Metabolic Management Center: An innovation project for the management of metabolic diseases and complications in China

Over the past decade, epidemiologic studies have revealed a tremendous increase in the prevalence of diabetes and related mortality worldwide, especially in Asia.1-3 The general population-based survey in China in 2010, using the American Diabetes Association 2010 criteria, revealed that the prevalence of diabetes and prediabetes in adults was 11.6% and 50.1%, respectively, indicating that China has the highest diabetes prevalence in Asia and largest absolute disease burden of diabetes in the world.1 Lifestyle changes, aging, and obesity have become the main reasons for this increase in the prevalence of diabetes.1, 4 Consequently, the economic burden is increasing accordingly. It was estimated that, in 2017, diabetes-related global healthcare expenditure was nearly US$850 billion for those aged 18 to 99 years, with the main reason for the high cost being the treatment of diabetes-related complications.5 In China, the economic expenditure caused by the diseases is greatly increased compared with decades ago, and is expected to rise in the future.6, 7 In dealing with the prevention and treatment of diabetes, China has several challenges to face. First, in contrast with the high prevalence of diabetes, awareness of, adherence to treatment and control status among diabetic patients are relatively unsatisfactory,1 with the serious imbalance in the ratio of physicians to patients making it difficult to achieve early diagnosis and management of diabetes and its related complications. Second, the existing hospital treatment system can barely meet the needs of the rapidly increasing diabetes population. Patients with diabetes and other metabolic diseases need comprehensive examination and evaluation of possible complications, but the process from testing to diagnosis and to treatment is time consuming. Third, the Healthy China 2030 strategy (http://www.who.int/healthpromotion/conferences/9gchp/healthy-china/en/, accessed 10 September 2018), released in 2016 by the State of China to improve the overall health of its citizens, is currently in progress and being actively promoted, and the management of chronic diseases (including diabetes, hypertension, and dyslipidemia) should be handled at different levels within a tiered medical services policy. Because there are gaps between recommended guidelines and the real-world care for diabetes in China due to wide variations in the economy, cultural development, and medical service standards in different regions, it is necessary to first establish a pilot and standard system to deal with the challenges that can be replicated and extended to different regions nationwide, and to then dynamically integrate advanced technologies into this system. In order to meet all the challenges in the treatment of metabolic diseases, the National Metabolic Management Center (MMC) was founded in 2016. With advanced medical equipment and Internet of Things (IoT) technology, the MMC is committed to creating an online and offline integrated solution for diabetes, and for the entire spectrum of metabolic disease, to achieve a more convenient and precise model of care for patients. The MMC is focused on establishing highly efficient diagnosis and treatment, as well as comprehensive disease management both in and out of hospital. All MMCs in China have the same structure in terms of facilities, layout, and