 We have two friends of public health from our campus who join us for this series. Professor in statistics is being here at UCI. It's actually a study and statistics program here. We have a very good friend to public health. Many of these are from our campus. Anybody else wants to ask Dr. Ira any thing about his life? He likes to tell the story of how it's not about what he's supposed to talk about. How long do you want him to speak? Don't ask questions that could provoke him. How are you? I'm very good. Are you able to stay for a month? Okay. It is my distinct pleasure to introduce Dr. Chris Ayer, who is the medical director for the Mary and Dick Amin Diabetes Center at Polk Hospital in Port Beach. He is a great friend of public health revealed in part by his commitment to a population-based management of diabetes, one of the biggest disease burdens that the country and the entire world actually faces in its growing. He's practiced medicine internationally. He has served many, many boards to guide how we do medical practice in public health effectively. He has won many awards and he is also one of the beneficiaries of student education for the public health program here. He has placed some of our students in the diabetes clinic and so he's a teacher, he's a medical practitioner and just a wonderful human being. I'm looking forward to this presentation. Thank you. Thank you, Deli. My voice does carry the only problem I have is that I tend to speak a little too fast and if you feel that way, raise your hand and I'll slow down. Thanks Deli, Deli and I have come to work together the last few years and the best is yet to come. As far as Deli is concerned, our center is concerned. What I thought I would do is give you a brief background about Mary and Dick Amin Diabetes Center, about Polk Hospital. And then I'll expand it into diabetes as a public health problem. Then I will challenge you to take up the offers at the center that you found. So let me start by saying the history of Mary and Dick Amin Diabetes Center. I was chief of staff in 2001. Those of you who do not know medical politics, chief of staff is in an elected position at Hogue Haslub. The term, we are the officers of the medical staff. The state of California expects the medical staff to be independent of the administration for the simple reason that the patient should be taken care of, not because of the cost it will be, but because the patients have to. And because doctors are claimed to be uniquely qualified to run patient care effects. All medical care affairs in the state of California must be driven by medical executive committee and medical staff. And the board of trustees are ultimately responsible for everything that happens. And they are posed by law Title 22 to make sure that the medical staff is adequately funded, to be self-regulating, so that the advice and consent that they provide to the board regarding clinical matters is by the medical executive committee and medical staff. There are various definitions and various commitments that medical staff has to make. It is not to protect their own self-interest, but to protect the interests of the patients and the state of California insists on that. Hence the medical staff elect their own officers and their own department chiefs and at Hogue Hospital the term for the officers is six years, two years as the chief of staff elect, two years as the chief of staff and two years as the ex chief of staff. The chief of staff at Hogue Hospital carries probably very powerful position. It is third only after the chairman of the board, the CEO and the chief of staff. I was very fortunate to be elected and when I became the chief of staff I had already been involved in the development of various protocols for diabetes. I met the chairman of the then chairman of the board Mr. Allen, whose granddaughter had become diabetic at the age of two just the previous year. So he was passionate, he was driven. So with his help and the then CEO help we started the small diabetes education center at Costa Mesa. That education center then started becoming bigger. With a lot of help and support from various people we went to the board, went to the community and said we need to have a comprehensive diabetes center. Whether it is right or wrong, most of the policies that we have developed, some of us at least, always developed those policies by asking the people who deliver and asking the people whom we serve. We wanted them to be part of the program that would evolve around them. So Mr. Allen wanted a diabetes center. So he said go ahead and prepare a business plan. I'm a doctor, I don't know business plan. I did something and his office actually was across here in the tall building, UCI, where Chakra restaurant is and all those tall buildings. So his office was here. I gave him the plan. He's such a nice man. He doesn't comment on the bad qualities. He approaches like, if you're good, let me work with you. So he put it aside. Then a couple of years later, he said, dream. Dream as far as you can. This is his work. We're still there. And if you were given everything that you want and if you want to provide care for the diabetics, come up with the plan. I had an administrator at that time who was a close friend of mine. He's now the chief administrator for Durban, Mr. Brathwaite. He and I sat down and started working. My mentor was Dr. Joe Ship, who set up diabetes clinics all over the world. And he goes to India even now without taking malaria tablets. And he has set up clinics everywhere. So he's my mentor. I asked him how to do it. So we came up with key elements, which are, that will be comprehensive, which I've served everybody. And especially the underserved. And without consideration for ability to pay, and shall never close. Because ladies and gentlemen, economy is bad. Hospitals, most of them depend on the profits they make. The margin in the hospital is about 3 to 5 percent. The margin in my office is 55 percent. So the hospitals have to be very, very careful how they spend the money. Diabetes program does not produce money. In the first program, they will stop in any hospital's diabetes program. It is true everywhere. So we have to have all this in place. And we presented a business plan. And Robert negotiated the chart