1. Diabetes Screening and Risk Factors: Safe Smart Screening (SSS) Dr Samya Ahmad Al Abdulla

2. I, Dr. Samya Ahmad Al Abdulla DO NOT have actual or potential conflict of interest in relation to this presentation.

3. Population Health Screening in Qatar
The QNHS is based on the Triple Aim of Better Health, Better Care, Better Value.
Triple Aim will include life expectancy, years of potential life lost, disease burden (the incidence and/or prevalence of chronic disease), hospital utilization rates, clinical quality measures and cost.
“ Screening refers to the use of simple tests across an apparently healthy population in order to identify individuals who have risk factors or early stages of disease, but do not yet have symptoms” (WHO, 1968)
“A national screening program is fundamental to the design of the future diabetes care model. The program will screen the long-term resident population to identify individuals who are healthy, those who are at high risk (e.g. obese or overweight with a family history of diabetes), and those who meet pre-diabetes or diabetes criteria. Identifying and registering these different groups will enable each to receive continuous and coordinated patient-centric support through each phase of the new diabetes care model: lifestyle intervention counseling, patient empowerment and education, annual exam tracking, clinical care, and complication prevention”. (NDS, 2016 – 2022)

4. Patient identification
A robust situational analysis including review of data, patient feedback and staff opinion determined current and desired future states:
FROM TO
Undiagnosed diabetes; little identification of pre-diabetes
Patient identification
All those with diabetes or pre-diabetes identified
Single, shared registry of target cohort
Registry
Fragmented lists of diabetes patients
Care Plans
No systematic care plans for patients
Individual plans for all those with diabetes or pre-diabetes
Pathways
Inconsistent care pathways
Clearly defined pathways
Diabetes SMART Clinics program target (i.e. what we want to achieve)
Description of current situation and what we want to achieve through Diabetes SMART Clinics program
Accountable Care SMART Clinics in Qatar: introduced by Brookings Institute to Qatar through the office of The World Innovation for Health (WISH), with the aim of providing inputs to a global policy based on the learnings from a pilot program on Diabetes
Objectives of program:
Healthy population focus on diabetes management
Improve integration of care among providers
Better alignment of resources/funding - reduced costs
Agreed KPIs monitored consistently across organisations
KPIs
Various KPIs monitored separately across organisations

5. Why Diabetes - what is the significance for Qatar?
Four out of ten adults with diabetes in the Middle East and North Africa are undiagnosed.
The estimate in 2015 is that 17% of the adult population in Qatar, or about 85,000 individuals, have diabetes compared to 8% of the global prevalence (IDF, )
Diabetes as we all know places a large impact on the population of Qatar
Given the prevalence of such a disease and in collaboration with the National screening framework”, the screening for DM and its risk factors is essential to reduce disease burden and its complications
A population based screening offered through PHCC and in collaboration with HMC and the MOPH has been piloted to systematically screen our population
Patients are screened using the “SMART health check” that evaluates their risk factors and plugs them into a preventative management plan to ensure better health outcomes

6. Additional Health Risk Factors
CVD:
An estimated 17.7 million people died from CVDs in 2015, representing 31% of all global deaths. Of these deaths, an estimated 7.4 million were due to coronary heart disease and 6.7 million were due to stroke.
These diseases have remained the leading causes of death globally in the last 15 years, and they are the leading causes of death in High income economies. Source: WHO (2015)
Mental Health:
1 in 5 people are affected by depression and anxiety at some point in their lives (10% of world population).
Depression increases the risk of NCDs and impacts effectiveness of NCD treatment.
Lack of treatment for common mental disorders has a high economic cost.
The most common mental health disorders can be prevented and treated at relatively low cost if screened and identified early.
Obesity:
In the MENA region 73% of females and 69% of males are classified as obese (BMI ≥30)
Qatar has the 6th highest rate of obesity among males in the MENA region
Source: WHO (2015)

7. Primary Care based screening model
The primary objective of the SMART Health screening is to act as a gateway into the full range of primary health care services and support the population of Qatar to take steps to maintain or improve their health.
Priority patients are identified and invited to screen and their risk stratification assessed.
Management / treatment plans are set up based on individualized care needs

8. SMART Health Checkup Assessment Appointment – What the nurse does:
The Comprehensive SMART Health Check
SMART Health Checkup Assessment Appointment – What the nurse does:
SMART Health Checkup Consultation Appointment – What the physician does:
Vital signs (BP, weight, height, waist circumference, temp) and ECG.
Assessment: personal medical history (incl. mental health screening); family medical history; social history.
Lab orders include: CBC, CMP, HbA1c, Thyroid Function Test (TSH) and Lipid Panel (non-fasting)
Review the information obtained in the checkup assessment and lab results.
Perform a physical examination.
Explain to the patient their health status.
Determine what health care needs the patient has and develop a personalized care plan to meet the identified needs.
Provide any necessary counselling, treatment, referrals or further investigations.

9. Key findings
The findings were picked up through the physical/biomedical measures for the 4494 persons who underwent SMART Screening.

10. HbA1c Result explained by physician
The Comprehensive SMART Screening – HbA1c pathway
HbA1c Result explained by physician
Non-diabetic HbA1c ≤ 5.6%
PHCC Provide educational advice and leaflets
Recall patient for rescreening after one year
Pre-diabetic HBA1c %
Personalised Care Plan
Diabetic HbA1c ≥ 6.5%
Personalised Treatment Plan

11. In summary, the purpose of the SMART Screening includes:
Identify and understand community health priorities through engaging and screening the population
Support future strategic forecasting, including expenditure and health outcomes
Initiate personalized treatment and maintenance measures to reduce the burden and cost of disease on the health system
Improve health outcomes for the community by reducing morbidity
Encourage co-ordination of care between providers
Integrate care with other locally relevant strategic priorities