/dl

４）Uric Acidemia ≧8.0mg/dl

５）LDL-Chol ≧140mg/dl

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What do What do ““Specified Examination for Health and RelationsSpecified Examination for Health and Relations”” mean?mean?

Including healthcare instruction and encouragement Including healthcare instruction and encouragement of medication, in addition to health examinationof medication, in addition to health examinationInsurersInsurers’’ duty, which is based on the lawduty, which is based on the law　　　　　　

Cost is depend on InsurersCost is depend on InsurersIf insurers neglect their duties, they have to pay If insurers neglect their duties, they have to pay bigger shares of the support for medical of the latter bigger shares of the support for medical of the latter high ages as a penaltyhigh ages as a penaltyTarget number is about 50 million (45% of the Target number is about 50 million (45% of the population) in Japan. population) in Japan. It intends to make the results of health examination It intends to make the results of health examination standardized electronic data.standardized electronic data.

Standardized electronic data of Standardized electronic data of health examinationhealth examination

Code of medical institutes and healthcare instructors, JLAC10, HCode of medical institutes and healthcare instructors, JLAC10, HL7L7

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

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

Japanese government, prefectures can accumulate the huge Japanese government, prefectures can accumulate the huge anonymousanonymous data for statistical purpose.data for statistical purpose.

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Circulation of medical and insurance Circulation of medical and insurance information after 2011information after 2011

Medical institutes

Citizens (patients)

Insurance medical fee paymentfund

Insurers(payers)

Insurance info（medical action info）

Medical info(medical result info）

Healthcare info（health exam result info）

To organize “National DB of Electronic Ｈealthcare Record (EHR)”

Insurance info（medical action info）

Insurance info（medical action info）

20112011～～

20112011～～

20082008～～

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.

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USA

Japan

Start as a consultant for hospital

Classical　Disease Management　Model

Classical　Disease Management　Model 　　Recent　Disease Management Model　　Recent　Disease Management Model

Success cases

l in USA (e.g. AHW)

USA Classical　Disease Management　ModelUSA Classical　Disease Management　Model

USA Recent　Disease Management　ModelUSA Recent　Disease Management　Model

Unique in Japanese type Disease　Management○Edutainment（education + entertainment）○Support system of Non-specialist by specialist

by critical pathway system

Unique in Japanese type Disease　Management○Edutainment（education + entertainment）○Support system of Non-specialist by specialist

by critical pathway system

Alteration of public medical insurance system creates

a new business for outsourcing of medical insurance

by local governments.

＊private insurance company also need disease

management as in USA

Coupon incentive

by effort pointing

system

＜problem in the days＞　　　poor access and high dropped out　　　

　＜NEEDS＞　　　　 down medical cost paid by insurance companies

　＜problem now＞　　１．Deficit of specialists for diabetes　２．Need to down medical cost keeping quality

＜definition＞Adding to Disease Managementmodel in USA, it has bigger incentive for doctors and patients.

＜definition＞Adding to Disease Managementmodel in USA, it has bigger incentive for doctors and patients.

<Needs>Establishment of “Japanese type”Disease　Management Model in Japan

　　　1980’s＞　　　　　＞　　　　2005　　　＞　　future

　＞　＞　　　　　＞　　2006　　＞　　＞　　＞　　MANAGED CARE

Change to Outsourcing of medical insurance

Summary of CARNA ProjectSummary of CARNA Project

Out Bound Call Center

Patients

Mail

Phone

Primary Dr.（Company Dr.）

Points

Coupon

Strengthen RelationshipStrengthen Relationship

DM Dentist Kidney Ophthalmologist

Specialists

Team Care

Service

Clinics

Relational Critical Pathway

EdutainmentEdutainment

Tourism Co.

Restaurants

Service Providers Service Providers

Gymnasium

Private Insurance Co.