databases, as well as the same routine daily operations, aiming to establish a platform with standardized diagnosis and treatment of metabolic diseases and their long-term follow-up. This platform of treatment is called the “One Center, One Stop, and One Standard Model.” In the MMCs, patients can enjoy one-stop care to receive a comprehensive series of services from registration, tests, evaluation, prescriptions, to health education. Under the guidance of the MMC Experts Committee, more than 400 stringent standard operating procedures are set up for quality control of the MMC operation. Furthermore, with technological innovations (e.g. the “all-in-one machine,” which ingeniously integrates different examination equipment), the process of screening for complications can be greatly shortened. In addition, the MMC has established an independent digital medical record system integrating real-time in- and out-of-hospital information of patients into a centralized medical data center that can be exported through various IoT instruments, including apps, Wechat, and a teleconsultation system, to enable patient care to be extended from the MMC to anytime, anywhere outside the center. The objective of the MMC is to launch a new metabolic disease community management model based on the Internet health information platform. Moreover, the MMC helps improve adherence to and the effectiveness of treatment for patients, thus benefitting both patients and doctors. The proprietary electronic medical database in the MMC will make dynamic big-data analysis in diabetes epidemiology, prevention, diagnosis, and treatment very efficient and effective. Furthermore, this nationwide standardized care system also forms a collaborative research network for prospective interventional studies on treatment and prevention. Therefore, in the long run, the MMC will offer large amounts of data and evidence from hospital-based care to achieve long-term optimal health outcomes, enabling a replicable standard care model across the entire country that can form the base for future healthcare policy improvement. Currently, MMCs have been launched in approximately 100 hospitals and are providing care to more than 40 000 diabetic patients nationwide. By the end of this year, nearly 300 hospitals, including community hospitals, will be involved in the MMC network to truly enable a system of tiered medical services for diabetes management. Recently, medical tools were developed to facilitate the screening, diagnosis, and treatment of diabetes in MMCs using artificial intelligence technology. One example is the Rui Ning Zhi Tang (瑞宁知糖), a diabetes risk assessment tool. The model of this assessment tool was constructed based on cohort follow-up data from the national large-scale epidemiological study, the Risk Evaluation of cAncers in Chinese diabetic Individuals: a lONgitudinal (REACTION) Study.8 With this tool, people can be informed of their risk of developing diabetes in the next 3 years and obtain individualized recommendations, thus identifying subjects at high risk of diabetes and contributing to prevention and early diagnosis. The second example is the Rui Ning Yu Tang (瑞宁预糖), also called the “metabolic index,” which predicts cardiovascular risk using six routine parameters. This was developed to assess the risk of diabetes-related cardiovascular complications within 3 years, and the model has been validated in large populations with favorable accuracy and reliability. The