Diabetes Care Performance Report 2016

This report is intended only for the use of the individual entity to which it is addressed and may contain
information
that is privileged, confidential, and exempt from disclosure.
Disclaimer:
The content of this report is based on information mainly gathered from published secondary
sources. Although best efforts have been made to ensure that the information and data
contained here is reliable, no representations are made as to its completeness, timeliness or
quality. Majority of data originated from the Ministry of Health institutions hence
generalizability is limited to the population of which they represent. Anyone may reproduce,
publish or otherwise use the content of this report as the concepts and information herein are
already in the public domain. However, acknowledgement to Malaysian Healthcare Performance
Unit, Ministry of Health Malaysia would be appreciated.
Suggested citation is: Malaysia Diabetes Care Performance Report 2016 (2017) Malaysian
Healthcare Performance Unit, Ministry of Health Malaysia, Kuala Lumpur.
Acknowledgement of Publication:
We would like to thank the Director General of Health Malaysia, for his permission to publish
this article.
Published by:
Malaysian Healthcare Performance Unit

National Institute of Health,
c/o Deputy Director General (Research and Technical Support) Office
Ministry of Health Malaysia
Block E7, Federal Government Administrative Centre
62590 Putrajaya,
Malaysia.
Tel : (603) 8000 8000

Fax : (603) 8888 6187
Email : contactmhp@crc.moh.gov.my, kkm@moh.gov.my
This report is intended only for the use of the individual entity to which it is addressed and may contain information
i
FOREWORD 1
The national landscape for diabetes mellitus (DM) is grim. It is undeniably one of our top
priorities in tackling the burden of disease as the impact it has is significant not only upon
families but also on the health system as well as the nation.
Against this backdrop, this baseline performance assessment of our health services in this area
is timely. We now have estimation of some of the parameters of care and outcomes like rate of
diabetes related admission and rate of diabetic complications based on validated clinical
database. Not only that they are good for assessment, the distribution ie disaggregation by
certain criteria such as state, district, urban/rural, ethnicity, gender and age-group would make
policy makers and health managers more aware of variations in service provisions and
outcomes and what can be done to minimize those gaps.
Although this report is limited concerning the level of data disaggregation, yet this preliminary
report can be a catalyst for better data and hence better reports in future.
One cannot improve what one does not measure - with that I commend this effort at measuring
our performance and I wish the team well for their future projects.
My advice is for all stakeholders to start using this and future reports for their policy and
decision making with the common aim in mind for better care and better outcome for our
rakyat!!
YBhg Datuk Dr Noor Hisham Abdullah

Director General of Health
Ministry of Health, Malaysia
ii
FOREWORD 2
MHP is the DG’s aspiration - as a mean to have a governance tool for monitoring and evaluating
performance of the health system or subsystems.
2016 was MHP third year and this report is their second attempt at assessing a selected
subsystem (disease-specific) performance assessment, their first being the cardiovascular care
performance report.
The attempt to introduce performance assessment using scorecards is rather new in the
nation’s health arena - people need to adapt to it and soon when they find it useful the work will
become less challenging.
I must acknowledge that MHP have been successful in engaging the various stakeholders and
data holders in converting readily available data into actionable information.
However there will always be room for future improvement, building on lessons learnt from
this first report. I urge all the pertinent players to make use of the report.
Again I would like to remind that this report belongs to us; it is our assessment of our system,
and thus we welcome any constructive feedbacks or comments.
Lastly I would like to thank all those who have contributed in many ways to make our DG’s
aspiration a reality.
YBhg Datuk Dr Shahnaz Murad

Deputy Director General of Health (Research and Technical Support)
Ministry of Health, Malaysia
iii
ACKNOWLEDGEMENTS
We wish to thank YBhg. Datuk Dr Noor Hisham bin Abdullah, Director General of Health and
Datuk Dr Shahnaz binti Murad, the Deputy Director General of Health (Research & Technical
Support) for their guidance. We also sincerely thank the Director of National Clinical Research
Centre, Dr Goh Pik Pin for her strong support. Acknowledgement of contribution goes to all
state health directors and other stakeholders listed below:-
Y.Bhg. Datuk Dr Lokman Hakim b. Sulaiman

Timbalan Ketua Pengarah Kesihatan (Kesihatan Awam)
Kementerian Kesihatan Malaysia
Y.Bhg. Dato' Dr Hj Azman bin Abu Bakar

Pengarah
Bahagian Perkembangan Perubatan
Dr Md. Khadzir bin Sheikh Hj. Ahmad

Timbalan Pengarah
Pusat Informatik Kesihatan (PIK)
External reviewer
Professor Niek Klazinga

Health Care Quality Indicator Project Directorate for Employment, Label, and Social Affair
(OECD)
Contributors
Dato’ Dr Hj Ahmad Razin Dato’ Hj Ahmad Mahir Dr Syed Mud Puad Syed Amran
Pengarah Kesihatan Negeri Wakil Pengarah Kesihatan Negeri
Jabatan Kesihatan Negeri Kelantan Jabatan Kesihatan Negeri Perak
Dato’ Dr Hassan Merican Omar Naina Merican Dr Bariyah Kadas

Wakil Pengarah Kesihatan Negeri Wakil Pengarah Kesihatan Negeri
Jabatan Kesihatan Negeri Pulau Pinang Jabatan Kesihatan Negeri Selangor
Dato’ Dr Norhizan Ismail Dr Lokman Rejali

Pengarah Kesihatan Negeri Wakil Pengarah Kesihatan Negeri
Jabatan Kesihatan Negeri Kedah Jabatan Kesihatan Negeri Sembilan
Dr Wan Abdul Rahim Wan Muhammad Dr Amirullah Ahmad Arshad

Wakil Pengarah Kesihatan Negeri Wakil Pengarah Kesihatan Negeri
Jabatan Kesihatan Negeri Pahang Jabatan Kesihatan Negeri Melaka
Dr Hjh Fatimah Othman Dr Mohd Zaki Abdul Hamid

Pengarah Kesihatan Negeri Pengarah Kesihatan Negeri
Jabatan Kesihatan Negeri Johor Jabatan Kesihatan Labuan
Dr Fatimah Muda Dr G. R. Letchuman Ramanathan

Wakil Pengarah Kesihatan Negeri Pakar Perunding Kanan Perubatan
Jabatan Kesihatan Negeri Terengganu & Ketua Jabatan Perubatan,
Hospital Raja Permaisuri Bainun, Ipoh
iv
Dr Muhammad Arif B Mohd Hashim Dr.Noor Raihan Khamal
Wakil : En Ahmad Bazli B Abu Shuib Ketua Penolong Pengarah Kanan
Pakar Perunding Kanan Patologi & Ketua Cawangan Penyakit Tidak Berjangkit
Jabatan Patologi
Hospital Kuala Lumpur Dr.Masliha Harun
Ketua Penolong Pengarah Kanan
Dr Zanariah Bt Hussein Cawangan Penyakit Tidak Berjangkit
Pakar Perunding Endokrinologi, Bahagian Kawalan Penyakit
Hospital Putrajaya
Mohd Nazri Abdullah
Dr Rozlan B Ishak Cawangan Penyakit Tidak Berjangkit
Timbalan Pengarah Penyakit (PTB), Bahagian Kawalan Penyakit
Cawangan Penyakit Tidak Berjangkit (NCDC)
Bahagian Kawalan Penyakit, Siti Fairuz Mohd Zukri
Jabatan Perangkaan Malaysia
Dr Kamaliah Bt Mohamad Noh
Timbalan Pengarah Dr Rotina Bt Abu Bakar
Cawangan Kesihatan Primer Ketua Penolong Pengarah Kanan,
Bahagian Pembangunan Kesihatan Keluarga Bahagian Kawalan Penyakit
Dr Fathullah Iqbal Abdul Rahim Datin Dr Siti Haniza Bt Mahmud

Timbalan Pengarah Setiausaha
Pusat Informatik Kesihatan Institut Penyelidikan Sistem Kesihatan
Dr Vickneshwari Ayadurai Dr Nazrila Hairizan Bt Nasir

Pakar Perubatan Keluarga Pakar Kesihatan Keluarga
Klinik Kesihatan Taman Medan Klinik Kesihatan Putrajaya
Dr Muhammad Fadhli Mohd Yusoff Dr Omar B Mihat

