Artikel Penelitian

Current Practice in the Management of

Type 2 Diabetes in Indonesia:
Results from the International Diabetes
Management Practices Study (IDMPS)

Pradana Soewondo

International Diabetes Management Practices Study (IDMPS) Study Group

Abstract: Increasing obesity, sedentary lifestyle and aging population have significantly con-
tributed to the explosion of type-2 diabetes. In addition, the consequences of its complications
have caused substantial morbidity and mortality. The major goal of diabetes treatment is to
achieve good metabolic control, thus preventing the onset of the long-term complications. Un-
fortunately, there is still insufficient data on the quality of care of diabetic patients especially on
type-2 diabetic patients in Indonesia. This study focused on diabetic patients seen by general
practitioners, internists and endocrinologists, to assess its management, HbA1c achievement,
and resources used. This study was part of The International Diabetes Management Practices
Study (IDMPS) wave 2006, which was a cross-sectional study and also longitudinal follow up.
Sixty eight physicians, consisted of 48 general practitioners (GPs)/internists and 20 endocri-
nologists, have reported 674 patients with type-2 diabetes mellitus who are currently receiving
varied diabetes mellitus treatment. Among those patients, 21 patients only treated with lifestyle
modification, 523 patients received only Oral Glycaemic Lowering Drug (OGLD), and 130
patients received insulin with or without OGLD. The average HbA1c in this study was 8.27% and
only 37.4% reached the target value of HbA1c less than 7%. The majority of patients did not
attain the recommended glycaemic target. This indicates the presence of a gap between recom-
mendations of most recent guidelines and the actual practices. J Indon Med Assoc. 2011;61:474-
81
Keywords: Diabetes, Indonesia, Type of medication, Target achievement

474 J Indon Med Assoc, Volum: 61, Nomor: 12, Desember 2011
 Current Practice in the Management of Type 2 Diabetes in Indonesia

Kondisi Pengelolaan Diabetes Melitus Tipe 2 di Indonesia:

Hasil dari International Diabetes Management Practices Study (IDMPS)

Pradana Soewondo

International Diabetes Management Practices Study (IDMPS) Study Group

Abstrak: Meningkatnya populasi dengan obesitas, gaya hidup sedenter serta usia lanjut sangat
memberikan pengaruh bagi peningkatan diabetes tipe 2 dan komplikasinya. Tujuan utama terapi
diabetes adalah untuk mencapai kontrol metabolik yang baik sehingga dapat mencegah terjadinya
komplikasi jangka panjang. Namun sayangnya, data di Indonesia mengenai kualitas penanganan
pasien diabetes tipe 2 masih belum mencukupi. Studi ini melibatkan pasien diabetes yang ditangani
oleh dokter umum, internis dan endokrinologis, untuk menilai pengelolaan, pencapaian target
HbA1c, dan pemanfaatan sumber daya. Penelitian ini merupakan bagian dari The International
Diabetes Management Practices Study (IDMPS) yang diselenggarakan pada tahun 2006, yang
merupakan suatu penelitian potong lintang dan kemudian dilanjutkan pemantauan secara longi-
tudinal. Enam puluh delapan dokter yang terdiri dari 48 dokter umum/internis dan 20
endokrinologis, melaporkan 674 pasien diabetes tipe 2 yang mendapatkan pengelolaan diabetes
yang bervariasi, yang terdiri dari 21 pasien hanya diterapi dengan perubahan pola hidup, 523
pasien hanya mendapatkan obat hipoglikemik oral (OHO) dan 130 pasien mendapatkan insulin
dengan atau tanpa OHO. Rata-rata pencapaian kadar HbA1c sebesar 8,27% dan hanya 37,4%
pasien yang mencapai target HbA1c kurang dari 7%. Sebagian besar pasien diabetes tipe 2 tidak
mencapai target glikemik sesuai rekomendasi. Hal tersebut mengindikasikan adanya kesenjangan
antara rekomendasi dan praktik klinis sehari-hari. J Indon Med Assoc. 2011;61:474-81
Kata Kunci: Diabetes, Indonesia, Jenis obat, Pencapaian target