because if there were no children, it is not comprehensive. We underserved children. Hope does not know how to take care of children. So we need to have them. We need to have all the doctors. We need to have psychologists, social workers. We need to have educators. All in one building. So we prepared a plan and submitted to the then board of directors and the chairman. By then we had a new senior, a new chairman. And they approved the plan and the board said, go ahead. It was going to cost us half a million dollars. And we went to the foundation, which raises money for us. So I removed the president in it. And they said, why not? Why not 18? Is it fine? Then the business office came and said that you cannot run this for 18. So we need to have 24 million dollars. So we actually have 24 million dollars in order to do all of it. We raised that. And it will be 24 million in the next three years. That's because people in our service area are very generous. But the program cannot be because what I want or what the nurses want. So we contacted all the people who deliver care in the community. Children's Hospital of Orange County, JDRF. You can see JDRF walk next week that this week. EDA, Latino Health Access. All the people who put them in one building. We said we're going to develop a center. By the way, the board name is Centres Mediante Caledadine Center. So these people and our own community medicine department, we spent. We make a lot of profit. But most of the profit is either put back into the community building or we have a community medicine department. So in function of that community medicine department, we disperse funds from our profit, from the operating profit. And we have to call them into. Some of you may already know about this, but community medicine. So we developed that center. We developed a program. The program will be that we'll take care of children. Charter is given the sole responsibility. We take care of young adults. We develop a program. Then we will take care of the elderly. We take care of pregnant women. So those are all in it. When we talk about underserved, we talk about children, Hispanic population, other population. So that's how the center was formed. The whole diabetes care has always been in the forefront. My wife always tells me when you talk like this, it looks as though you're gloating. I gloat with great humility because HOG has given us a lot of resources. The resources are almost unbelievable. I mean, I'm really very happy at this moment with that. Whatever we ask for, they give it to us. In order that that's the right thing to do with the patient. So we started improving diabetes care many years ago when we improved blood production. When the doctor called like 2 o'clock this morning, I got called for a patient's blood glucose and I had to give insulin. There were many areas that were taking place. So we formed the first super team which was the medical error reduction team. So we organized a way of ordering the medications in a standardized form except that I will convey my sincere apologies for doing that. I created a monster which was bad. We created an order set to deliver orders for insulin which is not the right thing to do. But I soon made up by changing those order sets. That was the first experience. Then in the late early 2000, 2003, reports came about saying that if you manage diabetes patients with high blood sugar very tightly in critical care, you can reduce the reduced length of stay, reduce complications. So we went to the hospital administration and quality improvement committee and we said we want to reduce that. So we developed an algorithm based insulin treatment which was standardized with less radiation. That's what we are supposed to do. So that became very successful. Then the quality department said, would you like to do that in the entire hospital? So I'm looking for doing all these things. You see, moving the doctors has always been very passionate. So we developed hospital-wide program. We have one of the 300 hospitals in the country which uses only three insulins in the hospital. We do not have any other medications. The doctors are like Captain Scully. You know, Captain Scully has control tower directing his traffic. You remember Captain Scully who landed the plane in Hudson River? What did he do? Every pilot has the same way of contacting the control tower. From the control tower contact the pilot the same way. There can be no changes. It's flight 230 turn left. Pilot will say, control tower, flight 230 will turn left. They have to read through the law. They control. All flights are controlled. But algorithm-based treatment when it is controlled, doctors dissent it. You know what? Right from the day we go into medical school, we are founded. You are responsible for your patient. You are responsible for your patient. You are responsible. Anything happens to your patient. You are responsible. So we developed this God complex. Because, you know, all of you know that. We think we are super human beings because we are made to be responsible. We don't like people telling us how to take care of our patients because very jealous of our patient care. We take care of it very seriously. But when you give them predetermined order sets, they feel emasculated. They feel they cannot control it. But they are Captain Scully's. What did Captain Scully say when the control tower said turn right, go to LaGuardia. He said negative. And he turned left to land in Hudson River. Now, so the order set that we created has resulted in cost savings for us because we do not have any other medications except for three units left. The order set also has put us in the top quartile of the hospitals in the country. They call and ask me why not the top this side. And we are this year. Only UCLA is better than us. So that was a major achievement except that those orders which we created in the critical care are not going to be too dangerous. I'm sure some of you were following medical policies and medications. If you manage critical care patients very tightly, 90 days post treatment, there was an international study that showed that those people who are controlled tightly, they die more than those people who are not. So we have to wake up. So we have changed the entire order sets. We also will be giving intravenously insulation in a standardized algorithm based manner delivered by a computer based software which will be started first of January. They are all being trained. That's the end of tool. Hospital wide we have relaxed the standards. One order cannot fit everybody. So that is also being will be approved by the medical executive committee. They are tomorrow they will start. That is in the hospital. 