Pakar Kesihatan Awam Ketua Sektor Kesihatan
Institute Kesihatan Umum Mental, VIP & AST, Khas C,
Bahagian Kawalan Penyakit
Dr.Noraini Mohd Yusoff
Ketua Penolong Pengarah Kanan Puan Suhaya Bt Komari
Cawangan Kesihatan Primer Penolong Pengarah Kanan Gred E44
Bahagian Pembangunan Kesihatan Keluarga Pusat Informatik Kesihatan
Dr.Fatanah Binti Ismail Puan Viola Michael

Ketua Penolong Pengarah Kanan Pegawai Dietetik U54, NCD,
Cawangan Kesihatan Primer Bahagian Kawalan Penyakit
Bahagian Pembangunan Kesihatan Keluarga
Malaysian Healthcare Performance Unit
Team lead: Members:
Dr. Jamaiyah Haniff Dr Nor Aini Abdullah

Dr Theyveeka Selvy Rajoo
Project lead: Dr Ariza Zakaria
Cik Nadiah Hanis Hashim
Dr Mohd Kamarulariffin Kamarudin
Cik Nuramalina Abdullah
v
CONTENTS
List of tables ...................................................................................................................................................................... vii

List of figures .................................................................................................................................................................... vii
List of abbreviations .................................................................................................................................................... viii
EXECUTIVE SUMMARY .................................................................................................................................................. 1
MALAYSIAN DIABETES CARE PERFORMANCE SCORECARD ........................................................................ 3
Chapter 1 Introduction................................................................................................................................................... 5
Background .................................................................................................................................................................... 6
Objectives ........................................................................................................................................................................ 6
Methodology & Analysis ........................................................................................................................................... 7
Chapter 2 Malaysian Diabetes Profiling ............................................................................................................... 12
Demographics ............................................................................................................................................................ 13
Prevalence of DM ...................................................................................................................................................... 14
Prevalence of DM Risk Factors ............................................................................................................................ 16
Chapter 3 Diabetes Care Performance Indicators............................................................................................ 19
Where we stand......................................................................................................................................................... 20
Human Resources & Primary Care Facilities ................................................................................................ 21
Process of Care........................................................................................................................................................... 23
Health Outcome ......................................................................................................................................................... 25
Admission Rate ..................................................................................................................................................... 25
Chronic Complications ....................................................................................................................................... 27
Clinical Targets ..................................................................................................................................................... 29
Conclusion ........................................................................................................................................................................ 31
Recommendations......................................................................................................................................................... 32
APPENDIX ......................................................................................................................................................................... 33
BIBLIOGRAPHY .............................................................................................................................................................. 57
GLOSSARY......................................................................................................................................................................... 59
vi
LIST OF TABLES
Table 1: Data availability, coverage, and levels of disaggregation of selected performance

indicators ............................................................................................................................................................................. 9
Table 2: Prevalence of diabetes, 2006-2015 ..................................................................................................... 14
Table 3: State variation of diabetes prevalence, 2015 .................................................................................. 15
Table 4: Diabetes risk factor prevalence, 2015 ................................................................................................ 17
Table 5: State variations of diabetes risk factor prevalence, 2015 .......................................................... 17
Table 6: Human resources for health and primary care facility distribution, 2015 or the nearest
year ...................................................................................................................................................................................... 21
Table 7: State variation of number and density (per 100 000 population) of human resources for
health, 2015. .................................................................................................................................................................... 22
Table 8: Percentage of patients with diabetes who received standard care, 2012. .......................... 24
Table 9: Hospital admission rate (per 100 000 population) for uncontrolled DM with or without
complications, 2014. .................................................................................................................................................... 26
Table 10: State variation of hospital admission rate for diabetes (per 100 000 population), 2015.
............................................................................................................................................................................................... 26
Table 11: Percentage of patients with documented complications, 2012. ........................................... 28
Table 12: Clinical target achievement, 2012 ..................................................................................................... 30
LIST OF FIGURES
Figure 1: Breakdown of cases by age group, 2009-2012 ............................................................................. 13

Figure 2: Breakdown of cases by ethnicity, 2009-2012 ............................................................................... 13
Figure 3: Trend of national prevalence of diabetes, 2006-2015............................................................... 14
Figure 4: Distribution of undiagnosed diabetes by age group, 2015 ...................................................... 15
Figure 5: Trend of diabetes risk factors prevalence, 2006-2015 ............................................................. 16
Figure 6: Malaysian rankings of selected performance indicators .......................................................... 20
Figure 7: State variation of primary care facility density, 2012................................................................ 22
Figure 8: Yearly trend of diabetes process of care, 2009-2012 ................................................................ 23
Figure 9: Hospital admission rate for uncontrolled dm with or without complications per 100
000 population, 2010-2014 ...................................................................................................................................... 25
Figure 10: Rate of diabetic complications, 2011 vs 2012 ............................................................................ 27
Figure 11: Yearly trend of diabetes clinical target achievement, 2009-2012 ..................................... 29
vii
LIST OF ABBREVIATIONS
AAR Average Annual Rate

BMI Body Mass Index
BP Blood Pressure
BPKK Bahagian Pembangunan Kesihatan Keluarga
CPG Clinical Practice Guideline
DM Diabetes Mellitus
FBG Fasting Capillary Blood Glucose
FMS Family Medicine Specialist
GP General Practitioner
IDF International Diabetes Federation
IFG Impaired Fasting Glucose
KK Klinik Kesihatan (Health clinics)
LDL Low Density Lipoprotein
MEMS Malaysian Endocrine & Metabolic Society
MOH Ministry of Health Malaysia
NADI National Diabetes Institute
NCD Non-communicable Disease
NDR National Diabetes Registry
NGO Non-profit Non-governmental Organization
NHEWS National Health Care Establishment and Workforce Statistics
NHMS National Health and Morbidity Survey
OECD Organization for Economic Co-operation and Development
SMRP Sistem Maklumat Rawatan Perubatan
WHO World Health Organization
viii
EXECUTIVE SUMMARY
Malaysian diabetic scenarios
The prevalence of diabetes mellitus (DM) is on the rise (the average annual growth is about 5%);
about half consists of undiagnosed cases. This phenomenon is likely attributable to the increasing
prevalence of obesity and pre-diabetes state in the general population.
Among the states, Kedah recorded the highest prevalence of DM while WP Putrajaya recorded the
highest prevalence of adult obesity.
Age-standardized prevalence of DM in Malaysia is almost three times higher than that of OECD-34
average, and remarkably higher than the majority of comparator countries.
Age-standardized prevalence of obesity in Malaysia is almost double the prevalence of obesity in

China, Singapore, Indonesia and India.
The Malaysian prevalence of physical inactivity in 2010 was the highest among the comparator
countries.
Resources and facilities
We observe a positive growth in human capital and number of health care establishments that
provide diabetes services in Malaysia from 2009 to 2015.
There are unequal distributions of resource between states. State of Kelantan has comparatively
lower primary care facility density per population but is among the states with highest prevalence of
DM. On the other hand, Kuala Lumpur has the highest primary care facility density per population
but is among the states with the lowest prevalence of DM.
Private General Practitioners (GP) provide the widest coverage of primary care services inclusive of
diabetes care services in Malaysia. This phenomenon may put affordability as the key driver to
accessibility.
Process of care
From 2009 to 2012, the proportion of patients with diabetes in the health clinics who received the
expected care (funduscopy, urine microalbumin and HbA1c testings) increased by an annual rate of
6%, 8% and 5% respectively. In the same time period, proportion of patients who achieved clinical
target for HbA1c and LDL had increased from 19% to 24% and 31% to 38% respectively.
However, the number of patients with diabetes with normal BMI (< 23kg/m2) is less than one fifth of
the total population with diabetes. In addition, patients with diabetes that have blood pressure
controlled within the accepted range (< 130/80mm/Hg) are only less than half of the total population
with diabetes.
1
Outcomes
There was an overall decrease in the rate of diabetes related admission from 2010 to 2015 in public
hospitals. However, the admission rate trend particularly for diabetes with short term complications
was the opposite; the rate in 2015 was higher than the rate in 2010.
The rate of diabetic retinopathy, nephropathy, myocardial infarction, diabetes foot ulcer and lower
limb amputation has decreased by a factor of about one to seven per cent. However, rate of
cerebrovascular complications have increased by five per cent since 2011.
The reported prevalence of complications among diabetes patients in primary care settings in
Malaysia is generally lower than the comparator countries potentially due to under-reporting.
2
MALAYSIAN DIABETES CARE PERFORMANCE SCORECARD
AAR AAR
Year Achievement Standard
(%) period
Input
1. Endocrinologist per 100 000
2015 0.24 - - -
populationPP
2. Number of Family Medicine
2015 281 ↑8.6 2009-2015 -
Specialist (FMS)P
3. KK to population ratio 2015 1: 32 519 - - -
4. Number of KK with FMS 2015 242 ↑6.2 2009-2015 -
5. Primary care facility per 10 000