Introduction

The incidence of diabetes mellitus, particularly type-2

diabetes is increasing dramatically across the world because
of increasing obesity, sedentary lifestyle and population
aging, and is the cause of substantial morbidity and mortal-
ity. This explosive increase in the prevalence of type-2 dia-
betes and the consequences of its complications and asso-
ciated disorders represents the greatest health care chal-
lenge facing the world today. 1-6
The United Kingdom Prospective Diabetes Study
(UKPDS) reported that early treatment and good control of
diabetes can decrease the morbidity and mortality by de-
creasing its chronic complications.7 Each 1% reduction in
updated mean HbA1c was associated with risk reductions
of 21% for diabetes-related deaths, 14% for myocardial inf-
arction, and 37% for microvascular complications.8 There-
fore the major goal of treatment of diabetic patients is to
achieve good (near normal) metabolic control, thus prevent-
ing the onset of the long-term complications. Unfortunately,
there is still an insufficient data on the quality of diabetes
care, especially on type-2 patients in non-Western coun-
tries, including Indonesia.9,10
IDMPS study is one of the largest population-based
studies of diabetic patients in developing countries. The aim
was to assess the therapeutic management of type-2 diabe-
tes mellitus in the current medical practice in 27 countries in
Asia, Latin America and the Middle East and Africa. In Indo-
nesia, the current diabetes practice was based on recommen-
dation from the PERKENI (The Indonesian Society of Endo-
crinology). PERKENI had developed the type 2 diabetes
guidelines since 1993 and it had been revised several times
until 2006.11
In Indonesia, this study was one of few studies that
was done to investigate the disease burden and quality of
care in diabetes. The results would be very important to im-
prove the quality of diabetes care in Indonesia.
Method
The IDMPS conducted in five waves which focuses on
diabetes patients seen by general practitioners (GPs) and
diabetic specialists who are experienced in insulin therapy. It
provided an international perspective to identify practices
variations across countries, and evaluated compliance to
international guidelines of management of diabetes in differ-

J Indon Med Assoc, Volum: 61, Nomor: 12, Desember 2011 475
Current Practice in the Management of Type 2 Diabetes in Indonesia

ent areas of the world. This study was performed as a cross
sectional study and followed by a longitudinal study (ob-
servational study) for a period of 9-month, each doctors
might use different diabetic guidelines that mirror real life
management of these subjects who were currently treated
for diabetes mellitus. In Indonesia, majority of doctors used
national guidelines which developed by PERKENI.
A random sample of physicians experienced in insulin
therapy was selected in each participating countries and
asked to enroll the first 10 patients with type 2 diabetes
within 2 weeks period. Patients’ exclusion criteria were less
than 18 years of age, concomitant participation in another
clinical study, participation in previous wave of the IDMPS
and current temporary insulin treatment because of condi-
tions such as gestational diabetes, pancreatic cancer or sur-
gery.
A cross-sectional survey of management practices was
conducted for all patients during the 2-week recruitment pe-
riod using standardized paper case report forms completed
by the recruiting physicians. Descriptive analysis was per-
formed on the database. Qualitative data were summarized in
frequency tables, and quantitative data were summarized in
quantitative descriptive statistics (frequency, mean, standard
deviation, median, range). Statistical analyses were conducted
with the SAS Software version 8.02.
Results

