1. 6/Aug/2008 in Queen’s town 6/Aug/2008 in Queen’s town Outcomes of Japanese Disease Management for Metabolic Syndrome Medical WG in APAN Queen’s town Naoki Nakashima, M.D., Ph.D. Department of Medical Informatics Kyushu University Hospital

2. Background of the project Pre-Diabetes Not Cared Specialist Doctors Cared 130 million citizen in Japan 10 million 4 million 1million Family doctors Dropout Acute and Chronic Diabetic Complications Increase of Medical Cost 3million Diabetes Mellitus Problems １． Continuously increasing patients and complications ２． Low hospitalization rate of patients (51%) ３． Shortage of specialist Drs. (=3,300 ） for diabetes Patients QOL Medical cost

3. Japanese Government started “ Particular Health Check-up System (PHCS = Tokutei Kenshin)” from April 2008 All of 40 ～ 74yo Japanese citizen (56 million) will have to take standard health examination All of 40 ～ 74yo Japanese citizen (56 million) will have to take standard health examination List of basic examination List of basic examination Questionnaire (weight change, smoking, exercise) Questionnaire (weight change, smoking, exercise) A physical examination A physical examination Height, Weight (BMI), Waist, Blood Pressure Height, Weight (BMI), Waist, Blood Pressure Blood/Urine chemistry Blood/Urine chemistry TG, HDL-C, LDL-C, GOT, GPT, γ-GTP, TG, HDL-C, LDL-C, GOT, GPT, γ-GTP, Fasting Blood glucose HbA1c, Hemoglobin, glucosuria Fasting Blood glucose HbA1c, Hemoglobin, glucosuria Moderate and high risk groups are required to receive standard healthcare counseling Moderate and high risk groups are required to receive standard healthcare counseling

4. Flow from health check-up to healthcare counseling Low risk group Moderate risk group High risk group Information provide Face to face counseling (once) Follow up (e-mail, phone) 75.1 ％ 13.4 ％ 11.5 ％ Intervention 2 Intervention 1

5. Data Accumulation And Stratification Arrangement of Health Check-up Annual Health Check-up Arrangement of Health counseling Navigation system of counseling Health counseling Dunning of Health Check-up Planning next year Data analysis Daily Health counseling and Support Encourage to attend a clinic Dunning of Health counseling Information Provided for all Motivation Support for moderate and high risk groups strong Support for high risk group For patients of Life Style Diseases Yearly Work Flow of PHCS as a Disease Management Start ! Stratificatio n Interventio n 2 AnalysisPlan Assessment Interventio n 1

6. Stratification Logic in PHCS 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 Obesity Grouping for Healthcare counseling Strong Support Group Motivation Support Group Informatio n provided Group ≧2≧2 1 ≧3≧3 1, 2 0 Number of Risk Factors* 65-74y.o. 0 *Risk Factors ① Blood Glucose ： Fasting ≧ 100 mg/dl HbA1c ≧ 5.2 % Under medication ② Lipidemia ： Triglyceride ≧ 150 mg/dl HDL-cholesterol<40 mg/dl Under madication ③ BP ： Systoric ≧ 130 mmHg Diastoric ≧ 85 mmHg Under medication ④ Smoking history ： + * ④ is counted if there is one point at least in ①～③.

7. Expected Privacy Problem of PHCS ・ Insurers will have economical penalties from 5year later, if they can not achieve outcomes the government sets. ・ Insurer has close relationship to each company in Japan. ・ Companies may start discrimination of obese employees with PHCS data (employment, salary, career, duty, etc). ・ We should make a strict law which prohibits illegal use of privacy data by insurers ASAP.

8. Carna Consortium Kyushu University Diabetes Specialist Doctors Saiseikai Kumamoto Hospital Kyushu Electronic Power Co. and group （ QIC ， QBS ） Tokio Marine & Nichido Fire Insurance Co. Fukuoka Prefecture Medical Association Fukuoka City Medical Association The Authorization document from Fukuoka Prefecture Medical Association Members Assented by 2003-2005 Japan Science and Technology Agency (Ministry of Education, Culture, Sports, Science and Technology ) 2005 Ministry of Economy, Trade and Industry 2006 Ministry of Economy, Trade and Industry 2008 Ministry of Economy, Trade and Industry 2008 Japan Science and Technology Agency 2008 Ministry of Health, Labour and Welfare 2008 Ministry of Education, Culture, Sports, Science and Technology Funded by

9. IT system developed by Carna for PHCS Data management system Booking system Navi system for indigivual meeting Management System for follow up counseling Evaluation and reporting system Navi system for group meeting Navi system for follow up counseling develped Under developed

