The number of individuals with type 2 diabetes mellitus (T2DM) in Singapore, a Southeast Asian city-state with a population of 6.5 million, is estimated to grow from 400,000 to 670,000 by 2030 and to an alarming 1.0 million by 2050 with the continuing rise in the prevalence of obesity [
1]. Total economic costs per working-age patient with T2DM in 2010 were estimated to be US$5,646, with total economic costs of US$787 million; this is estimated to rise to US$7,791 per patient and total economic costs of US$1,867 million by 2050 [
2]. The presence of complications and need for inpatient care are major contributors to these increasing costs. Diabetic nephropathy is a major cause of morbidity and mortality. Asian ethnicity, uncontrolled hypertension and proteinuria are major risk factors for progression to end-stage renal failure [
3]. Control of multiple risk factors, as in the Steno-2 study [
4], has been shown to improve cardiovascular outcomes, increase the length of time free from incident cardiovascular disease, reduce the risk of death from all causes and reduce the progression of nephropathy as measured by worsening proteinuria, glomerular filtration rate (GFR) and serum creatinine. Previous trials have also suggested the utility of the chronic care model [
5], structured recall [
6], regular nurse contact [
7], technology-enabled diabetes self-management education and support [
8,
9] and a multifaceted approach in dealing with diabetes mellitus [
6]. While most researchers have agreed that good glycemic outcomes are achievable through committing to appropriate intensive therapy and a team approach [
10], there are multiple barriers to the implementation of quality diabetes mellitus care. In particular, barriers to good diabetes mellitus care can include the absence of a system to prioritize clinical resources for patients who require more intensive management, inadequate self-empowerment of patients, inadequate use of effective behavioral modification techniques, ineffective use of technology to enable diabetes self-management education and support and the need to self-fund glucose monitoring devices and monitoring and treatment consumables.
Accordingly, we aim to find out whether stratifying patients according to their risk of developing diabetic complications, and channeling purposefully structured clinical resources to high-risk patients will be more effective than usual care in controlling diabetes mellitus and cardiovascular risk factors and in reducing clinical event rates. We plan to structure clinical resources such that these patients will have accessibility to interdisciplinary team clinic consultations, interspersed with remote follow up of their conditions by diabetes nurse educators (DNEs). The use of messaging systems, a diabetes-specific smartphone application and smart tablets with diabetes self-management educational material will be individualized for patients, according to their preferences for communication and their technological literacy. The aim is to test whether these changes to the diabetes healthcare system will improve outcomes, yet remain sustainable in the current climate of heavy clinical workloads.
Diabetic macrovascular disease, manifested by accelerated atherosclerosis, and its complications are the leading causes of morbidity and mortality in patients with T2DM. Individuals with diabetes mellitus have twofold to fourfold higher peripheral rates of arterial disease and an approximately 15 times greater rate of lower extremity amputations [
11]. At present, atherosclerotic lesions in the carotid arteries detected by ultrasound appear to represent total atherosclerotic burden [
12] but this has been found to be only weakly related to plaque burden in other peripheral arteries [
13]. Compared with carotid arterial plaques, the association between lower extremity atherosclerosis and general atherosclerosis has received much less attention. Our research aims to measure changes in femoral intima-media thickness (IMT) in high-risk patients with diabetes mellitus in response to intensive intervention, and investigate whether imaging to determine peripheral atheroma burden can help in predicting and preventing urgent and emergent peripheral vascular disease intervention.