Table 1. Distribution of Subjects Based on Demographic Characteristic

Variable Type 2
Lifestyle modification OGLD Insulin + Total

Gender
Male (%) 10 (50.0) 229 (43.9) 65 (50.8) 304 (45.4)
Female (%) 10 (50.0) 293 (56.1) 63 (49.2) 366 (54.6)
Age
Less than 40 yrs (%) 3 (14.3) 31 (5.9) 9 (6.9) 43 (6.4)
40 - 65 yrs (%) 16 (76.2) 410 (78.4) 91 (70.0) 517 (76.7)
More than 65 yr (%)s 2 (9.5) 82 (15.7) 30 (23.1) 114 (16.9)
Mean (SD) 51.4 (10.8) 55.0 (10.1) 56.4 (10.4) 55.2 (10.2)
Median 52.0 54.0 56.0 55.0
Family history of DM
No (%) 6 (30.0) 216 (41.3) 49 (37.7) 271 (40.3)
Yes (%) 14 (70.0) 307 (58.7) 81 (62.3) 402 (59.7)
Duration of Diabetes
Less than 1 yrs (%) 7 (33.3) 143 (28.5) 16 (12.6) 166 (25.6)
1 - 10 yrs (%) 11 (52.4) 290 (57.9) 77 (60.6) 378 (58.2)
More than 10 yrs (%) 3 (14.3) 68 (13.6) 34 (26.8) 105 (16.2)
Mean (SD) 4.7 (4.6) 5.5 (6.1) 8.7 (7.3) 6.1 (6.4)
Median 3.0 4.0 7.0 4.0
Smoking habit
Smoker (%) 1 (4.8) 27 (5.2) 12 (9.2) 40 (5.9)
Ex smoker (%) 5 (23.8) 56 (10.7) 13 (10.0) 75 (11.0)
Non smoker (%) 15 (71.4) 440 (84.1) 105 (80.8) 560 (83.1)
Obesity
Under weight (%) 1 (4.8) 14 (2.7) 8 (6.2) 23 (3.5)
Normal weight (%) 12 (57.1) 271 (52.6) 67 (51.9) 350 (52.6)
Over weight (%) 6 (28.6) 175 (34.0) 47 (36.4) 228 (34.3)
Obese (%) 2 (9.6) 55 (10.7) 7 (5.5) 64 (9.7)
BMI Mean (SD) 24.9 (4.9) 24.8 (3.8) 24.6 (4.8) 24.8 (4.0)
BMI Median 24.9 24.4 24.6 24.5
Waist circumference
Mean (SD) 88.1 (11.1) 88.6 (11.4) 90.7 (11.8) 89.0 (11.5)
Median 88.0 88.0 90.0 88.0
Systolic blood pressure
Mean (SD) 130.1 (22.6) 132.8 (19.8) 132.2 (23.1) 132.6 (20.5)
Median 120.0 130.0 130.0 130.0
Diastolic blood pressure
Mean (SD) 80.6 (9.1) 83.4 (9.7) 81.1 (9.4) 82.9 (9.7)
Median 80.0 80.0 80.0 80.0
Latest HbA1C
Mean (SD) 7.0 (1.2) 8.1 (2.1) 8.9 (2.4) 8.3 (2.2)
Median 8.0 8.0 7.0 8.0
Fasting blood glucose
Mean (SD) 156.1 (47.9) 171.1 (77.1) 169.0 (75.2) 170.3 (76.1)
Median 147.1 150.1 142.7 148.1

476 J Indon Med Assoc, Volum: 61, Nomor: 12, Desember 2011
 Current Practice in the Management of Type 2 Diabetes in Indonesia