CARNA office

Individuals

Local Government

CompanyPublic HealthInsurance

＝Service＝Secondary, Tertiary Prevention①Provide Care Plan, Outcome Management　　（Relational Critical Pathway）

②Question to Find Complications Earlier③Question to Check knowledge・Education ④Push to Go to Clinic・Avoid to Drop Out⑤Quick Report of HbA1c to Patient⑥Provide and Manage the CARNA Points

Primary Prevention⑦Group Education by Video Lectures⑧Individual “Target” to Get the Points

Service

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Summary of CARNA ProjectSummary of CARNA Project

Out Bound Call Center

Patients

Mail

Phone

Primary Dr.（Company Dr.）

Points

Coupon

Strengthen RelationshipStrengthen Relationship

DM Dentist Kidney Ophthalmologist

Specialists

Team Care

Service

Clinics

Relational Critical Pathway

EdutainmentEdutainment

Tourism Co.

Restaurants

Service Providers Service Providers

Gymnasium

Private Insurance Co.

CARNA office

Individuals

Local Government

CompanyPublic HealthInsurance

＝Service＝Secondary, Tertiary Prevention①Provide Care Plan, Outcome Management　　（Relational Critical Pathway）

②Question to Find Complications Earlier③Question to Check knowledge・Education ④Push to Go to Clinic・Avoid to Drop Out⑤Quick Report of HbA1c to Patient⑥Provide and Manage the CARNA Points

Primary Prevention⑦Group Education by Video Lectures⑧Individual “Target” to Get the Points

Service

⑥ Provide and Manage the CARNA Points

・Nothing happen by my efforts on diet and exercise （patient）

Point system

Evaluation Evaluation by Drby Dr

Visit clinicVisit clinic

Improvement Improvement HbA1cHbA1c

DECDECNOVNOVOCTOCTSEPSEPAUGAUGJULJULJUNJUNMAYMAYAPRAPRMARMARFEBFEBJANJAN

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

As like as “millage system” in flight companies, patient can exchange the accumulated points with coupons of various

healthy service or item.

You got 2200 points！！

Provide and Manage the CARNA Points

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Couponcatalog

CARNA　ARGORISM

RCPVisiting day’s

Education sheets

RCP overview

stratification Question at regsitration

(clinic）

Summary Comment list

Summary sheets

（12 items）

Template of Letter to

Specialist DrLetter toSpecialist Dr

Question at registration

（patient）

Constant question

Rapid reportComment list

Interval question（patient）

Document for

education

Messagefrom

CARNAoffice

Comment Sheets forexam result

Check and

record sheet

Rapid report(HbA1c）

Retinopathy（３）

nephropathy（４） Neuropathy（２）

Diabetes foot（２）

Basic Sheet（insulin +／-）

（Interval of visit at clinic (３) ）

Atherosclerosis（２）

Relational Critical PathwayWe 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)

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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　　 診察医　　中島　直樹 ※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　　　　　） 1 2 3 4 5 6 7 8 9 10 11 12

OC VC 時刻 内容/アクション 01 食事療法ができている □ □ □ □ □ □ □ □ □ □ □ □

02 運動療法ができている（実測値を記入） □ □ □ □ □ □ □ □ □ □ □ □

H01 身体所見、神経系、眼所見、皮膚、下肢、口腔が異常がない 03 薬物療法の管理ができている □ □ □ □ □ □ □ □ □ □ □ □

H02 高血糖、低血糖がない 01 服薬（内服薬・インスリン）について理解できている □ □ □ □ □ □ □ □ □ □ □ □

H03 合併症の検査所見がない 02 疾患（糖尿病）について理解できている □ □ □ □ □ □ □ □ □ □ □ □

F01 食事療法ができている 03 食事（食事療法）について理解できている □ □ □ □ □ □ □ □ □ □ □ □

F02 運動療法ができている 04 運動（運動療法）について理解できている □ □ □ □ □ □ □ □ □ □ □ □

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

K02 疾患（糖尿病）について理解できている 01 糖尿病網膜症がない □ □ □ □ □ □ □ □ □ □ □ □

K03 食事（食事療法）について理解できている 01 糖尿病腎症がない □ バリアンス □ □ □ □ □ □ □ □ □ □

K04 運動（運動療法）について理解できている 01 糖尿病神経障害がない □ □ □ □ □ □ □ □ □ □ □ □

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 01 糖尿病足病変がない □ □ □ □ □ □ □ □ □ □ □ □