85 percent, 90 percent of diabetes care is in the outpatient community, not in the hospital. But we have done some of this. So as I said, the key elements of the center were community comprehensive, serve the underserved, now without consideration for ability to pay, never shall it close. And we want it to be from cradle to grave. That's the basis of outpatient, variantly calendar diabetes center. This is the variantly calendar diabetes center some of you have already come there and seen the place. Those of you who have not come and visited us will show you around. It's a very fabulous center. We have children's wing, we have physicians' offices, we have companies who small family and we are very happy. My office is directly behind that. Directly behind. Keeping track of all the people working, making sure they're working. So what are the projections for Orange County? I have, those of you are interested in more statistics. This is our business development office. They're a great resource for us. Whatever we want, they'll call it out and give it to us. And I have the table at the end. I won't be talking about it, but if you're interested, we'll be happy to provide those details. These are projections. The population in Orange County in 2010 will be about 75,846. And 250,000 in the office. I want you to remember this. There are slides coming down. Keep in mind this burden that is going to be. If there was ever a problem that could be solved, I want you to remember this. There are slides coming down. Keep in mind this burden that is going to be. If there was ever a problem that could be solved, if there was ever a problem that public health... Most of the details we have obtained are from public health publications. Nothing can be more important for this country as I'm going to talk to you about the control of diabetes. I'll talk to you about some countries which are more diabetic now, little they spend on how much they're spending, but we're not getting the bank for the buck. The majority of diabetes with that population 5.5% of the people are diabetic 16, 1. The type 1 diabetics are slightly different. There may be some mistakes. Type 1 diabetics are those people who do not have insulin. Majority of them are children, but they will grow up into adults because of the care that they provide. And type 2 diabetics are environmental factors and other issues. But we see 12 and 13 year old young children with 200 pounds getting diabetes. So more type 1 patients are going to be older, more type 2 patients are going to be younger. Remember the complications of diabetes are terrible. And what's the incidence of diabetes this is what we expect that 7.2 for 1,600 9 females will be diabetics and new onset of type 1 diabetics will be about 2,081.35 There is a slight preponderance of females in type 1 diabetes we do not know the reason for it and the new onset type 2 diabetes as it says it's about 6 to 1, 7 to 1 more towards type 2 but we are seeing more type 1s. So diabetes yesterday ladies and gentlemen was the sixth leading cause of death. Heart disease is coming down lung cancer disease is coming down people are not smoking heart disease people are doing heavy life better medications automobile accidents common diseases as people stop smoking chronic lung diseases will get better. So diabetes is the next leading cause unfortunately it's increasing people because if you have diabetes for a long time and many of the type 1s started 2 or 3 they have more complications. So diabetes is a burden not only for the cost of care but from the mortality of lots of young and new and that's an important thing you must remember. What has happened if the cost of care is about $180 million we do not have the latest this is 2007 and 2008 which should be published I think in about 6 months the latest cost that $180 million is both direct and indirect cost. 22% of all hospital stays in this country is by diabetes and in our hospital 18 to 19% of our patients is all diabetes 23% of our patients who get cardiac surgery have diabetes and leading cause of blindness in the ages of 18 to 42 is diabetes leading cause of non-traumatic amputation in the same age as diabetes leading cause of people failure is diabetes. One amputation costs $70,000 one patient amputation of dialysis costs $150,000 it's not about amputation it's not about dialysis it's not about blindness it's about loss of self-esteem loss of productivity of those people imagine a 40 year old there are a few of them now but I used to have a lot of them sitting in the wheelchair not being able to see we look to a dialysis machine see the I mean you have many of them and this is that story unfortunately all this can be prevented that $180 billion we are spending 51% of them in the 51% I am out of money and the patient look I am surprised that diabetes is supposed to cause it seems to be in the right sense but where is the one going America has never helped itself we have been procedure driven we have been device driven we have never been community driven if there is one disease it begs for the community to be involved in that it's not a disease of the individual my wife is most of the life my daughter my friends everybody knows what my problem is it is not a disease of the individual it's not a disease I can take care of in my office it's a disease that has to be taken care of by the community but the way our health I am not being political yet the way our healthcare system is developed procedures and costly investments and devices we have not taken into consideration the human sufferings we do not know how to pay for my services when I spend 30 minutes to a diabetic family but I can pay $5,000 if I have to fix my hip I can pay $10,000 if I have to have any more eye because that's fancy device operation driven our healthcare developed from in the late 1800 trauma and infection those