2012 2.2 - - -
populationPP
Process of care
1. % Patients who had funduscopy
2012 44.0% ↑6.4 2009-2012 -
done within the last 1 yearp
2. % Patients who had foot

examination done within the last 1 2012 73.0% ↑0.3 2009-2012 -
yearp
3. % Patients who had urine checked

for micro-albumin within the last 1 2012 56.7% ↑7.7 2009-2012 -
yearp
4. % Patients who had HbA1c test

done at least once within the last 1 2012 78.0% ↑4.7 2009-2012 -
yearp
Outcome (Hospital admission per 100 000 population)
1. Uncontrolled DM without
2015 58 ↓ 7.6 2010-2015 -
complicationspp
2. DM with short term complicationspp 2015 19 ↑ 7.7 2010-2015 -
3. DM with long term complicationspp 2015 69 ↓ 1.0 2010-2015 -
3
AAR*
Year Achievement AAR period Standard
(%)
Outcome (Diabetic complications in primary care)
1. Rate of retinopathyp 2012 7.9% ↓6.5 2011-2012 -
2. Rate of nephropathyp 2012 8.9% ↓6.6 2011-2012 -
3. Rate of myocardial infarctionp 2012 6.0% ↓1.3 2011-2012 -
4. Rate of cerebrovascular diseasep 2012 1.4% ↑4.7 2011-2012 -
5. Rate of diabetic foot ulcerp 2012 1.4% ↓3.0 2011-2012 -
6. Rate of amputationp 2012 0.7% ↓0.6 2011-2012 -
Outcome (Clinical target achievements in primary care)

1. % Patients who achieved BP target
2012 40.9% ↓ 0.2 2009-2012 -
≤ 130/80mm/Hgp
2. % Patients who achieved HbA1c 1

2012 23.8% ↑ 7.1 2009-2012 >30%
target < 6.5%p
2
3. % Patients who had BMI < 23kg/m p 2012 16.6% ↓ 1.2 2009-2012 -
4. % Patients who achieved LDL target

2012 37.8% ↑ 7.3 2009-2012 -
≤ 2.6mmol/Lp
Impact
1. Prevalence of obesity (BMI ≥ 27.5
-2 2015 30.6% ↑ 3.0 2011-2015 -
kgm )
2. Prevalence of overweight (BMI ≥
-2 2015 64.0% ↑ 1.4 2011-2015 -
23.0 kgm )
3. Prevalence of IFG 2015 4.7% ↑ 1.3 2006-2015 -
4. Prevalence of insufficient physical

2015 33.5% ↓ 2.9 2006-2015 -
activity
2
5. Prevalence of overall DM 2015 17.5% ↑ 4.7 2006-2015 15.0%
P Public
PP Public and Private
1 Target from Malaysian Clinical Practice Guideline “Management of Type 2 Diabetes Mellitus (5th Edition)
2 Target for Malaysia by 2025: WHO NCD Global Monitoring Framework. Baseline year 2010 WHO
4
CHAPTER 1 INTRODUCTION
5
BACKGROUND
The progression of diabetes and cardiovascular diseases is a concern worldwide. National Health and
Morbidity (NHMS) survey, a series of community-based survey on the pattern of common health
problems, health service utilisation and health expenditure in Malaysia reports a steady uprising of
cardiovascular disease risk factor since 1986. One in three Malaysians were hypertensive; about one
in five were diagnosed with hypercholesterolemia; and one fifth of the population were found to
have diabetes (Institute for Public Health, 2015). These problems are expected to contribute further
to the growing incidence of cardiovascular complications namely the acute coronary syndrome (ACS)
and stroke.
To reduce the burden of disease, health promotion and disease prevention remain the most efficient
strategies as they could provide opportunities to curb diseases at earlier stages when the diseases
are often more responsive to treatment. Having implemented preventive measures or interventions,
there must be a mechanism in place for regular monitoring and evaluation in order to understand
underlying processes that may have resulted in any unintended outcomes.
Many different divisions within the Ministry of Health have been collecting data in various aspects of
health care as part of administrative, academic, clinical and quality improvement work. Malaysian
Healthcare Performance unit (MHPU) was established to transform those various databases into
actionable information as well as to benchmark health performance against best practices locally or
internationally. We aim to identify variation in practices and health outcomes in order to promote
health care innovation and improvement in the care delivery.
This report is intended to serve as a foundation for a more comprehensive work pertaining to
reporting of diabetes care performance in Malaysia. This current report focuses on performance
assessment of diabetes care before the year 2015 following a framework that incorporates various
health care system and quality domains used by the World Health Organization (WHO)(Organization
2003).
This report consists of three chapters. The first chapter is an introduction to health system
performance assessment, the report methodology and analysis. The second chapter describes the
demographic profiling of the population with type 2 diabetes in Malaysia. The third chapter reports
statistics concerning the service inputs and resources, the critical aspect of process of care in adults
with type 2 diabetes and the system outcomes.
OBJECTIVES
1. To describe the magnitude of current diabetic burden in Malaysia

2. To describe the performance of diabetes care based on latest available data.
3. To show the performance trending information
4. To describe variation in performance by state
5. To benchmark performance against OECD countries or other selected comparator countries.
6
METHODOLOGY & ANALYSIS
We employed disease-based approach to reflect performance across health programme and services.
The choice of diabetes as the topic is in keeping with the findings of Malaysian Burden of Disease and
Injury study (Ahmad Faudzi Yusoff, Gurpreet Kaur, Mohd Azahadi Omar, & Amal Nasir Mustafa, 2004)
that reported diabetes, ischemic heart disease and cerebrovascular disease as the top contributors to
mortality and disability-adjusted life year (DALY) in Malaysia.
Literature search was done on the topic related to quality of care and health care performance
assessment for diabetes using online search engines. The searching was purposive with priority given
to review articles and local studies that mention performance assessment in diabetes care or its
equivalents. A table comprising a list of diabetes care indicators was constructed and filled along as
new indicators were found during the literature search period. The indicators were grouped into the
domains of input, process, outcome and impact that reflect Donabedian’s conceptual model of
assessing quality in health system (Avedis Donabedian, John R. C. Wheeler, & Leon Wys, 1982). Each
indicator was deliberated by the MHPU team on the suitability (relevance in local context) and
potential data sources.
Majority of the indicators and their definition were taken verbatim from their respective source
documents. These are the commonly used indicators to describe health system performance
internationally. However, some of the indicators were replaced with an equivalent proxy to
accommodate local data definition and data availability. Corresponding data were synthesised from
published related documents and surveillance reports; they were reconstructed into a data frame in
an electronic spread sheet. Majority of the published data were aggregated numbers or rates at
either state or national level. Detailed information on the datasets used and their sources, coverage,
and levels of disaggregation are given in Table 1.
Data cleaning process involved manual tracking of wrongly entered value by at least one other
person using the original source documents as reference. A statistician service was utilised for data
proof-reading and reviewing of mathematical formula and rate calculation. If any discrepancies, the
correction was done on the master data spread sheet by the same person who constructed the data
frame.
Analysis largely involved visual analytics; plotting data using column or line graph- looking at the
trending over time or constructing three dimensional scatter plots- assessing the visual correlation.
No adjustment or standardization of rate was attempted.
In this report, performance is measured in four ways:
1. Whether or not Malaysia has reached a specific achievement target/standard.