C01 合併症がない 01 動脈硬化性疾患がない □ □ □ □ □ □ □ □ □ □ □ □

（単位：ヶ月目） 1 2 3 4 5 6 7 8 9 10 11 12

01 血糖値（空腹時・食後） □ □ □ □ □ □ □ □ □ □ □ □

02 HbA1c（グリコアルブミン） □ □ □ □ □ □ □ □ □ □ □ □

03 □ □ □ □ □ □ □ □ □ □ □ □

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）　 □ □ □ □ □ □ □ □ □ □ □ □

06 尿中アルブミン □ □ □ □ □ □ □ □ □ □ □ □

07 尿中蛋白定量 □ □ □ □ □ □ □ □ □ □ □ □

08 振動覚域検査・アキレス腱反射 □ □ □ □ □ □ □ □ □ □ □ □

09 □ □ □ □ □ □ □ □ □ □ □ □

10 PWV・ABI　 □ □ □ □ □ □ □ □ □ □ □ □

11 頸部血管エコー　 □ □ □ □ □ □ □ □ □ □ □ □

12 足部診察 □ □ □ □ □ □ □ □ □ □ □ □

13 口腔内診察 □ □ □ □ □ □ □ □ □ □ □ □

14 腹部エコー　 □ □ □ □ □ □ □ □ □ □ □ □

15 眼科受診 □ □ □ □ □ □ □ □ □ □ □ □

16 □ □ □ □ □ □ □ □ □ □ □ □

17 歯科受診 □ □ □ □ □ □ □ □ □ □ □ □

18 内服薬確認 □ □ □ □ □ □ □ □ □ □ □ □

19 教育シート評価 □ □ □ □ □ □ □ □ □ □ □ □

20 運動指導　（適宜） □ □ □ □ □ □ □ □ □ □ □ □

21 食事指導　（適宜） □ □ □ □ □ □ □ □ □ □ □ □

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 □ □ □ □ □ □ □ □ □ □ □ □

23 在宅自己注射指導管理料記載 □ □ □ □ □ □ □ □ □ □ □ □

24 自己測定記載？検討中 □ □ □ □ □ □ □ □ □ □ □ □

25 針加算記載？検討中 □ □ □ □ □ □ □ □ □ □ □ □

01 感覚障害がない（感覚鈍麻・知覚過敏など） □ □ □ □ □ □ □ □ □ □ □ □

01 振動覚低下がない[適正値：≧10] □ □ □ □ □ □ □ □ □ □ □ □

01 アキレス腱反射の消失がない □ □ □ □ □ □ □ □ □ □ □ □

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） □ □ □ □ □ □ □ □ □ □ □ □ 【教育・指導管理】 【事務局よりお知らせ】

01 □ □ □ □ □ □ □ □ □ □ □ □

01 □ □ □ □ □ □ □ □ □ □ □ □

01 口渇・多飲・多尿・体重減少・易疲労がない □ □ □ □ □ □ □ □ □ □ □ □

02 □ □ □ □ □ □ □ □ □ □ □ □

02 HbA1c[適正値：＜6.5%] □ □ □ □ □ □ □ □ □ □ □ □

03 尿中アルブミン[適正値：30～300mg/g・Cre] □ □ □ □ □ □ □ □ □ □ □ □ 【共有情報・その他】

03 尿中蛋白定量 □ □ □ □ □ □ □ □ □ □ □ □

03 血清クレアチニン[適正値：≦1.0] □ □ □ □ □ □ □ □ □ □ □ □

03 □ □ □ □ □ □ □ □ □ □ □ □

03 脂質[適正値：＜150（TG）]（空腹時の時のみ測定） □ □ □ □ □ □ □ □ □ □ □ □

03 収縮期血圧[適正値：≦130mmHg] □ □ □ □ □ □ □ □ □ □ □ □

03 拡張期血圧[適正値：≦80mmHg] □ □ □ □ □ □ □ □ □ □ □ □

03 胸腹部単純X線で異常がない　 □ □ □ □ □ □ □ □ □ □ □ □

03 心電図（非負荷）で異常がない　 □ □ □ □ □ □ □ □ □ □ □ □ 【薬剤処方】

03 PWV・ABIで異常がない □ □ □ □ □ □ □ □ □ □ □ □

03 頸部血管エコーで異常がない □ □ □ □ □ □ □ □ □ □ □ □

03 腹部エコーで異常がない（脂肪肝など） □ □ □ □ □ □ □ □ □ □ □ □

03 肥満がない[適正値：BMI≦25] □ □ □ □ □ □ □ □ □ □ □ □

©Saiseikai Kumamoto Hospital　　（コード番号；2005/02/19）

※3ヶ月目より腎症2期オプションシート追加

□ □

合併症C

□□ □ □ □ □□ □ □ □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

年 月 日 （ ）生活

動作F

アウトカム

知識・教育K

検査・処置T

脂質[適正値：＜200（TC），＜120（LDL）]※動脈硬化がある場合[適正値：＜180（TC)，＜100（LDL）]