are the big reasons why American health industry is more towards devices and fancy we have the best equipment we have the best talent to take care of but when it comes to cooperative community based treatment and measures we are not doing that when I was a GP in England see I got back to English accent for a second I had babies at home I took care of dying patients at home I would give Brompton cocktail the cop would call me in the evening doctor would go, Brompton cocktail prescribed for the dying patient they kept lack of drug prescription I would have health visitors every morning from 8 to 8.45 telling me which patients need home visits which children needed to be seen which mothers needed to be seen before I started with general practice I got a call one evening before I started this is the Wicker here Wicker I am not a Christian doesn't matter you are the parish doctor so St. Stephen's parish meets every Wednesday in a church built in 980 the pews were still made of stone I had to be responsible for my brothers and that is the way the society is most of my ideas about taking care of people came from I didn't learn medicine I learned how to take care of human beings so that is a cultural shift so how best we can do is what we have to approach this so who else are responsible if I am as an Asian I am I am susceptible to diabetes African American Latino population South Asian which is me Chinese, Vietnamese Arabs Pacific Islanders are all at risk for type 2 diabetes 1.5 to 2 times more than a Caucasian as you go on campus the beginning of UCI is a deception of campus and covered and across this uni high University high school how many languages are spoken in the homes of those children some of you who are from UCI cannot answer this question from uni high cannot answer this question how many languages are spoken in the homes of children attending University high can anybody guess those of you who came from uni high cannot answer this question no you cannot because you know the answer try how many languages are spoken in the homes of children attending uni high a mile from here 24 35 12 15 55 plus 55 plus how can I develop a program for diabetes when I do not know how to explain to them in their languages majority of us are second in the first generation even the children who are very Americanized when they go home they have to eat the same food that we eat so we've got to remember that a public health problem of such enormous proportion made worse by not being able to deliver care in the manner they understand it and follow it so the United States is the capital of diabetes but don't you're not going to be there for a long time both India and China are chasing you very fast it's a competition between India and China China has one in ten of the population of that ten percent of the population as being diabetic India is the same about ten percent thanks God for Americanization of the rest of the world the reason they became diabetic is because genetically they had the genes but then when I go back home not anymore but when we used to go back home in order to buy a bar of soap had to get out of the house and walk in order to buy simple groceries I can get into my car and go to the supermarket we had to walk and bring back so the society was made about lots of exercise and we didn't eat a lot of carbohydrate but it was worth the first generation of doctors who came to this country were from India you know 27 percent of doctors in this country are from overseas 87 percent of them are from India and the first set of doctors who came in the 60s with Medicare being passed all of them are dead they all died of heart disease so they have a genetic problem because our life decayed to fruit we started eating McDonald's hamburger we drove in cars so we get into a car come to 24 hour fitness a mile away you could have walked there and come back so the genetic predisposition environmental changes all make diabetes more obvious in this population 8 percent of our population are diabetic we see patients for the first time with complications 50 million are risk for diabetes and can you imagine the burden that the society is going to pay while we are the capital will soon be overtaken by China India depending on their increased exercise so according to some public health officials it's a fabulous article if you are interested I'll be happy to provide this this is the projection that we'll be spending 50 billion dollars for the care of the nation now so at Billion E-Cal and Diabetes Centre we cannot solve the world's problem but if those elements were to be part of us these are the programs we have created and we'll be talking about that in a minute child childrens they are their responsibility we have a community support program one of them told from UCLA she is a public health student from UCLA she is coming back to work with us she has done the community based program like we did we do everything at the centre we asked all those people who needed support from us what they wanted and we have developed a program in English unfortunately for the community we also feel those of you who are diabetics who are friends who are diabetics at your age group it's the most challenging time when you finish pediatric care which is done as a family you come to adult care in my office it's 15 minutes and majority of us doctors do not know much about diabetes they patients no more and it's a troubling time socially, emotionally physically it's a challenging time and there are different group of people they do not want parents they do not want doctors but they need help so based on the experience of the family members Herbert family the family just opened their eye centre I think maybe for yesterday here the family gave us a lot of money to develop a special program for young adults with type 1 diabetes between 18 and John is helping us with publishing that report we have sweet success sweet success is a program for women who get diabetes during pregnancy and who have diabetes pregnant we are the California affiliate we have had some very good success our Spanish program recently got a state award and the uberath family I'm sure most of you know who uberath they gave us quite a lot of money to develop a program dedicated to improving women's health with