third example is the Rui Ning Zhu Tang (瑞宁助糖), the so called “Dia-Master” auxiliary system, which uses artificial intelligence to modify the diagnosis and treatment processes of diabetes by first standardizing and integrating desensitized patient information with the experience of the nation's top experts, then consolidating the latest international and domestic diabetes-related guidelines and literature to construct a medical knowledge map, finally providing medical advice for patient care. Today, we are facing great challenges and heavy workloads to control diabetes; hence, the set up of MMCs should be an endeavor to optimize diabetes management by establishing standardized care procedures across the entire country. This is one of the steps by which China can develop a comprehensive plan to conquer this disease and improve its long-term outcomes, as well as to lessen the huge economic burden associated with diabetes. The MMC is also a good example of chronic disease management through standardization of procedures and innovations in disease care by applying IoT technology in developing countries worldwide. No funding received. The authors report no conflicts of interest in this work. 在过去的十年中, 流行病学研究显示, 在全球, 尤其是亚洲, 糖尿病及其相关死亡率急剧上升1-3。依据2010年美国糖尿病协会的诊断标准, 我国2010年流行病学数据显示, 成人糖尿病和糖尿病前期的患病率分别为11.6%和50.1%,表明中国是亚洲糖尿病患病率最高的国家, 也是世界上糖尿病绝对负担最重的国家1。生活方式的改变, 社会老龄化和肥胖已经成为糖尿病患病率上升的主要原因1,4。同时, 也给社会和经济的发展带来了沉重的负担。据估计,2017年18至99岁年龄段与糖尿病相关的全球医疗保健支出近8500亿美元, 高昂花费的主要原因是糖尿病相关并发症的治疗5。在中国, 与几十年前相比, 由相关疾病引起的经济支出大大增加, 并且预计将会持续升高6,7。 在糖尿病的预防和治疗上, 我国面临着巨大的挑战。首先, 与糖尿病的高患病率相比, 糖尿病患者的治疗意识、依从性及控制状况相对较差1,医患数量比例严重失衡, 难以实现对糖尿病及其相关并发症的早期诊断和治疗。其次, 现有的医疗体系难以满足迅速增长的糖尿病患者的需求。糖尿病和其他代谢性疾病患者需要对可能的并发症进行全面检查和评估, 但是从检测到诊断再到治疗的过程非常耗时。另外, 我国于2016年发布《“健康中国2030”规划纲要》(http://www.who.int/healthpromotion/conferences/9gchp/healthy-china/en/, accessed 10 September 2018),旨在全面提高国民健康水平, 目前正在全面推进, 完善慢性病(包括糖尿病、高血压和血脂异常)的分级诊疗制度。由于不同地区的经济、文化发展和医疗服务标准差异很大, 因此推荐的指南与中国真实世界的糖尿病诊疗之间存在差距。为应对这一挑战, 有必要建立一个试点和标准体系, 可以复制、扩展到全国不同地区, 并可以动态地将先进的技术集成到这个系统。 为了应对代谢性疾病治疗的所有挑战, 国家标准化代谢性疾病管理中心(National Metabolic Management,CenterMMC)于2016年成立。凭借先进的医疗设备和物联网(Internet of Things,IoT)技术,MMC致力于为糖尿病和整个代谢性疾病谱创建线上线下、院内院外多重获益的诊疗模式, 以实现更方便、更精确、更高效的糖尿病诊疗。 全国所有的MMC在设施、布局、数据库等方面都有相同的结构, 日常运行也规范一致, 旨在建立一个对代谢性疾病进行规范化诊疗和长期随访的平台。该平台将围绕“一个中心, 一站式服务, 一个标准”的核心思想, 为患者提供从注册、检测、评估、处方到健康教育等一站式全方位服务。目前在专家委员会的指导下, MMC为代谢中心运行的质量控制建立了400多个严格的标准操作规程。此外, 通过技术革新(如“代谢一体机”巧妙地集成了不同的检测设备),可以大大缩短并发症的筛查时间。另外,MMC还建立了一套独立的数据管理系统, 实时采集患者的院内和院外信息, 并同步整合到中心数据库, 该数据库还可以通过各种物联网工具出口, 包括APP、微信和远程会诊系统等, 将对患者的健康状况管理从MMC扩展到中心以外的任何时间和地点。 MMC的目标是在互联网健康信息平台的基础上建立一种新的代谢性疾病综合管理模式, 有助于提高患者治疗的依从性和有效性, 从而使患者和医生同时获益。MMC专有的电子医疗数据库将会使糖尿病流行病学及其预防、诊断和治疗中的动态大数据分析过程变得非常有用且高效。此外, 这一全国性的标准化医疗体系还形成了一个协作研究网络, 可用于代谢性疾病治疗和预防的前瞻性干预研究。因此, 从长远来看,MMC将会产生大量临床诊疗的数据和证据, 以此获得长期最优的健康结局, 从而使可复制的标准诊疗模式遍布全国, 为未来医疗保健政策的改进奠定基础。 目前,MMC已在约100家医院推出, 并为全国4万多名糖尿病患者提供诊疗服务。至今年年底, 将有包括社区医院在内的近300家医院参与到MMC中, 以真正实现糖尿病管理的分级诊疗体系。 最近,MMC利用人工智能技术开发医疗工具, 以促进糖尿病的筛查、诊断和治疗。其中, “瑞宁知糖”可用于评估糖尿病患病风险。该评估软件是基于全国大型临床流行病学研究“REACTION研究”的队列随访数据8。通过“瑞宁知糖”, 人们可以了解自己在未来3年内罹患糖尿病的潜在风险, 并获得个体化建议, 从而识别糖尿病高风险的受试者, 有助于糖尿病的预防和早期诊断。 第二个工具是“瑞宁预糖”, 也称为“代谢指数”, 它通过6个常规参数, 来预测未来3年罹患糖尿病相关心血管并发症的潜在风险, 该模型已在大样本人群中得到验证, 具有良好的准确性和可靠性。 第三个工具是“瑞宁助糖”, 即“Dia-Master”人工智能用药引擎。该引擎通过革新糖尿病的诊断和治疗模式, 首先将患者脱敏信息进行标准化整合, 结合国内顶级专家的经验, 汇总国际和国内最新的糖尿病相关指南和文献, 构建医学知识图谱, 最终为患者诊疗提供医学建议。 当下, 我们正面临着缓解和控制糖尿病发展势头的巨大挑战, 承担着繁重的工作任务; 在此背景下, 通过在整个国家建立标准化诊疗模式, 建立MMC是优化糖尿病管理的一次努力和尝试。这是我国制定全面计划, 控制糖尿病等代谢性疾病并改善其预后, 减轻与糖尿病相关的巨大经济负担的步骤之一。MMC也是全球发展中国家应用物联网技术制定疾病诊疗标准化流程和革新的一个很好的例子。