Hypertension Clinical Trial
Official title:
Effects of Multidisciplinary Intensive Targeted Care in Improving Diabetes Outcomes: a Randomized Controlled Pilot Study - the Integrated Diabetes Education, Awareness and Lifestyle Modification in Singapore (IDEALS) Program
This study aims to investigate whether channeling purposefully structured resources to patients at high risk of developing diabetic complications to interdisciplinary team clinic consultations, interspersed with closer remote follow-up and aided by simple technology will be more effective than usual care in controlling diabetes mellitus, controlling multiple cardiovascular risk factors and reducing clinical event rates.
The prevalence of diabetes in Singapore is estimated to grow from 400,000 to 670,000 by 2030
and an alarming one million by 2050 with the continuing rise in obesity prevalence. The
current system currently has no formal stratification of patients for channelling of
structured resources to patients that require more intensive treatment and follow-up (those
at higher risk of progressing to having complications from diabetes due to poor glycemic
control, or those who have signs of early complications).
We will therefore be researching effective health system delivery strategies to improve
achievement of treatment targets (eg. HbA1c, blood pressure, LDL) and reduce vascular
complications of diabetes mellitus (retinopathy, proteinuria, end stage renal disease,
ischemic heart disease). These include:
- Stratification and channelling purposefully structured resources to patients with poorly
controlled diabetes mellitus defined as having an HbA1c >9% on 2 or more occasions, and
patients with diabetic complications (estimated glomerular filtration rate eGFR
30-60ml/min or proteinuria >0.5g/day or urine microalbumin:creatinine ratio >300mg/g)
- Training of all doctors/DNEs/dietitians involved in the counselling of patients in the
field of motivational interviewing
- Providing easy accessibility to resources to allow patients to self-monitor their
capillary blood glucose and blood pressure in between clinic visits - loaning of blood
pressure units and glucometers for short (1-2 week) periods regularly
- Providing frequent telephone counselling by DNEs and Renal Pharmacists with regards to
titration of medications, in particular ACE-inhibitors or angiotensin-receptor blockers
to reach treatment targets
- Utilisation of social media and smart phone/tablet applications for relevant patients to
improve and increase patient-healthcare professional interaction with regards to
diabetes, provide daily bite-sized education via tablet/smart phone media/social media
and improve compliance to exercise targets
;
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