diabetes we will also be working on weight management, prevention of diabetes diabetes, self-management education for all diabetes care nutritional services insulin management consumption services and translation research and for this at the end because that to us is the most critical thing our work will not be recognized unless we partner with institutions like yours unless we publish together unless we work together to make sure that what we do makes sense and the other people can carry out so if a small department of our hospital I mean I talked with but actually it's a very small department but it has big ideas and we have already collaborated with UCI we have UCINA's project working on it at the center we are going to work with Hispanic female we are working with San Jose State University to develop a diabetes program for Asians because their food is quite different and how am I supposed to take care of a person who how many of you like Indian food I cannot teach diabetes care for the Indian population because I haven't gotten any so we have developed that we are also working with John to make sure that again our program is successful we I think one of your one of your students is going to start his master's degree so I want everything is over he is starting so we are going to even pay him actually to work there and another young scientist of the year is going to start working on pollution and the effect of pollution on diabetes so that has also been approved by the so you are already working with us UCI at the center as I said earlier Latino family program we are going to develop instructional materials for taking care of diabetes diabetes is a major public health issue we have to get involved in any of this we are ready to work with you on any of this we want to develop a culturally sensitive program once again this is not politics but we have failed to take care of our diabetic population by preventing them from coming into the hospital by not recognizing what they want to learn how they want to learn I still remember Sherry who is a passionate person with women and diabetes she came one day and said this is all I have 10% of our population pregnant women are Indian see diabetes care is affected by culture, economics and ability to understand what we want to say so the Indian women they are highly educated they have no financial problems because all of them are software engineers and but they go home and eat their own food this is one page that is all we have so we have developed new plans based on the food they eat understood the calories that each Indian food will be able to provide for them so we want to do that you know what is the Bogue Hospital in Irvine we opened two months ago you know what is our population that we have to serve 32% of Mandarin speaking Chinese 17% of Farsi speaking Persian so almost the majority of our population we cannot serve them unless we understand the way they like to think and behave so all the programs that I am talking about whether it is self management whether it is community support young adults, prevention improved outcomes or reduced costs of care we would like to work with you and I am sure all of you are passionate about this and I was talking to you about the tables these are the tables what I am offering to you today is for you to work with us in terms of the projects long term you are not doing anywhere so we are happy to collaborate we already have some ideas about how to collaborate and with this support and your support hope we will be able to work with you so with that I would like to leave some time for questioning and I I promise you I will answer very briefly any questions let me tell you what I always do this I give everybody a chance so let's start with the last row and if you don't ask questions it doesn't matter if you ask questions that's fine anybody in the last row? last row you are not last row yet last row okay go ahead sorry can you develop diabetes? no if you were to think of diabetes as the body's inability to manage triggers there needs to be more than what you put in you must have the genetic need, genetic basis the environmental factors obesity, lack of exercise medications, infections so eating sweets under those circumstances and not exercising with the racial and ethnic genetic background with other forces you may start the obesity and develop diabetes to say that you will develop diabetes because you may actually go ahead in previous slides you mentioned about 25% of the population doesn't know they know they have diabetes how do you assume that? most of it is all hey public health people these are you the guys who are giving us all these facts let me tell you what it is diabetes is not diagnosed very early because there are no symptoms for diabetes the excessive urination excessive thirst, loss of weight muscle weakness all come much later by the time you are diagnosed 50% of your pancreas is lost so we are already dealing with issues so both by mathematical models and by scientific studies we know that patients who have diabetes because of lack of symptoms it's only these you know how I was diagnosed so I was here in practice I started as an endocrinologist and you know device manufacturers come in show me their device how it was good and she gave me my blood sugar I tell you what I ate that morning I had eaten co-sandwich mashed potatoes and hash browns so it was fairly 5,000 calories I think and the lady after she tested me she sort of went pale blue green and red she said okay doctor I think my machine is not good I said no what was the problem I was perfectly healthy I was happy I started practicing he said well no my machine is wrong no what was the problem my blood sugar was 270 I didn't even know and here I am an endocrinologist so the reason for that is because many of them do not have any symptoms that's why you had a question I was wondering if you could mention a couple specific projects or roles that we as students come in yes actually I can so you have diabetes self-management education program that's the SME which is the core of our function that we need to develop for a population who are non-English speaking population we've got Vietnamese population we don't know how to teach them we have Spanish we are developing that