This wave of the cross-sectional study was carried out
in 27 countries (Algeria, Argentina, Bulgaria, Chile, China,
Colombia, Dominican Republic, Egypt, Guatemala, Gulf coun-
tries, Hong Kong, India, Indonesia, Lebanon, Malaysia,
Mexico, Morocco, Panama, Romania, Saudi Arabia, South
Africa, South Korea, Taiwan, Thailand, Tunisia, Turkey, Ven-
ezuela). Overall 1538 physicians included at least one pa-
tient. A total of 21791 patients was recruited and 20739 of
them were included in the whole population for analysis.
In this article, we only analyzed Indonesian data. A to-
tal of sixty eight physicians, consisted of 48 general GPs/
internists and 20 endocrinologists, have reported 674 pa-
tients with type-2 diabetes mellitus who are currently receiv-
ing varied diabetes mellitus treatment. Study analyzed from
all data which consist of 21 patients received lifestyle modi-
fication through dietary and exercise, 523 patients received
only Oral Glycaemia Lowering Drug (OGLD) and 130 pa-
tients received insulin with or without OGLD.
Among all subjects, there were almost equal number of
male and female, and most of them were on 40-65 years old
age group. The number of active and non active smoker dia-
betes patients was low. In addition, almost half of diabetic
patients were overweight and obese. HbA1c is relatively high
with level 8.3% and uncontrolled fasting blood glucose. (See
Table 1 for details)
Dislipidemia and hypertension are the two most preva-
lent concomitant conditions of diabetes. More than 50% cases
also suffered from dislipidemia and almost 48% have high
blood pressure. Most cases suffered from at least one dia-
betic complication. (See Table 2 for details).
Neuropathy is the most common complication among
type-2 diabetic cases with more than 50% of subjects show
abnormal neurological signs. The second most common com-
plications are retinopathy and nephropathy with more than
30% of cases. (See figure 1 for details).
Most of patients had visited GPs/ internists, while only
30% visited endocrinologists. Nevertheless the patients who
visited endocrinologists were likely more frequent to visit

Table 2. Distribution of Subjects Based on Co-morbid and Complication

Variable Type 2
Lifestyle modification OGLD Insulin + Total

Hypertension
Yes with treatment 8 (38.1) 230 (44.2) 59 (45.4) 297 (44.3)
Yes but no treatment 0 17 (3.3) 5 (3.8) 22 (3.3)
No hypertension 13 (61.9) 273 (52.5) 66 (50.8) 352 (52.5)
Dislipidemia
Yes with treatment 8 (40.0) 179 (42.6) 53 (50.0) 240 (44.0)
Yes but no treatment 4 (20.0) 36 (8.6) 12 (11.3) 52 (9.5)
No dislipidemia 8 (40.0) 205 (48.8) 41 (38.7) 254 (46.5)
Late complication
At least one 9 (69.2) 290 (70.6) 97 (85.8) 396 (73.7)
No complication 4 (30.8) 121 (29.4) 16 (14.2) 141 (26.3)

R e tin o p a th y
N e u ro p a th y
P r o te in u ria
D ia ly s is
F o o t u lc e r
A m p u ta tio n
A n g in a
M y o c a rd in fa rc
H e a rt fa ilu re
S tro k e
P e rip h e ra l V D

0 .0 1 0 .0 2 0 .0 3 0 .0 4 0 .0 5 0 .0 6 0 .0 7 0 .0

O G LD In s u lin p lu s D ie t/E x e rc is e

J Indon Med Assoc, Volum: 61, Nomor: 12, Desember 2011 477
Current Practice in the Management of Type 2 Diabetes in Indonesia

the physicians. In addition, more than 60% of patients had Table 5. Distribution of Subjects Based on the Target Achieve-
never had diabetes education session. The patients who ment
were given insulin were more frequent to attend the diabetes Variable Type 2
education session. (See table 3 for details). Lifestyle OGLD Insulin + Total
Diabetes mellitus has reduced the productivity of the modification

Target achieved
Table 3. Distribution of Subjects Based on Physicians’ Specialty, Yes 5 (23.8) 203 (38.8) 44 (34.1) 252 (37.4)
Diabetes Education and Follow up Visit No 16 (76.2) 320 (61.2) 85 (65.9) 421 (62.6)
Value of last HbA1c
Variable Type 2 measurement
Lifestyle OGLD Insulin + Total Mean 7.04 8.12 8.76 8.27
modification