- Health related activities and outcomes are measurable; a target is ideally set to assess
the progress of any implemented strategy in health promotion or intervention.
2. Whether there have been desirable changes in the latest achievement compared to the
achievement of previous years.
- Desirable changes are expected trend of achievement based on historical data. An
increasing trend is desirable for positive outcomes while decreasing trend is desirable for
unwanted outcomes.
7
3. The average annual rate of change (AAR) of the achievements over a time period ;
- AAR is calculated by taking the geometric mean of the annual percentage difference
between the baseline achievement (beginning value) and the current achievement
(ending value) with the assumption that the achievements have been compounding over
the specified time period. The mathematical formula is given by:
( )
AAR = ( )
4. Malaysia achievement in comparison with selected OECD countries and other comparator
countries.
- OECD has an online updated database that conglomerate common statistics from various
member countries in time series. OECD as a benchmark is our attempt to close the gap
so as to achieve the standard enjoyed by developed nations.
All indicators along with the data were discussed with and presented to the respective stakeholders
for reconciliation. Improvement and additional work were tailored according to the stakeholders’
suggestions and needs.
Findings are reported using the following symbols and colour codes:
↑ Increased since previous year Desirable change

↓ Decreased since previous year Indicator of concern
→ Remained the same since previous year Status quo
- Missing or unavailable information
A note about making comparisons (limitation):
 All indicators are presented in crude measure without adjustment to baseline

characteristics or risks. Therefore, comparability of rates between different periods of
data collection or regions is limited.
 The report findings are based on secondary aggregated data. Degree of ascertainment,
duplications, and missing data could not be fully verified.
 Majority of data represents only the public sectors and Ministry of Health institutions
although the interpretations in this report are meant to describe the Malaysian
scenarios as whole. Potentially, there are data from other sectors that have yet to be
explored by the time this report is published
 Due to the nature of this report that used aggregated data from multiple sources, direct
causality or longitudinal relationship cannot be established and the findings cannot be
inferred without estimate adjustment or predictive modelling.
8
Table 1: Data availability, coverage, and levels of disaggregation of selected performance indicators
Indicator Time period Coverage Data source Domain
1. Prevalence of DM
 Overall NHMS
2006-2015 By state Impact
 Known DM (Published)
 Undiagnosed DM
2
2. Prevalence of obesity (≥ 27.5 kg/m ) NHMS
(Published)
2
3. Prevalence of pre-obese (23-<27.5 kg/m ) NHMS
(Published)
4. Prevalence of impaired fasting glucose NHMS

(IFG) 2006-2015 By state Impact
(Published)
5. Prevalence of insufficient physical activity NHMS

(Published)
6. Diabetes age-adjusted comparative National IDF

prevalence 2015 Impact
aggregate (Published)
7. Obesity age-standardized adjusted National WHO

prevalence 2014 Impact
8. Insufficient physical activity age- National WHO

standardized prevalence 2010 Impact
NHEWS
9. Number of Endocrinologist
(Published)
2009-2015 By state Input
MEMS
(Unpublished)
10. Number of FMS By state BPKK
2008-2015 Input
MOH only (Unpublished)
11. Primary care clinics to population ratio NHEWS

2012 By state Input
(Published)
12. Endocrinologist density per 100 000 MEMS

population by state 2015 By state Input
(Unpublished)
9
Table 1: Data availability, coverage, and levels of disaggregation of selected performance indicators
(continued)
Indicator Time period Coverage Data source Category
13. Proportion of diabetics who have had:
• Urine test for micro-albumin

National
• Funduscopy NDR Process of
2009-2012 aggregate
• Foot examination (Published) care
• HbA1c test MOH only
Done within the last 1 year of the audit
period.
14. Proportion of diabetics who have

achieved clinical target:
National
• BP ≤ 130/80 mmHg aggregate NDR
2 2009-2012 Outcome
• BMI < 23 kg/m (Published)
MOH only
• LDL ≤ 2.6 mmol/L
• HbA1c < 6.5 %
15. Proportion of diabetics with

complications:
• Retinopathy National
• Nephropathy aggregate NDR
2009-2012 Outcome
• MI (Published)
• Cerebrovascular MOH only
• DFU
• Amputation
16. Admission rate by state
• Uncontrolled DM without
complications National
aggregate SMRP
• DM with short term 2010-2014 Outcome
(Unpublished)
complications MOH only
• DM with long term complications
• Total DM related admission
NHEWS: National Healthcare Establishments & Workforce Statistics (Hospital) 2008-2009

National Healthcare Establishments & Workforce Statistics (Hospital) 2012-2013
National Healthcare Establishments & Workforce Statistics (Primary Care) 2012
NDR: National Diabetes Registry Report, Volume 1, 2009-2012
NMCS: National Medical Care Statistics (Primary Care) 2014
NHMS: The Third National Health and Morbidity Survey (NHMS III) 2006, Vol 2
National Health and Morbidity Survey 2011 (NHMS 2011). Vol. II: Non-Communicable Diseases
National Health and Morbidity Survey 2015 (NHMS 2015). Vol. II: Non-Communicable Diseases, Risk Factors & Other Health
Problems
OECD: Health Statistics 2015

stats.oecd.org
10
BPKK: Bahagian Pembangunan Kesihatan Keluarga
IDF: International Diabetes Federation, Annual Report 2013

International Diabetes Federation, Annual Report 2015
WHO: Global Status Report on Non-Communicable Disease 2014
SMRP: Sistem Maklumat Rawatan Perubatan
MEMS: Malaysian Endocrine & Metabolic Society
11
CHAPTER 2 MALAYSIAN DIABETES PROFILING
12
DEMOGRAPHICS
Demographic breakdown for T2DM population in Malaysia based on National Diabetes Registry
(NDR) report is illustrated in Figure 1 and Figure 2 for age groups and ethnicity respectively. From
2009 to 2012 there were 653,326 registered T2DM patients. The mean age was 59.7 years old;
41.6% were men and 58.4% were women. In term of ethnicity, 58.9% were Malay, 21.4% were
Chinese and 15.3% were Indian (Ministry of Health, 2013).
Half of the population with T2DM were from the 45-54 age group or younger. The racial distribution
of the registry population reflected the general Malaysian ethnic compositions which were made up
mostly by the Malay ethnic group (Jabatan Perangkaan Malaysia, 2015). However, until 2012 only
644 KKs out 959 KKs were involved in NDR data entry. Due to potential case ascertainment bias,
population inference of any statistical estimates in the report may be limited.
FIGURE 1: BREAKDOWN OF CASES BY AGE GROUP, FIGURE 2: BREAKDOWN OF CASES BY ETHNICITY,

2009-2012 2009-2012
Other Foreigner/
≥80 <18 18-29
Malaysian Unknown
1.1 0.2 2.1
4.2 0.2
65-79
15.2 30-44 Indian
20.1 15.3
Chinese Malay
55-64 58.9
28.7 21.4
45-54
32.6
Data source: National Diabetes Registry Report 2009-2012
13
PREVALENCE OF DM
T2DM is a global public health concern. Four out of five people with T2DM now live in low to middle
income countries (World Health Organization, 2010). The rise of T2DM in those regions may be due
to urbanisation and economic development that have led to changes in the population lifestyle.
Furthermore, the phenomenon of population aging may have also contributed to the increase in the
number of population at risk. Malaysian scenario is no different than the observed global trend.
National Health Morbidity Survey (NHMS) demonstrates the phenomenon of high blood glucose
level progression in Malaysia over a period of two decades (2006-2015). The prevalence of diabetes
among the respondents aged 18 and above was showed to have increased over time.
FIGURE 3: TREND OF NATIONAL PREVALENCE OF DIABETES, 2006-2015
Undiagnosed
Known 17.5
15.2
11.6 53%
% 53%
39%
2006 2011 2015
Data source: National Health and Morbidity Survey
Table 2: Prevalence of diabetes, 2006-2015

2006 2011 2015 AAR
(%) (%) (%) (%)
1.1. Prevalence of overall DM 11.6 15.2 17.5 ↑ 4.7
1.2. Prevalence of undiagnosed DM 4.5 8 9.2 ↑ 8.3
1.3. Prevalence of known DM 7 7.2 8.3 ↑ 1.9

