Diabetes care in China: Innovations and implications

Abstract

Diabetes has become an important public health concern in China, with a rapid increase in prevalence from 0.67% in 1980 to 9.7% in 2007 and, then, a slight increase to 11.2% in 20171. China currently has the largest number of people with diabetes worldwide, with nearly one-quarter of global cases being found in China. In 2019, approximately 824,000 adults were estimated to die as a result of diabetes and related complications, with its estimated diabetes-related health expenditures ranking second to that of the USA1. The increasing prevalence of diabetes, high avoidable morbidity and mortality as a result of diabetes and diabetic complications, and related substantial economic burden make diabetes one of the greatest health challenges in China. Due to an uneven distribution of medical resources in China, with a lack of high-quality human resources and insufficient capacity in primary healthcare, the burden of non-communicable diseases on the whole society is high. Since 2009, the Chinese government has started the deepening of health system reform, and included type 2 diabetes as one of the two major non-communicable diseases into basic public health services to strengthen the public health system2. Regarding diabetes, the basic public health services package includes screening, regular follow up including a minimum of four blood glucose tests per year and blood pressure measurement, and health education. In addition, it was promoted to expand education and training for general practitioners (GPs); create a contracting system for GPs to improve the quality of primary healthcare; and establish a tiered service delivery system including tertiary, secondary and primary healthcare providers to better use of health resources, and the integration of healthcare delivery among different levels of health institutions. In Shanghai, the diabetes management services provided through community health service centers (CHSCs) have been started as pilot work since 2005. Since 2007, as a result of suboptimal diabetes management found in primary care, the Shanghai Jiao Tong University Affiliated Sixth People's Hospital has started a pilot model, an integrated hospital-community hierarchical diabetes management system, through seven CHSCs and a tertiary general hospital in Shanghai2. In this pilot model, the tertiary general hospital provided technical training for GPs and nurses in CHSCs to improve their capability for screening, diagnosis, treatment and health education of diabetes. Through the implementation of this model, the proportions of those achieving glycemic targets and receiving chronic complication screening have increased2. In addition, a multidisciplinary combined screening, diagnosis, treatment and follow-up platform for diabetes has been developed, and it has facilitated a close collaboration between tertiary general hospitals and primary healthcare institutions. It makes it feasible for high-risk general population and patients to receive timely and appropriate health education, diagnosis, and treatment services, and facilitates a better allocation of health service resources. With the continuous promotion of basic public health services, approximately 630,000 patients with diabetes were being managed at CHSCs by 20161. However, it does not give enough attention to improve synergy between public health initiatives and medical services. Based on the previous experience of the integrated hospital-community hierarchical diabetes management system, the Shanghai Municipal Government initiated a large project to develop a Shanghai Integrated Diabetes Prevention and Care System, the "Shanghai Integration Model (SIM)" (Figure 1), starting from 20151. The Shanghai Jiao Tong University Affiliated Sixth People's Hospital has been accredited as the Shanghai Technical Center for Diabetes Prevention and Clinical Care, with a close collaboration of the Shanghai Municipal Center for Disease Control & Prevention, and the Shanghai Eye Disease Prevention and Treatment Center. The SIM set out to promote the integration of primary and specialty care, as well as the content of diabetes care and public health services, including health education, screening, diagnosis and treatment, regular primary care, needed specialty care, care for complications, and self-management through peer support. All 240 CHSCs in 16 districts have been invited to participate in this project, with funding support from the Shanghai government. Through this project, prediabetes and diabetes screening for those at high risk, and complications screening for patients with diabetes were implemented in CHSCs, facilitated by the use of city-wide electronic patient registries, care coordination, and training and technical support from secondary and tertiary general hospitals, to enhance the capability of diabetes care in all CHSCs. In this project, approximately 325,000 individuals at high risk for diabetes have been screened for diabetes with the rate of newly-d