Specialty Indonesia is entering the epidemiological transition

GPs/ internists 13 (61.9) 387 (74.0) 71 (54.6) 471 (69.9) period, many degenerative diseases have recently showed
Endocrinologists 8 (38.1) 136 (26.0) 59 (45.4) 203 (30.1)
Diabetes education
significant increases. The latest national household survey
Given 8 (40.0) 168 (34.6) 49 (41.2) 225 (36.1) in 2007 reported that the incidence of diabetes in Indonesia
None 12 (60.0) 317 (65.4) 70 (58.8) 399 (63.9) had increased. The Indonesian national prevalence of diabe-
Mean (SD) 6.8 (4.7) 4.1 (3.3) 4.3 (3.9) 4.2 (3.5) tes was 5.7%, but 73.7% of them were undiagnosed.8 Previ-
Median 3.0 3.0 7.0 3.0
Follow up in the last 3 months
ous study on diabetes care in Indonesia was the DiabCare
By GPs/ internists Asia study series. The latest DiabCare study (n=1785) was
Followed up 1 (33.3) 105 (60.7) 23 (47.9) 129 (57.6) in 2008. It was a cross sectional, hospital based study in-
None 2 (66.7) 68 (39.3) 25 (52.1) 95 (42.4) volving 18 hospitals from all around Indonesia; performed a
By endocrinologists
Followed up 13 (100.0) 332 (95.4) 96 (98.0) 446 (96.1)
collection of data on demography, diabetes status, manage-
None 0 16 (4.6) 2 (2.0) 18 (3.9) ment and complications. 9 IDMPS, an international study on
diabetes management practice, was a cross sectional and a
longitudinal study which mostly done in private practice.
The IDMPS recorded resource use associated with type 2
sufferers. Only less than 35% of patients had a formal work,
diabetes in such a wide range using a standardized protocol
furthermore almost 10% of them had to take sick leave due to
in developing countries in Asia, Latin America and the Middle
diabetes. (See table 4 for details).
East and Africa. 10 Consequently our study could add sig-
Success rate of the diabetic treatment is measured by
nificant information regarding the quality of existing diabe-
achievement of HbA1c target less than 7%. This value was
tes care in Indonesia.
refered to international diabetes societies (ADA, EASD)
Based on demographic characteristics, various epide-
which have made global recommendations aiming to achieve
miological studies reported that women have a slightly higher
optimal levels of glycaemic control. The HbA1c average was
risk of contracting diabetes.11 Not surprisingly, this study
8.27% and only 37.4% had reached the HbA1c target of <7%.
has recruited a little bit more female type-2 diabetes patients
The OGLD-only-treated groups achieved better HbA1c level
compared to male patients (54.6% vs 45.4%). This finding
compare to insulin-treated group. (See table 5 for details)
supported the basic health research finding in 2007 which
Discussion
reported that the prevalence of diabetes in female and male
were 6.4% and 4.9% respectively. The mean age of IDMPS
Table 4. Distribution of Subjects Based on Working Productivity study patients was 55.2 (SD 10.2) years old, quite high, given
and Hospitalization the life expectancy in the developing world. Furthermore,
Variable Type 2 only 6.4% were aged less than 40 years old. Nevertheless,
Lifestyle OGLD Insulin + Total most patients (76.7%) were in 40-65 years old age group,
modification younger than in the developed countries. This finding is in
concordance with the finding from the basic health survey
Working productivity
Unemployed 13 (61.9) 283 (54.2) 63 (48.5) 359 (53.3) in 2007, which showed that the diabetes prevalence in that
Normal work 8 (38.1) 195 (37.4) 31 (23.8) 234 (34.8) age group was between 10.5%-13.5%. The DiabCare study
Sick leave 0 32 (6.1) 32 (24.6) 64 (9.5) found the mean age of diabetes patients was 58.91 (SD 9.74)
Unable to work 0 12 (2.3) 4 (2.3) 16 (2.4) years old.10
Hospitalized
Yes 2 (12.5) 41 (12.5) 26 (28.0) 69 (15.8) Genetic trait might play important role among Indone-
No 14 (87.5) 288 (87.5) 67 (72.0) 369 (84.2) sian diabetics. Most subjects (59.7%) reported to have fam-
Mean (SD) 2.5 (2.1) 1.2 (0.4) 1.0 (0.2) 1.1 (0.5) ily history of diabetes. Genetic susceptibility was also re-
Median 1.0 1.0 2.5 1.0 ported as one of risk factor for increasing diabetes preva-