* AAR is calculated for period 2006-2015
14
FIGURE 4: DISTRIBUTION OF UNDIAGNOSED DIABETES BY AGE GROUP,
2015
100%
80%
60%
40%
20%
0%
Known DM Undiagnosed DM
Data source: National Health and Morbidity Survey 2015
Table 3: State variation of diabetes prevalence, 2015

Prevalence of Prevalence of Prevalence of
Overall DM Undiagnosed DM Known DM
Kedah 25.4 ↑ 7.2% 16.1 ↑ 15.8% 9.3 = 0%
Perlis 20.6 ↑ 4.8% 9.7 ↑ 6.5% 10.9 ↑ 3.5%
Johor 19.8 ↑ 6.6% 11 ↑ 11.6% 8.8 ↑ 2.6%
Perak 19.4 ↑ 4.9% 7.4 ↑ 4.5% 11.9 ↑ 5.1%
Negeri Sembilan 19.3 ↑ 2.6% 8.8 ↑ 3.2% 10.5 ↑ 2.0%
WP Putrajaya 19.2 ↑ 21.5% 13.9 ↑ 34.9% 5.3 ↑ 3.6%
Terengganu 18.6 ↑ 5.9% 9.9 ↑ 7.0% 8.7 ↑ 4.8%
Kelantan 18.5 ↑ 5.2% 11.3 ↑ 9.7% 7.1 ↑ 0.5%
Pulau Pinang 18.1 ↑ 2.2% 9.1 ↑ 4.7% 9 ↑ 0.1%
WP Kuala Lumpur 17.4 ↑ 3.7% 9.3 ↑ 5.0% 8.1 ↑ 2.3%
Melaka 16.7 ↑ 1.1% 8.4 ↑ 8.9% 8.3 ↓ 3.5%
Selangor 15.5 ↑ 2.9% 7.7 ↑ 8.2% 7.8 ↓ 0.7%
Pahang 14.8 ↑ 2.3% 8.6 ↑ 8.9% 6.3 ↓ 2.8%
Sarawak 14.8 ↑ 4.5% 6.6 ↑ 1.1% 8.3 ↑ 8.2%
Sabah & WP Labuan 14.2 ↑ 12.1% 8.3 ↑ 6.7% 5.9 ↑ 22.7%

2011-2015 for WP Putrajaya and Sabah & WP Labuan
What does this mean for Malaysia?

1. The prevalence of DM among the general population is on the rise and about half were
undiagnosed. Kedah, Perlis and Johor are the states with the highest DM prevalence.
2. Prevalence of undiagnosed DM cases in Malaysia is growing more rapidly than the
prevalence of known DM with annual increment of 8.3% and 1.9% respectively. Higher
prevalence of undiagnosed cases can be found in Kedah and WP Putrajaya.
3. About 90% of cases below the age of 30 were undiagnosed.
4. The proportion of undiagnosed cases and the rate at which it grows is a concern. Unless
efforts are concentrated on active screening on seemingly healthy population, the burden of
disease related to cardiovascular disease and diabetes will only become more evident.
15
PREVALENCE OF DM RISK FACTORS
Despite the efforts undertaken since 1990s through “Kempen Cara Hidup Sihat”, the prevalence of
NCDs and NCD risk factors continue to rise. A situational analysis in 2010 revealed that the
implementation of NCD programs and activities were confined only within the Ministry of Health
territories (Ministry of Health, Annual Report 2010 Non-Communicable Disease (NCD) Section,
2010). Therefore, National Strategic Plan for NCD was implemented to encourage inter-sectorial
collaboration and address lack of policy in creating health promoting environment in Malaysia
(Ministry of Health, 2010). In 2013 the Ministry of Health initiates a program “Komuniti Sihat Perkasa
Negara” (KOSPEN) that serves as an impetus to boost the existing health promoting mechanism and
intervention at the community level
(http://www.infosihat.gov.my/infosihat/projekkhas/kospen.php). Subsequently, we have seen
improvement in some areas based on findings from National Health and Morbidity (NHMS) surveys
from 2006 to 2015.
FIGURE 5: TREND OF DIABETES RISK FACTORS PREVALENCE, 2006-2015
Prevalence of IFG
Prevalence of overweight
BMI ≥ 23 kgm-2
61% 64%
4% 5% 5%
43%*
2006 2011 2015
Prevalence of insufficient physical
44% activity
2006 2011 2015 35% 34%
Prevalence of obesity
Prevalence of pre-obese
2
*Prevalence for overweight in 2006 follows BMI ≥25kg/m 2006 2011 2015
Obesity is defined using a lower threshold (BMI ≥ 27.5kg/m2) than the WHO international standard
(BMI ≥ 30 kg/m2) to reflect higher percentage of body fat and risk of cardiovascular disease or
diabetes at lower BMI among Asian populations (World Health Organization, 2004).
Impaired fasting glucose (IFG) denotes pre-diabetes state and is categorized based on capillary whole
blood glucose level within 5.6-6.1mmol/L range taken from subject who fasted for at least 8 hours
(Institute for Public Health, 2015).
Insufficient physical activity is considered when the total MET/minute based on recalled activity is
less than accumulated 150 minutes per week of moderate-intensity activity or equivalent (Institute
for Public Health, 2015).
16
Table 4: Diabetes risk factor prevalence, 2015
Value 3 AAR Comparison
Period Target
(%) (%) (%)
No
4.1. Prevalence of obesity 2015 30.6 ↑ 3.0 -
increase
No
4.2. Prevalence of pre-obese 2015 33.4 ↑ 0.1 -
increase
4.3. Prevalence of IFG 2015 4.7 - ↑ 1.3 -
4.4. Prevalence of insufficient physical

2015 33.5 30.0† ↓ 2.9 -
activity
4.5. Male waist circumference > 90cm 2015 38.2 - ↑0.5 -
4.6. Female waist circumference > 80cm 2015 60.2 - ↑2.7 -

3
Target for Malaysia by 2025: WHO NCD Global Monitoring Framework. Baseline year 2010.
† Target by 2025; Reduction by 10% from baseline year 2010
* AAR is calculated for period 2006-2015 for 4.3 - 4.6; 2011-2015 for 4.1 & 4.2
Table 5: State variations of diabetes risk factor prevalence, 2015

Prevalence of
Prevalence of Prevalence of pre- Prevalence of
insufficient
obesity obese IFG
physical activity
WP Putrajaya 43.0 ↑ 12% 34.4 ↓ 1.3% 6.5 ↑ 53% 32.5 ↓ 13%
Melaka 36.0 ↑ 5.3% 33.6 ↓ 0.1% 3.5 ↓ 0.9% 37.8 ↓ 0.4%
Perlis 36.0 ↑ 1.0% 30.7 ↑ 1.3% 4.0 ↑ 1.8% 27.8 ↓ 6.1%
Negeri Sembilan 35.6 ↑ 6.0% 30.4 ↓ 0.7% 6.4 ↑ 11% 33.7 ↓ 0.3%
Kedah 33.2 ↑ 4.2% 32.4 ↓ 1.2% 6.4 ↑ 4.3% 33.6 ↓ 1.0%
Selangor 32.7 ↑ 3.8% 33.4 ↑ 0.8% 4.3 ↓ 0.7% 39.9 ↓ 2.9%
Pahang 32.5 ↑ 3.6% 31.5 ↓ 0.5% 4.3 ↑ 2.6% 26.0 ↓ 2.1%
Terengganu 32.5 ↑ 3.7% 29.7 ↓ 2.4% 3.5 ↓ 1.5% 30.7 ↓ 0.6%
Sarawak 32.3 ↑ 4.9% 31.0 ↓ 1.1% 2.9 ↓ 5.4% 40.8 ↓ 1.8%
Johor 29.8 ↑ 1.0% 33.5 ↑ 0.4% 7.2 ↑ 11% 32.9 ↓ 3.6%
WP Kuala Lumpur 29.6 ↑ 6.7% 34.2 ↓ 1.9% 3.8 ↓ 5.1% 36.4 ↓ 3.8%
Perak 29.5 ↓ 0.5% 34.7 ↑ 2.5% 5.3 ↑ 0.6% 28.1 ↓ 4.8%
Kelantan 28.8 ↓ 0.5% 30.7 ↓ 3.4% 6.6 ↑ 4.3% 25.8 ↓ 3.1%
Pulau Pinang 27.8 ↑ 0.8% 37.3 ↑ 0.7% 4.2 ↓ 4.1% 25.5 ↓ 5.2%
Sabah & WP Labuan 23.9 ↑ 3.2% 36.9 ↑ 1.7% 3.3 ↓ 6.9% 30.1 ↑ 5.0%