curriculum we have Asian we have Chinese so that's one thing I mean you can help us develop the program we'll give you the core components and you can tell us how to do it community support how am I going to teach Chinese population and tell them these are the various services which have nutrition, education, exercise cooking but we need to do it in the manner that they feel comfortable with young adults it is not only the Caucasians who get type of diabetes even though it's predominant but non-Hispanic Spanish speaking population are also getting this there are very young people who take care of them and they speak a different language at home so prevention this is the best thing that 180 billion I've talked about is 51% of it is complications you know if you are a person who is likely to be a diabetic and we can identify those by simple diet and exercise that's what Lawrence is going to do he's going to develop that weight management program for us one of your students is going to start his practicum there he's been given the task of developing weight management program so diet exercise alone without medication can retard the onset of diabetes and maintenance of weight is though difficult without medications can prevent complications these are scientific facts evidence based care so I think you can help us develop that and you're not very good at assessing the needs you're not very good at evaluating a program you can help us do that we have a new electronic medical record that we are going to implement which is starting we have 113 metrics we've got about new performance measures that we want to use dashboard want to publish it on our website how well we are doing how bad we are doing you can help us develop that we want to reduce cost so we're going to various companies and insurance companies if you came to our institution and if you followed our methodology of prevention maintenance better control we can reduce cost because cost of care for me $10,000 $1400 a year supplies alone that's a lot of money that's a lot of money do you know so you can help us demonstrate that a we are too expensive reduce the cost and we can translate it to other communities none of them is proprietary we're not going to own any of these we will happily share with others and that's what we are doing do you know how much India is spending on diabetes care published 1.4 billion 8% of them are diabetes anybody take a guess it's not 50 million 50 million 1 billion they are going to spend they just announced last week $32 million and we are spending 180 plus at the method of evaluating a diabetic control is by a test called hemoglobin A1c which is 3 months control do you know what's America's hemoglobin 6.5 is the best anything about that is not that good but 7 is ok what is America's average hemoglobin A1c and what do we get for $180 million anybody 7.9 guess India with less than 30 million you know what their hemoglobin A1c is 7.9 go for it you're not spending on it effectively we can do better next row talk so if you go into a little more detail about the measures that you have to evaluate the effectiveness of this program sure tell me I'm wasting my time you'll be happy to listen you see what I learned by working with John John Bellimac is from health care policy research he's been working with me for a long time what you guys are very good at is understanding how the program is to be structured and how the effectiveness of the program you can tell us Chris you're wasting your time you will not succeed in this because we need to know that what we think is though we have asked the people what they want but we may have structured the program inefficiently most definitely sure that's what critical thinking is all about take instruction from anybody if you do this you'll get this what you're doing you will not achieve see at the end of the day your program is successful or not is by the design design is all about design and what do I know about this I'm a doctor how I know is to take care of patients that's what we want we want critical analysis of what we do what would result maybe I can follow up so because it's not a curable disease what is the single measure of success I mean how do you know at this moment isn't this sad such a vast disease the hemoglobin A1C is the only marker but those of you who are interested will be happy to share our metrics of success or metrics of better care very tough care metrics we have put for ourselves will be happy to share that with you those are all processes but you know at the end of the day watch my role in life reduce suffering and reduce death if I do not show that Mary and Dick have in diabetes and to reduce complications sufferings reduce mortality death I haven't done anything but all those outcomes must have processes I hear a lot about the genetic predisposition of diabetes but is there a particular gene or what does that exactly mean we just hear that a lot excellent question it's so easy to throw this out that was the study published so the doctor was told predict diabetes in a population the gene lab said we will predict population so the doctor by asking this question at a cost of no more than $50 predicted how many of them will become diabetic the genetic lab at a cost of $10,000 predicted how many of them will become diabetic the answers were the same therein lies that we are not yet very sophisticated in the diagnosis there are many genetic predisposition many genetics are being identified but at this moment it is at the research lab not at the bench not at the clinical lab so expensive but not very satisfactory in terms of predicting there are really the one or two genetic studies which have demonstrated some patients with diabetes will develop cardiac complications as you know cardiac death is the single most common cause of death in diabetic and many will not that's about all we can say so one of the things we want to do is we want to be one of the community based predictors of diabetics not only clinical genetics but that's very expensive the answer to that is not yet specific I know recently among diabetes physicians are kind of in this push to remove the type 1, type 2 label towards more insulin dependence and insulin resistance in order to kind of better assess care do you have any opinions