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）

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）

血糖（空腹時）[適正値：80≦血糖＜130]または（食後）[適正値：140≦血糖＜180]

患者状態H

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，尿素窒素，クレアチニン，尿酸，AST，ALT，γ-GTP）

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）

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）

網膜症

先々月

先月

　　合併症に変化があればご記入ください

○　インスリン　無（現状）　　→　○　腎症　2期（現状）　→　○　網膜症　無（現状）　 →

○　神経障害　無（現状）　 →

○　動脈硬化症　無（現状）　 →

○　足病変　無（現状）　 →

基本シート：インスリン　（無・　有）

足病変　０（無）

HbA1c（％）

No１（２期）

8

6

7

5以下

No２（３期）

N ３（４期）No１（単純網膜症）

No１（有）

　０（無）

9

　０（無）

No１（有）

No１（有）０（無）

　０（無）

No２（増殖前網膜症）

HbA1c（％）腎症

No１（２期）

8

6

7

5以下

No２（３期）

No１（単純網膜症）

神経障害

No１（有）

　０（無）

9

動脈硬化症

No１（有）

No１（有）０（無）

　０（無）

No２（増殖前網膜症）

先々月

先月

　　合併症に変化があればご記入ください

○　インスリン　無（現状）　　→　○　腎症　2期（現状）　→　○　網膜症　無（現状）　 →

○　神経障害　無（現状）　 →

○　動脈硬化症　無（現状）　 →

○　足病変　無（現状）　 →

Structure of RCPStructure of RCP

OUTCOME

TASK

ASSESEMENTASSESEMENT

ASSESEMENTASSESEMENT

Condition of Condition of

COMPLICATIONCOMPLICATION

Identification

Assessment

Stratification

Intervention

Measurement

ContinuousReassessment

The Six Factors of Disease Management in Carna

Members of insuranceIntroduction from primary doctors

QuestionnaireData from health examData from primary doctors

Age, Sex, HbA1c, Complications, Therapy, Characters, Self-efficacy

Phone call, mail,E-mail, Web,From primary doctors, Critical pathways

HbA1c, Complications, Therapy, Self-efficacy, Behavior, Medical cost

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CarnaCarna’’ss Basic Strategy for Disease ManagementBasic Strategy for Disease Management

Relational Critical Pathway based on guideline of each chronic disease

Standard MedicalProcess

Avoid a Lawsuit

Improved patientsatisfaction

Prevention of Complication

Promote CommunicationBetween Patient & Dr

Keep medicationAvoid drop out

Effective redistribution of

Medical C

osts

Future Directions Future Directions

TokyoKumamoto

Pref.

Regional development

Primary prevention

Secondary prevention

Disease Development

Post cance

r ope

Depre

ssion

IHD

Heart F

ailure

CO

PD

Asth

ma

Secondary/Tertiary Prevention of

Diabetes MellitusIn Fukuoka Prefecture

CARNA in 2006

13

ConclusionConclusionThe bill to reorganize the public medical insurance, which The bill to reorganize the public medical insurance, which

will be enforced in 2008, and the project of 100% online will be enforced in 2008, and the project of 100% online reimbursement, which will be achieved in 2011, will change reimbursement, which will be achieved in 2011, will change the circumstances of circulation and accumulation of the circumstances of circulation and accumulation of medical, healthcare and insurance information. We need to medical, healthcare and insurance information. We need to reconstruct a secure and patientreconstruct a secure and patient--centeredcentered social system. social system.

As a model of a part of the social system, we presented a As a model of a part of the social system, we presented a Japanese style disease management for diabetes mellitus.Japanese style disease management for diabetes mellitus.

If you have any questions, call to Carna office, +81-92-642-6459carna@med.kyushu-u.ac.jp