AAR is calculated for period 2011-2015 for Sabah & WP Labuan and WP Putrajaya
3NCD Global Monitoring Framework. (2015). Retrieved October 06, 2016, from
http://www.who.int/nmh/global_monitoring_framework/en/
17
1. 64% of general population were overweight (BMI ≥ 23) and half of that exceeded the obesity
threshold (BMI ≥ 27.5) in 2015.
2. WP Putrajaya has the highest prevalence of obesity compared to other states.
3. There is a modest increase in the prevalence of IFG from 4.2% in 2006 to 4.7% in 2015.
4. People are getting more physically active with decreasing proportion of population with
insufficient physical activity over the 2006-2015 periods. Nonetheless, about one third of the
population still remained inactive in 2015.
5. The increasing prevalence of obesity and pre-diabetic states are among the key contributors
to diabetic burden in Malaysia. However, a more comprehensive review must be made in
the light of other important covariates like dietary habit or other unmeasured social
confounders.
6. Weight circumference (WC) is an independent risk factor for diabetes. WC as an indicator
highlights predisposition to diabetes even among population with normal BMI.
18
CHAPTER 3 DIABETES CARE PERFORMANCE
INDICATORS
19
WHERE WE STAND
Our national health priorities include enhancing the health care delivery system to increase access to
quality care, and reducing the disease burden, both communicable and non-communicable diseases.
While we have achieved commendable improvement in the life expectancy and maternal and child
mortality indicators, we are still behind in our performance in comparison to the countries with
higher economic status.
World Health Organization (WHO) and International Diabetes Federation (IDF); two important
international advocators for diabetes prevention came out with the global action plan focusing
particularly on lifestyle interventions in hope of reducing the burden of diabetes that is affecting all
over the world especially in the developing countries (World Health Organization, 2013). In line with
the global aspiration, we continue to work within our capacity to pursue the goal of delivering a
world-class health care system. There are indeed variations and differences between health system
of different countries in term of its capacity, processes and outcomes depending on the system
intended objectives. However, making OECD countries as our benchmark will give us insight into the
potential improvement that can be undertaken at our local settings given the aspiration of Malaysia
becoming one of the developed nations.
FIGURE 6: MALAYSIAN RANKINGS OF SELECTED PERFORMANCE INDICATORS
Diabetes age-adjusted Obesity age-standardized Insufficient physical

comparative prevalence adjusted prevalence activity age-standardized
2015 2014 prevalence, 2010
Malaysia 17.9 United States 33.7 Malaysia 52.3

United States 10.8 New Zealand 29.2 New Zealand 39.8
Singapore 10.5 Australia 28.6 United Kingdom 37.3
China 9.8 United Kingdom 28.1 Singapore 33.1
India 9.3 OECD-34 23 United States 32.4
Germany 7.4 Germany 20.1 OECD-31 26.1
New Zealand 7.3 Malaysia 13.3 China 24.1
OECD-34 7 China 6.9 Australia 23.8
Indonesia 6.5 Singapore 6.2 Indonesia 23.7
Australia 5.1 Indonesia 5.7 Germany 21.1
United Kingdom 4.7 India 4.9 India 13.4
th
Data source: IDF Diabetes Atlas 2015 (7 Edition)
WHO Global Status Report on NCDs 2014

1. The age-standardized prevalence of diabetes in Malaysia is 2.6 times higher than the OECD-
34, and remarkably higher than some regional countries.
2. The age-standardized prevalence of obesity in Malaysia almost doubles the prevalence in
China, Singapore, Indonesia and India.
3. Malaysian prevalence of insufficient physical activity is the highest among the OECD
countries.
4. Statistics regarding sedentary lifestyle and obesity are commonly reported but both factors
are only few out of many other risk factors that can be associated with diabetes. However,
the chances are likely that these two risk factors contributed a significant portion to the
diabetic scenario in Malaysia.
20
HUMAN RESOURCES & PRIMARY CARE FACILITIES
Generating resources or inputs is one of the functions a health system performs along with
stewardship, financing and health service provision. Inputs to the health system are combined to allow
the delivery of a series of interventions or health actions with the final objectives mainly to improve
the population health status. These inputs particularly human resources, physical resources such as
facilities and equipment, and knowledge are factors that would enable health system to perform to its
potential. Thus, a well-thought strategy for input generation is very critical. (The World Health Report
Health Systems Improving Performance, 2000).
Inputs in term of adequate number of health care facilities and resources are also requisite to ensure
universal accessibility to health care. In Malaysia, despite the highly subsidized public health care
provision and additional service coverage offered by the private practices, issues like long queues, drug
rationing or poor transportation system can be potential contributors to inequity in service delivery
(Ministry of Health, Country Health Plan, 2015).
Table 6: Human resources for health and primary care facility distribution, 2015 or the nearest year
Year Value Target AAR (%)
Public Private Public Private
6.1. Number of Endocrinologist 2015 54 22 - ↑9.1 ↑4.4
6.2. Total endocrinologist

2015 0.24 - -
per 100 000 population
6.3. Number of Family Medicine
2015 281 - ↑8.6
Specialist (FMS)
6.4. Number of health clinic (KK) 2015 959 - ↑2.9
6.5. KK to population ratio 2015 1: 32 519 - -
6.6. Number of KK with FMS 2015 242 - ↑6.2
6.7. Total primary care facility

2012 2.2 - -
per 10 000 population
FMS refers to family medicine specialist in Klinik Kesihatan. (Data until July 2015)
Primary care facility includes both health clinics and private General Practitioners
AAR is calculated for period 2009-2015
Data source: National Health Establishment & Workforce Statistics (NHEWS) Survey
Bahagian Pembangunan Kesihatan Keluarga (BPKK) Ministry of Health
Malaysian Endocrine and Metabolic Society (MEMS)
21
FIGURE 7: STATE VARIATION OF PRIMARY CARE FACILITY DENSITY, 2012
Klinik Kesihatan Private clinics Average

4.1
2.8 2.6
per 10,000 2.6 2.5 2.4 2.3
population 2.2 Malaysia
1.8 1.8 1.8 2.2
1.6 1.6 1.6
1.1
Data source: National Medical Care Statistics (Primary Care) 2014
Table 7: State variation of number and density (per 100 000 population) of human resources
for health, 2015.
Number of KK
Number of Number of KK
Endocrinologist Density 2 with FMS
FMS 2015 2015
2015
Public Private
WP Kuala Lumpur 14 8 1.24 19 16 14
Negeri Sembilan 2 0 0.18 16 47 15
Selangor 9 9 0.29 40 74 36
Pulau Pinang 5 2 0.41 15 30 15
Melaka 2 1 0.34 11 29 10
Perak 3 1 0.16 21 85 20
Johor 3 0 0.08 21 94 18
Pahang 2 0 0.12 19 84 18
Kedah 1 0 0.05 25 58 23
Perlis 0 0 0.00 4 9 4
Terengganu 1 0 0.09 21 46 19
Sarawak 3 1 0.15 27 204 17
Kelantan 4 0 0.23 20 80 18
a
WP Putrajaya 4 0 4.82 - - -
WP Labuan - - - 1 1 1
Sabah & WP Labuan 1 0 0.03 21 102 14
2
FMS refers to family medicine specialist in Klinik Kesihatan. (Data until July 2015)
a
Putrajaya data for KK and FMS are incorporated into Kuala Lumpur
WP Labuan data for endocrinologist is incorporated into Sabah
Data source: National Health Establishment & Workforce Statistics (NHEWS) Survey
Bahagian Pembangunan Kesihatan Keluarga (BPKK) Ministry of Health
22
1. There is an increasing number of Endocrinologist and FMS at an annual rate of 4.8% and 8.6%
respectively. However lack of utilization data here (e.g. patient turnover rate) limit the
interpretation of these indicators in term of service accessibility.
2. Private General Practitioners (GP) provided the widest coverage of primary care services in
Malaysia. This phenomenon may put affordability as the key driver to accessibility.
3. The increasing disease prevalence will create demand for services. Efficient services therefore
will rely on optimal allocation of resources especially in public sectors.
PROCESS OF CARE
Model of good care (MOGC) for diabetes in primary care setting involves monitoring of glycaemic
control and annual screening for any development of diabetic chronic complications (Ministry of
Health, 2008). MOGC incorporates selected clinical examinations made routine for all patients with
diabetes during their follow up appointments at the health clinics. For example, a standard
qualitative urine dipstick test for proteinuria or urine test for microalbuminuria will be performed in
all diabetic patients annually to monitor progression of nephropathy. Other routine basic tests
include electrocardiogram (ECG), foot examination, blood test for HbA1c and funduscopy. To help
with monitoring and auditing, all diabetic patients in Malaysia are registered with the National
Diabetes Registry (NDR).
NDR is a database that records clinical data of patients with diabetes in Malaysia. The main data
comprises of demographic as well as conservative number of diabetes-related variables. Data with
more comprehensive variables that cover follow up status, medication list, lab results and processes
of care are collected separately through audit surveys. The audits are done only on sampled medical
records and involve examining the type of test and screening scheduled for patients within previous
1 year from the audit date. Since audit samples are generated randomly every year, individual
compliance to annual screening or follow up cannot be determined.
FIGURE 8: YEARLY TREND OF DIABETES PROCESS OF CARE, 2009-2012
Funduscopy examination Urine test for microalbumin
51% 57%
45% 47%
38% 39% 44%
37%
2009 2010 2011 2012 2009 2010 2011 2012
Foot examination HbA1c test

