Proposed Topic (Most preferred): :
Clinical Safety and Quality Service I (Projects aiming to improve efficiency and effectiveness of care delivery to meet international standards)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service III (Projects aiming at quality service to patients and their carers)
Authors (including presenting author) :
Hui LC, Lam TM, Lau WH, Koo F, Yip KY, Leung SH, Ko SH, Chen XRC, Li YC
Affiliation :
Department of Family Medicine and Primary Healthcare (FM&PHC), Kowloon Central Cluster (KCC)
Introduction :
Type 2 diabetes mellitus (T2DM) is a prevalent chronic disease in primary care settings. The Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) in primary care aims to stratify risk, screen complications, triage care, empower patients, and individualize treatment. This multidisciplinary program has been proven to reduce all major events by 30-60% in patients without diabetic complications. However, due to the high health burden, some patients may not have the chance to be enrolled in the program, raising concerns about the equitable allocation of care resources. Disease registries with administrative data have been recognized as effective tools for controlling, monitoring, and evaluating health programs.
Objectives :
1.To develop a comprehensive diabetes registry. 2.To implement changes to improve the coverage and monitoring of regular diabetic risk assessment and management. 3.To assess the improvement in the coverage of RAMP-DM after implementing changes.
Methodology :
From year 2022, different strategies were implemented to enhance the diabetes registry system: 1.Proactive patient identification: Data of T2DM patients managed in 13 General Out-patient Clinics (GOPCs) of KCC were retrieved from the Clinical Data Analysis and Reporting System (CDARS) to form a diabetes registry. Patients who had attended any of the 13 GOPCs for follow-up in the past one year were included. Patients without enrollment in RAMP-DM in the past three years were identified. Priority was given to younger patients (<65 years old) with poorly controlled DM (HbA1c level >7%). The list of patients with future follow-up appointments was sorted according to clinics. 2.Multidisciplinary working through: Nurses reviewed the list and checked patient information in the Computer Management System (CMS). The daily lists were then sorted by date and consultation room (CR) number by clerical staff and distributed to each CR. During consultations, doctors ordered blood and urine investigations and referred the patients to RAMP-DM. If RAMP-DM was not arranged, the reason was documented in the CMS notes. 3.Dual gatekeeping for defaulters: For defaulted cases, doctors decided whether to call back the patient for RAMP-DM as the first level of gatekeeping. If it was determined that the patient need to be contacted, nurse and clerical staff then reached out to the patients by telephone to provide further information and encouraged them to attend the program as a second level of gatekeeping. The outcome of the enhanced service coverage was assessed after one year of implementation. The Chi-square test was used to examine the statistical significance of changes.
Result & Outcome :
A total of 61,237 T2DM patients managed in 13 GOPCs of KCC were identified in the diabetes registry in the year 2022. The majority were male (52.3%) with a mean age of 66.7±12.4 years. Among them, 22,842 (37.3%) patients had not been enrolled in RAMP-DM within the last three years. Of the patients without RAMP-DM, 7,287 (31.9%) subsequently attended the program. After one year of implementing the diabetes registry, the RAMP-DM coverage rate significantly improved. The percentage of patients enrolled in the program increased from 62.7% to 74.6% (P<0.001). With the implementation of a comprehensive diabetes registry, coupled with the adoption of multidisciplinary strategies, significant improvements were observed in resource allocation, service equity, and the coverage of RAMP-DM.