478 J Indon Med Assoc, Volum: 61, Nomor: 12, Desember 2011
 Current Practice in the Management of Type 2 Diabetes in Indonesia
lence in Asia. Chan et al12 reported that cigarette smoking
was one of risk factors for the increasing diabetes preva-
lence in Asia.12 This study found 5.9% and 11% of patients
were active smokers and ex smokers respectively, which was
lower than national figure of smokers (45.8% of adult male
population).13 Obesity is also confirmed as a common risk
factor for diabetes in Asia.11 This study found that 34.3%
and 9.7% of diabetes patients were overweight and obese
respectively. The mean of BMI was 24.8 (SD 4) kg/m2, and
the mean waist circumference was 89.0 (SD 11.5) cm. The
DiabCare study reported lower mean BMI, which was 23.4
kg/m2.
This study found high HbA1c level (8.3%) and high
fasting glucose level (170.3 mg/dL). These findings were in
line with the DiabCare study, who reported HbA1c level of
8.1% and fasting blood glucose of 142.2 mg/dL. The OGLD-
only treated groups achieved better HbA1c level compare to
insulin-treated group. This might be caused by the bias of
indication, in which patients with better glycemic control
were still given the OGLD, while patients with worse glyce-
mic control were switched to insulin regimen or were given
insulin from the start. In addition, there might be a lack of
optimal insulin titration in the real life setting.
The DiabCare study reported that the mean of SBP was
131.4 (SD18.1) mmHg. There were 57.4% of patients received
anti hypertension medication. Our study reported the same
finding that the mean of SBP was 132.6 (SD 20.5) mmHg.
Nevertheless our study reported lower percentage of hyper-
tension treatment, 47.6% had hypertension, 44.3% received
treatment, while 3.3% without treatment. The DiabCare study
reported that there were 54% and 14.1% of patients had LDL
and TG above target respectively. In addition, 11.3% male
and 21.1% female had HDL above target. Among those pa-
tients, 34% of them received lipid lowering treatment. 10 Our
study reported 53.5% patients with dyslipidemia, but only
44% received treatment while 9.5% were without treatment.
These findings show us that the metabolic control of dia-
betic patients were not good enough to prevent diabetic
chronic complications.
In all countries of Asia region including China, Hong
Kong, Indonesia, India, South Korea, Malaysia, Taiwan and
Thailand, the presence of microvascular complications (47%)
was also identified as a significant predictor of resource use,
but to a lesser extent than macrovascular complications
(20%).14 Our study found microvascular complications, such
as neuropathy, retinopathy and nephropathy, more often than
the macrovascular complications. This finding supports pre-
vious findings on the DiabCare study. Our study reported
that neuropathic symptoms are frequent initial causes of
medical consultation that lead to diagnosis. Therefore neur-
opathy was the most prevalent diabetic complication among
subjects in Indonesia followed by retinopathy, and nephro-
pathy.
Our study also found that the rate of screening for dia-
J Indon Med Assoc, Volum: 61, Nomor: 12, Desember 2011
betic complications were still low, the same finding from the
DiabCare study. Diabetes management needs an implemen-
tation of strategies of prevention or delay of macro- and
microvascular complications and adequate control of
hyperglycaemia. Our study reported that diabetes caused
9.5% of sick leave 2.4% loss of employment. Diabetes also
caused hospitalization in 15.8% of patients. These two find-