77% 78%
72% 70% 73% 68% 71%
63%
2009 2010 2011 2012 2009 2010 2011 2012
23
Table 8: Percentage of patients with diabetes who received standard care, 2012.
Rate AAR Comparison

Period Standard
(%) (%) (%)
4
8.1. % Patients who had funduscopy The US
2012 44.0 ↑6.4 -
done within the last 1 year 62.8
8.2. % Patients who had foot 5
The UK
examination done within the 2012 73.0 ↑0.3 -
87.0
last 1 year
8.3. % Patients who had urine 5
The UK
checked for micro-albumin 2012 56.7 ↑7.7 -
77.9
within the last 1 year*
8.4. % Patients who had HbA1c test 5
The UK
done at least once within the 2012 78.0 ↑4.7 -
91.3
last 1 year
*Does not include qualitative test for proteinuria
†AAR is calculated for period 2009-2012

1. The percentage of diabetic patients who received standard follow-up care in health clinics is
increasing since 2009. The overall achievements however, were still lower compared with the
UK and US.
2. The positive trend in achievements reflects our on-going efforts to ensure that the best clinical
practice and quality of care have applied.
3. The proportion of diabetics who received the standard follow-up care ranges from 40% to 80%.
Few circumstances should be taken into consideration when interpreting the proportions:
a. Date for clinical examinations for some patients was given later than the NDR audit
period.
b. In addition, some of the patients may be recent defaulters or may have their follow-
up clinic records not updated due to having test like funduscopy done in other
health clinics.
4 Centers for Disease Control and Prevention. Diabetes Report Card 2012. Atlanta, GA:
Centers for Disease Control and Prevention, US Department of Health and Human Services; 2012.
5 Health and Social Care Information Centre, National Diabetes Audit 2012-2013.
Report 1: Care Processes and Treatment Targets. UK.
24
HEALTH OUTCOME
ADMISSION RATE
The indicators related to hospital admission for diabetes used in this report include admission rate
for uncontrolled DM without complications (ICD-10 codes: E10.9, E11.9, E13.9, E14.9) and DM with
short or long term complications (OECD, Definitions for Health Quality Indicators).
The short term complications refer to complications including coma, hyperosmolarity and
ketoacidosis, caused by relative shortage of insulin in the body (ICD-10 codes: E10.0, E10.1, E11.0,
E11.1, E13.0, E13.1, E14.0, E14.1) (OECD, Definitions for Health Quality Indicators). These
complications can happen to any person with diabetes especially during an acute stress. Long term
complications on the other hand, includes renal, eye or circulatory complications (ICD-10 codes:
E10.2-10.8, E11.2-11.8, E13.2-13.8, E14.2-14.8) (OECD, “Avoidable admissions: Uncontrolled
diabetes”, in Health at a Glance: Europe 2012, 2012). These complications are prevalent among
diabetes sufferers who have had diabetes for a long period of time.
Generally, a high admission rate can mean a true need for services. However, it can also reflect a low
threshold for admission, or a lack of accessible primary care services hence the poor glycaemic
control that leads to complications that needed admission. Admission rate indicators in this report
are meant to describe the outcome of quality of care. When quality of care has applied, we would
expect low or reducing rate of admission. The rate is calculated as a ratio between the number of
hospital discharges (ICD-10 coded) and the number of population aged 15 and above.
FIGURE 9: HOSPITAL ADMISSION RATE FOR UNCONTROLLED DM WITH OR WITHOUT COMPLICATIONS

PER 100 000 POPULATION, 2010-2014
Uncontrolled DM without
complications
86 82 78
54 55 58
per 100 000
2010 2011 2012 2013 2014 2015
Public Private
DM with short term complications DM with long term complications

18 19
72 76 69
per 100 000
per 100 000
13 67
12 11 41 49
8
2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015
Public Private Public Private
Data source: Sistem Maklumat Rawatan Perubatan (SMRP)
25
Table 9: Hospital admission rate (per 100 000 population) for uncontrolled DM with or
without complications, 2014.
Rate AAR† Comparison

Period Target
(Per 100 000) (%) (Per 100 000)
6
9.1. Uncontrolled DM without EU-15
2015 58 ↓7.6%
complications 53.8
7
9.2. DM with short term Australia
2015 19 ↑7.7% -
complications 27.4
7
9.3. DM with long term Australia
2015 69 ↓1.0% -
complications 97.3
8
9.4. DM hospital admission OECD-31
2015 145 ↓3.2% -
(total) 149.8
† AAR is calculated for period 2010-2015
6
EU-15: Data for 2011: Age-sex standardized to the 2010 OECD population 15+
8
OECD-31: Data for 2013: Age-sex standardized to the 2010 OECD population 15+
Table 10: State variation of hospital admission rate for diabetes ( per 100 000 population),
2015.
Uncontrolled DM with
Uncontrolled DM Uncontrolled DM with short
long term
without complications term complications
complications
WP Putrajaya 125 ↑ 71% 86 ↑ 199% 182 ↑ 69%
Melaka 115 ↓ 5.8% 40 ↑ 13% 75 ↓ 1.8%
Terengganu 66 ↑ 6.3% 22 ↑ 11% 83 ↓ 15%
Johor 76 ↓ 12% 17 ↑ 7.2% 87 ↑ 0.9%
Kedah 83 ↓ 5% 25 ↑ 2.3% 115 ↓ 5.5%
Negeri Sembilan 60 ↓ 13% 19 ↑ 1.5% 114 ↓ 3.8%
Perlis 70 ↓ 24% 24 ↑ 14% 97 ↑ 1.3%
Perak 74 ↓ 12% 28 ↓ 2.2% 94 ↑ 6.6%
Pahang 73 ↓ 9.3% 18 ↑ 16% 72 ↓ 3.0%
Kelantan 48 ↓ 7.1% 20 ↑ 4.3% 48 ↓ 7.9%
Pulau Pinang 73 ↓ 3.2% 18 ↑ 8.3% 116 ↑ 4.9%
Sarawak 35 ↓ 5.4% 19 ↑ 15% 29 ↓ 2.8%
Selangor 33 ↓ 0.5% 13 ↑ 17% 55 ↑ 0.2%
WP Kuala Lumpur 60 ↓ 8.5% 22 ↑ 13% 69 ↑ 3.6%
Sabah & WP Labuan 42 ↓ 5.3% 9 ↑ 8.3% 20 ↑ 11%
* AAR is calculated for period 2013-2015 for WP Putrajaya
Note: Data ascertainment for year 2012 was affected by transition of database system from standalone programme to
web-based client hence the notch observed in rate trending for that year.
6 OECD Health Statistics 2015, http://dx.doi.org/10.1787/health-data-en.