on that that's what I'm a very middle of the road guy neither this, nor this I follow ADA recommendations ADA has not yet come up with the changes the only changes they have agreed is 1A, 1B, type 1, type 2 and other causes type 2 diabetics and in type 1 diabetics there can be insulin resistance insulin resistance is exactly that that insulin is not able to work whether endogenous or exogenous so type 1, type 2 is a bad classification in my view the old classification would be insulin dependent and non insulin dependent that's even the worst classification so for want of any other term better at this moment will stick to that insulin resistance is part and parcel of type 2 you can reduce insulin you can resistance and you can reduce the need for insulin I do not know unless we're waiting for the next standards to be published in February until then we would have to however unsatisfactory it may be ok so you talked about this issue and Nellie had the question too if if there's all this cost associated with diabetes on the inpatient level but the leverage point to affecting diabetes is that be prevented in maybe at the outpatient level what sort of business but at the same time Hope Hospital isn't the payer for the patients it is the limit of care so how do you convince the hospital I want to ask you a question about 2 years ago how do you convince the hospital the hospital itself may not ever save money because of the activities at the diabetes center although society might so how do you make that case and maybe you can speak to what you're doing with the insurance companies too this will again my wife is talking to me now she's a phoenix but I can hear her cool it cool it cool it at the end this question was asked not far from here our CEO is a member of your faculty of the Miran School of Business and he was asked to give health economics and what Hope does just like I'm being asked to speak at the end of the day is the right thing to do period that's the only motivation it's the right thing to do for our patients that's what we're here for how did I convince it was very easy I mean because you know it's the right thing to do now whether we can convince the insurance companies convince the manufacturers of devices and drugs to come to a grand coalition of commonly delivered can you imagine that all diabetics in Orange County are being cared for in the same way I mean I think it will not cost 180 billion dollars I don't think it will cost more than a billion dollars the savings on that can you just imagine but do we have the capacity yes our next project in this I didn't address this we are going to our own institution we're going to challenge our institution we have a center here we have 6,000 employees there should be at least 480 diabetics 8% off give them to us and we will provide them and we will reduce your cost of medication that's our challenge and then we're going to work with position groups industries to give us their positions so I mean that's the only review it takes about 3 years for the program to be successful to show it proved out that it used cost that those are our next steps any other questions sorry I was going to say if you could or enact some policy locally in Orange County anything that you could do to help streamline awareness and education what do you think would be where would we start I've learned long time ago life is not simple in order to do that there has to be a coalition of the willing it doesn't matter we have to have early adopters who believe that this if they say diabetes is worse than HIV so we need to have lots of people who are ready to do a little more than look after themselves we need to I mean that's why public health is so important when you are the thinkers almost all the basis of all I've said here today is not from ADA it's from public health publications so we need to have the courage to come together and say look this is a problem for our children for adults this will bury their children ladies and gentlemen I promise you if you not take care of it because they are 12 year old 250 farmers with hemoglobin even 6 to 7 they have no future if we don't start controlling it so it will not be one it will be many there will be some who will not be interested but this is a democracy you cannot doubt but there has to be a coalition of the willing there has to be UCI at home must lead the sense that Orange County has a poor health I mean they just gave away UCI medical center for one dollar because Orange County did not want to take care of poor so I'm not a politically active I have no desire to be I'm not a policy advocate but there has to be a coalition of the willing I don't think there is one the one thing I would say is passion yes when you develop gestational diabetes what are the effects on their children yes very interesting question gestational diabetes is a condition where women during pregnancy develop type 2 diabetes and majority of the time soon after the birth of the baby as soon as the baby is born the diabetes disappears so that is gestational diabetes the long term prospects in them 50 to 70 percent of them become diabetic between a year and 10 years think about those women we have 4,000 deliveries in our hospital we have about 300 patients we have a slightly higher incidence of gestational diabetes at home because most of our child bearing women are what we call mature women in their 30s and late 30s don't get nervous but that's fact of life we have our women come in their suitcase on Friday evening we have to work on Monday that's our population so we have a slightly higher incidence of gestational diabetes and the babies are baby so there is birth trauma to mother the babies do not have they have hypoglycemia the babies have to go into ICU the babies have considerable abnormalities and those babies and those mothers have higher incidence of diabetes than the wife the only thing is it's different in Vietnamese it's different in Indians it's different in Caucasians so we need to develop different programs sir, yes do you have a niche for life spatial genealogy with a person come and work with you I'll give you a room I'll give you a computer sit there all day we'll get it done that's your practical see, that's it I've always got out of my lip BS a lot you showed