ings suggested that diabetes is associated with a significant
amount of direct and indirect expenses. The substantial im-
pact of complications on resource use clearly provides an
economic rationale for concerted efforts for earlier diagnosis
and implementation of appropriate treatment, considering
that most Indonesian diabetic cases were undiagnosed. In
addition, for prevention of further complications, we need to
perform diabetic complications screening among all diabetic
patients. 15
Most of the type-2 diabetes cases in this study were
treated by GPs/internists. Nevertheless, the patients who
were treated by endocrinologist were more likely to visit the
physicians frequently. This findings might be explained by
the fact that most of the patients who visited endocrinolo-
gist had already had advanced diabetes, been given com-
plex treatment regimen and insulin therapy. The Indonesian
GPs/internists preferred to prescribe their diabetic patients
with OGLD that is much simpler compared to the use of insu-
lin. On the other hand, the endocrinologists tend to be more
courageous to try various regimen types. They prescribed
insulin for some of type-2 diabetes patients with or without
OGLD.
In ensuring that diabetes patients will comply with their
life time medication, education session was organized by
specially trained diabetes educators during their clinic vis-
its. The diabetes educator provided important information
about the disease, the need for life time medication, and
trained the patients in managing the disease properly. Pa-
tients who were only prescribed OGLD got the least educa-
tion session compared to those relied to insulin or those
were given only lifestyle modification. 16 The endocrinolo-
gists have more contacts with the diabetes patients for the
last three months compared with the GPs/internists, espe-
cially among the type-2 diabetes patients who relied on
lifestyle modification. The GPs/internists have been visited
more by type-2 diabetes patients who used only OGLD as
their treatment.
However, the average of last HbA1c in this study was
8.27% and among all patients, it appeared that only 37.4% of
type-2 diabetes patients reached the target value of HbA1c
less than 7%. It was lower than China which has the highest
number (44%) of patients reached the target value of HbA1c
in Asia, followed by South Korea (40%).12 IDMPS demon-
strated that a minority of patients meet glycemic targets. As
reported in regions in the world, lack of glycemic control was
a strong predictor of resource use, with patients not at guide-
line-recommended HbA1c target significantly more likely to
479
Current Practice in the Management of Type 2 Diabetes in Indonesia
consume healthcare resources. 12 The highest number (58%)
of patients reached glycemic control was achieved in Panama,
meanwhile Egypt achieved the lowest number (16%).12 The
DiabCare study (n=1785) in 2008, a hospital based study
involving 18 hospitals from all around Indonesia, reported
that only 34.45% of diabetic patients reach the A1c target
less than 7%.
Our study showed that the mean of HbA1c levels were
different across treatment regiment, in which the A1c level
were lowest among lifestyle modification group and highest
among insulin group. Nevertheless, the proportion of sub-
jects achieved the A1c target was highest among OGLD
group and lowest among lifestyle modification group. Nev-
ertheless, lifestyle modification is the basic foundation in
diabetes management. Lifestyle modifications should be
implemented across all diabetes treatment regiments to