10. ICT system (1) for data management system for health check-up and healthcare counseling Down loadable Data upload by HL7, Csv or input by hand Automatic stratification Appropriate information according to each result of health check- up HL7 CDA data Down loadable Secure Internet browsing

11. ICT system (2) for navigation of health counseling 1.Quality management of counseling 2.Automatic providing of information 3.Management of Personalized plan 4.Education tool of instructor 5.Using many animation for education *All data are accumulated as HL7CDA

12. Verification study of PHCS in 2007 by the Carna (results of stratification)

13. Effects of Intervention on Loss of Weight in verification study in 2007

14. Effects of Intervention on Loss of Waist in verification study in 2007

15. Effects of Intervention on blood examination in verification study in 2007 （ indicator of diabetes mellitus ） Blood sugar nChange by interventionp value (mg/dl) All 175+0.24 ± 1.0 0.812 Lowrisk 94- 1.3 ± 0.650.054 Moderate risk 16- 0.5 ± 2.220.825 High risk 46- 1.2 ± 1.310.350 Having medication 19+12.0 ± 7.530.130 ＨｂＡ１ｃ (%) nChange by interventionp value ( ％ ) All144-0.03 ± 0.28 0.231 Low risk 74-0.03 ± 0.350.437 Moderate risk 15+0.04 ± 0.100.679 High risk 38-0.14 ± 0.050.004 Having medication 17+0.11 ± 0.130.419

16. Effects of Intervention on blood examination in verification study in 2007 （ indicator of dyslipidemia ） Triglyceride n Change by intervention (mg/dl) p value All144-15.2 ± 7.160.036 Low risk 74-3.91 ± 6.160.528 Moderate risk 15-24.4 ± 23.20.311 High risk 38-32.8 ± 20.80.124 Having medication 17-16.5 ± 19.70.413 ＨＤＬ cholesterol n Change by intervention (mg/dl) p value All175+2.71 ± 0.72<0.001 Low risk 94+3.70 ± 0.82<0.001 Moderate risk 16+4.25 ± 1.950.046 High risk 46+0.90 ± 1.730.606 Having medication 19+0.90 ± 2.700.744 ＬＤＬ cholesterol n Change by intervention (mg/dl) p value All155+2.27 ± 1.800.209 Low risk 83+0.90 ± 1.960.648 Moderate risk 15+5.75 ± 6.840.415 High risk 40+2.15 ± 4.390.627 Having medication 17+6.13 ± 6.160.335

17. Effects of Intervention on blood examination in verification study in 2007 （ indicator of liver function ） ＧＯＴ n Change by intervention (IU) p value All144-1.41 ± 1.040.176 Low risk 74+0.07 ± 0.650.918 Moderate risk 15-0.93 ± 0.860.296 High risk 38-3.95 ± 3.610.281 Having medication 17-2.59 ± 1.850.181 ＧＰＴ n Change by intervention (IU) p value All144-3.12 ± 1.170.009 Low risk 74+0.41 ± 0.950.672 Moderate risk 15-1.20 ± 2.350.617 High risk 38-9.90 ± 3.220.004 Having medication 17-5.50 ± 4.210.253 ｒＧＴＰ n Change by intervention (IU) p value All175-13.0 ± 4.320.003 Low risk 94- 1.9 ± 1.380.160 Moderate risk 16- 1.0 ± 4.810.838 High risk 46-25.6 ± 11.60.032 Having medication 19+47.7 ± 25.60.079

18. Conclusion In Japan, the new health check-up system followed by healthcare counseling, which has been enforced in April 2008, and the online reimbursement of medical fee, which will be achieved in 2011, will change the circulation and accumulation of health and medical information. We need to establish secure and patient-centeredsocial system for the alterations. As a model of the social system, we presented a newly developed Japanese disease management for diabetes mellitus “Carna”. In Japan, the new health check-up system followed by healthcare counseling, which has been enforced in April 2008, and the online reimbursement of medical fee, which will be achieved in 2011, will change the circulation and accumulation of health and medical information. We need to establish secure and patient-centered social system for the alterations. As a model of the social system, we presented a newly developed Japanese disease management for diabetes mellitus “Carna”. If you have any questions, call to Carna office, +81-92-263-4385 Or carna@med.kyushu-u.ac.jpcarna@med.kyushu-u.ac.jp

19. Please send all presentation files to nnaoki@med.kyushu-u.ac.jp nnaoki@med.kyushu-u.ac.jp If you have any questions, call to Carna office, +81-92-263-4385 Or carna@med.kyushu-u.ac.jpcarna@med.kyushu-u.ac.jp