a map of the United States with the pregnant wife and I was looking to see if there is a pattern the pattern will change because it depends on the population but I can give you a picture you all have access to that various populations in the United States have different intensities of diabetes and higher incidence of diabetes it's a constantly moving public health people it's constantly moving problems the more Hispanic population the more wealthy they become they eat the food but do not do what they're supposed to do so it's a safety proposition but the pockets in all cities in the States but there's higher incidence any other questions it's encouraging that you are able to have this foundation and serve under certain populations that don't have a million pay and you say passion is a part of that do you have a practical any practical place in the United States finding ways to serve under certain populations that act very comfortable I will have you all day on a Sunday at the center we'll provide you lunch and bring all your friends together and you know what I said we can have a meeting on the day and we'll bring Dr. Perry who's the community medicine director who's more passionate about this than I am and we can have lots of people in the community working on health access moms, you know SOS clinic we are actually as a matter of fact Jung and I are working on SOS clinic helping Spanish speaking women we cannot bring them to the center they get intimidated it's like lobby of four seasons it's really very fancy but we need to take banishment to them to their home so there are many methods you do not have to take the whole world you can take pocket isolated area and work with them and hand it over to the next year students and it needs to be continuous continuum of care is the bane of American health care there's no continuity of care all of them I saw a lady this morning she had seen an oncologist she had seen radiologist she had seen an ethnologist I don't have any of that she gave her a second opinion how can I give a second opinion if I don't the lack of continuity the lack of cohesion among various forces this is sad very sad the way every doctor rewrites the history why? I mean some of my colleagues very highly force for what they do charge download the flash drive and give it to the particular and I think that's something like that sir how effective is prevention in reducing incidents when you're only teaching prevention to those who already have an increased risk or have diabetes themselves and if you're focused on is there any efforts in trying to promote prevention outside hospital to those who don't necessarily have an increased risk in May you know you've got very smart students very good question diabetes is not a disease of the hospital we must get out of the hospital based care it should not be it's a disease of the community so diabetes care may cost us 51% of the 180 million dollars in the hospital one of the conventional chief operating officer asked this question why are you doing this? preventing these complications how will we make money because Friday afternoon 2 o'clock this was the question Friday afternoon to business development office you see that mindset should change it is not about taking care of patients who are sick in the hospital it's about keeping people outside the hospital keeping people well shifting emphasis, shifting thinking that's why we are not going to invest a lot of money in hospitals we're going to build a lot of outpatient facilities which combine prevention possibilities so that's number one don't think outside the hospital think community the reason why I'm interested in and I'm being very careful I'm not interested in taking care of problems which I do not know anything about health maintenance but chronic health is diabetes I know that we can prevent that diabetes from happening in substantial number of patients 60% reduction in the onset of diabetes 5.5 Lawrence when he comes he's going to have all these details given to him get me a weight reduction program for diabetes and weight reduction program for prevention of diabetes so those are everything I cannot have evidence to show that these people do not have complications I do not have but that is I have to surmise I'll tell you there are a couple of studies that are done in there is a study called VCCT Diabetes Complications Control Trials it was as an expense of 100 million dollars 3,000 young diabetics, type 1 diabetics were followed for 10 years to control tightly some of them or not the study was stopped for 6 years because within 6 years they expected a certain amount of complications took place so that established scientific practice the same group were followed 10 years later those who had type control drifted to poor control those who had poor control drifted up to diabetes guess what those people who were very well controlled during those 10 years still had better outcomes in their lives and those people who were not had increased death of cardiovascular disease and mortality so if you do it well if you do it well early and if you do it well before complications come in you seem to do well that has been confirmed in various studies or court trials and others so my argument is don't wait till the problems come in if you are predicted to have diabetes prevent it at early stages control it it's too late for a 75 year old man who had a stroke heart disease if you try to control it they will die soon if you try to because it's over so the aim of all projects we do it the center should be prevention and documenting over longitudinal time that made a difference some of it is assumption but I think healthy assumption is we need to give the word out to the community how do we get the information about diabetes how do you think you are in SOS has that been effective or is there a model or is this just starting these are all John has been with me for the last two years in the center of it he is helping us with all this effectiveness of what we do I do not think we have made a change but it's a long term plan we want to be constantly that's why I said we need to have a course of the building and actively participate SOS is our main focus so we need to study the product effectiveness I do not know how thank you very much