achieve glycemic control and to prevent diabetic complica-
tions.
Finally, Diabetes is a chronic health condition with
comorbidities and it is also associated with micro and
macrovascular complications. We can learn from this study
that diabetes lead to a huge resource use and also associ-
ated with significant direct and indirect cost.17 These conse-
quences could be reduced through early diagnosis, prompt
treatment, effective metabolic control and screening for dia-
betic complications. Even we have already had type 2 diabe-
tes guidelines since 1993, nevertheless the comprehensive
management of type 2 diabetes in Indonesia was not as we
expected. Our study showed that we still need to improve
quality of diabetes care in Indonesia. An integrated public
health approach and family medicine approach are crucial to
raise awareness of the wide reaching economic conse-
quences of diabetes-related complications, to increase fam-
ily support and participation, to educate patients and
healthcare workers and to allocate appropriate resources for
disease management.
Conclusion
In Indonesia, the majority of type-2 diabetic patients
were treated by GPs/internists. Most patients were given
OGLD alone. The average HbA1c in this study was high and
the majority of patients did not attain the recommended gly-
cemic target. This indicates the presence of a gap between
recommendations of most recent guidelines and the actual
practices. An integrated public health and family medicine
approach are crucial in improving quality of diabetes care in
Indonesia.
Acknowledgement
The author is especially grateful to all investigators who
have participated in IDMPS study: Prof. Dr. Askandar
Tjokroprawiro, SpPD, KEMD. Prof. Dr. RR Djokomoeljanto,
SpPD, KEMD. Prof. DR. Dr. Karel Pandelaki, SpPD.KEMD,
Prof. Dr. Ketut Suastika, SpPD. KEMD, Prof. DR. Dr. Agung
480
Pranoto, SpPD. KEMD, Prof. DR. Dr. Djoko Hardiman, SpPD.
KEMD, Prof. Dr. Asman Manaf, SpPD. KEMD, Prof. Dr. Syafril
Syahbuddin, SpPD. KEMD, Dr. K. Heri Nugroho, SpPD.
KEMD, Dr. Aris Wibudi, SpPD. KEMD, Dr. Ida Ayu Kshanti,
SpPD. KEMD, Dr. Wira Gotera, SpPD. KEMD, Dr. Sony
Wibisono, SpPD. KEMD, Dr. Dharma Lindarto, SpPD. KEMD,
Dr. Gatut Semiardji, SpPD. KEMD, Dr. Roy P. Sibarani, SpPD.
KEMD, Dr. Alwi Shahab, SpPD. KEMD, Dr. Tony Suhartono,
SpPD. KEMD, Dr. Sri Murtiwi, SpPD. KEMD, Dr. Mardianto,
SpPD. KEMD, Dr. Tjokorda Gde Pemayun, SpPD. KEMD, Dr.
Zulfahmi Wahab, SpPD, Dr. Nono Matarungan, SpPD, Dr.
Dedy K.Kurniawan, SpPD, Dr. ND Pangesti, SpPD,Dr. Tuty
Kuswardhani, SpPD. KGer, Dr. Ratna Saraswati, SpPD, Dr.
Suroto Lim, SpPD, Dr. Marwani Bratasaputra, SpPD, Dr. Maria
Riastuti, SpPD, Dr. Eva Decroli, SpPD, Dr. Irfani Riza, SpPD,
Dr. Imam Faturakhman, SpPD, Dr. Paul Harijanto, SpPD, Dr.
Ratni Rahim, SpPD, Dr. Yuanita Langi, SpPD, Dr. Hadi
Sulistyanto, SpPD, Dr. Eddy Prijambodo, SpPD, Dr. Jerahim
Tarigan, SpPD, Dr. Luthfan B.Purnomo, SpPD, Dr. Rizky
Perdana, SpPD, Dr. Abdullah Ammarie, SpPD, Dr. Zuhrial
Zubir, SpPD, Dr. Imam Suprianto, SpPD, Dr. Sapto Priatmo,
SpPD, Dr. Dasril Effendi, SpPD, Dr. Sunu Sugiyanto, SpPD,
Dr. Kuntjoro Yakti, SpPD, Dr. Budi Santoso, SpPD, Dr.
Sulistyawati Ohnio, SpPD, Dr. Pendrik Tandean, SpPD, Dr.
Zulkhair Ali, SpPD. KGH, Dr. Bimanesh Sutarjo, SpPD. KGH,
Dr. Abdurrahim Lubis, SpPD. KGH, Dr. Anton Cahaya, Dr.
Budi Ikhwansyah, Dr. Ervin Tampubolon, Dr. Gunawan
Arsyadi, Dr. Atyah Rasyid, Dr. G. Kunar Abadi, Dr. Davis
Ajiaribowo, Dr. Zulkarnaen, Dr. Sutrisno, Dr. Jalil Alfani, Dr.
Djoko Rahardjo, Dr. Sulhani Nurul Aini, Dr. Husaini Umar.
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