7 Australian Institute of Health and Welfare 2014. OECD Health Care Quality Indicators for Australia
2011–12. Cat. no. PHE 174. Canberra: AIHW.
8 OECD Health Statistics 2014
26
1. Overall diabetes related admission is decreasing for period 2010-2014 at an average annual
rate of 10% in public sectors. However, admission of DM with short term complications is
increasing.
2. Short term complications essentially reflect poor diabetes control. Thus, an increasing trend
is a concern.
CHRONIC COMPLICATIONS
Good glycaemic control can reduce micro-vascular complications (Stratton, Irene M et al., 2000).
Achieving glycaemic control essentially involves active participation from both the patients and their
care providers. Unfortunately, the degree of diabetes self-management is still poor in Malaysia (M.Y.
Tan & J. Magarey, 2008). As a result, development of complications from poor disease control
remains an issue as evidence by findings from a series of DiabCare surveys, a hospital-based cross-
sectional study on patients with type 2 diabetes (Zanariah Hussein, Sri Wahyu Taher, Harvinder Kaur
Gilcharan Singh, & Winnie Chee Siew Swee, 2015).
FIGURE 10: RATE OF DIABETIC COMPLICATIONS, 2011 VS 2012
9.6
8.4
8.9
2011
7.9 6.1
2012
%
6.0
1.3 1.4
0.7
1.4 1.3 0.7
27
Table 11: Percentage of patients with documented complications, 2012.
9,10,11,12
Rate* AAR† Comparison
Period
(%) (%) (%)
The US, Australia,
11.1. Prevalence of Retinopathy 2012 7.9 ↓6.5 Europe, Asia
35.36
The US
11.2. Prevalence of Nephropathy 2012 8.9 ↓6.6
34.5
The UK
11.3. Prevalence of MI 2012 6.0 ↓1.3 1.47
11.4. Prevalence of Cerebrovascular The UK
2012 1.4 ↑4.7 1.79
disease
Saudi Arabia
11.5. Prevalence of DFU 2012 1.4 ↓3.0
3.3
The UK
11.6. Prevalence of Amputation 2012 0.7 ↓0.6 <0.3
*Recalculated from NDR report 2009-2012 to exclude missing data. Each patient may have one or more complications
†AAR calculated for period 2011-2012

1. Rate of retinopathy, nephropathy, myocardial infarction, diabetes foot ulcer and lower limb
amputation has decreased by about 1% to 7%. However, cerebrovascular complication has
increased by 5% since 2011.
2. The reported rate of retinopathy, nephropathy, stroke and diabetes foot ulcer (DFU) in
Malaysia are generally lower than the comparator countries due to the different setting and
methods used for recruitment of study population.
9 Yau, Joanne W.Y. et al. “Global Prevalence and Major Risk Factors of Diabetic Retinopathy.” Diabetes Care 35.3 (2012):
556–564. PMC. Web. 8 June 2016.
10 De Boer, Ian H. et al. “Temporal Trends in the Prevalence of Diabetic Kidney Disease in the United States.” JAMA : the
journal of the American Medical Association 305.24 (2011): 2532–2539. PMC. Web. 8 June 2016.
Report 2: Complications and Mortality. UK.

12 Al-Rubeaan, Khalid et al. “Diabetic Foot Complications and Their Risk Factors from a Large Retrospective Cohort Study.”
Ed. Fabio Santanelli, di Pompeo d’Illasi. PLoS ONE 10.5 (2015): e0124446. PMC. Web. 8 June 2016.
28
CLINICAL TARGETS
Clinical Practice Guideline Malaysia 2009 (4th edition) for Type 2 Diabetes Mellitus management
outlined the desirable targets for patients with diabetes such as the following:
1. HbA1c ≤ 6.5%
2. Weight loss 5-10% of initial weight
3. BP ≤ 130/80 mmHg
4. LDL ≤ 2.6 mmol/L
However, depending on the person’s co-morbidity, some of the targets may be inapplicable due to
higher risk of causing harm. Therefore, the current CPG in 2015 (5th edition) advocated achievement
of individual targets that are tailored to individual risks (Ministry of Health, 2015).
FIGURE 11: YEARLY TREND OF DIABETES CLINICAL TARGET ACHIEVEMENT, 2009-2012
BP ≤ 130/80 mmHg BMI ≥ 23 kg/m2
41% 45% 42% 41%

17% 16% 16% 17%
2009 2010 2011 2012 2009 2010 2011 2012

HbA1c < 6.5% LDL ≤ 2.6 mmol/L
34% 35% 38%

25% 23% 24% 31%
19%
2009 2010 2011 2012 2009 2010 2011 2012
29
Table 12: Clinical target achievement, 2012
Achievement AAR† Comparison

Period Target
(%) (%) (%)
13
12.1. % Patient who achieved BP The UK
2012 40.9% - ↓ 0.2
target ≤ 130/80mm/Hg 66.7
13
12.2. % Patient who achieved The UK
2012 23.8% > 30%* ↑ 7.1
HbA1c target < 6.5% 26.2
14
12.3. % Patient who had Hong Kong
2 2012 16.6% - ↓ 1.2
BMI < 23kg/m 28.5
14
12.4. % Patient who achieved Hong Kong
2012 37.8% - ↑ 7.3
LDL target ≤ 2.6mmol/L 65.6
* Target from Malaysian Clinical Practice Guideline “Management of Type 2 Diabetes Mellitus (5th Edition)”
† AAR is calculated for period 2009-2012

1. There is a positive trend in percentage of patients achieving clinical target for HbA1c and
LDL, although the overall achievement is still lower than the countries like the UK and Hong
Kong.
2. The proportion of diabetic patients with normal BMI (< 23kg/m2) is only about 17% of the
total diabetic patients.
3. Additionally, proportion of diabetic patients with blood pressure that fall within the
accepted range (< 130/80mm/Hg) is about 41%.
Report 1: Care Processes and Treatment Targets. UK.
14 Fung, C. S. C., Wan, E. Y. F., Jiao, F., & Lam, C. L. K. (2015). Five-year change of clinical and complications profile of
diabetic patients under primary care: a population-based longitudinal study on 127,977 diabetic patients.
Diabetology & Metabolic Syndrome, 7, 79. http://doi.org/10.1186/s13098-015-0072-x
30
CONCLUSION
Areas where Malaysia is doing well:
 Malaysia is seeing positive growth in human resources and facility for primary care services
 More Malaysians are adopting active lifestyle as evident by recent NHMS survey
 NDR is a national database that covers almost all public primary care facilities for diabetes
cases. Patient with diabetes receiving treatment in health clinics are all registered into the
database for monitoring purposes
 Diabetes related admission to public hospital is reducing.
 Processes of care related to diabetes management at the clinics are improving.
Areas for concern:
 Diabetes prevalence is increasing steadily and about half of the cases were undiagnosed.
 Pre-diabetes state is under-diagnosed. A complete assessment of pre-diabetic state must
also include measurement of impaired glucose tolerance (IGT); a pre-diabetes state that is
more prevalent than IFG. Our national survey couldn’t include full assessment of pre-
diabetes state to include both IFG and IGT due to practicality issue.
 Malaysian prevalence of overweight, obesity and diabetes is the highest in the Asia Pacific
region
 Half of the population with type 2 diabetes are those 54 years old or younger
 Only less than half of population with diabetes had achieved the preferred clinical targets.
(lipid, blood pressure and weight targets are still not achieved)
 Admission for uncontrolled diabetes with short term complications is increasing indicative of
poor diabetes control. Discharge data in SMRP potentially include misdiagnosis or miscoding
due to human and technical error. Latest error rate study conducted as part of Quality
Assurance Programme in 2013 reveal a moderate error rate of 19%.
 Less than half of diabetic patients had received annual funduscopy test.
31
RECOMMENDATIONS
Unless management of diabetes is considered in a broader context beyond what transpired in the
doctor’s consultation room, the burden of disease will become more evident. The community and
the patient need to be empowered to manage diabetes especially in the aspect of primary and
secondary prevention respectively. To help achieve this goal, collaboration from key players with the
authority to provide built environment for health that facilitate healthy lifestyle should be more
encouraged.
Extensive screening programme with more resources put into screening possibly through KOSPEN
may be worth considering as cases of undiagnosed risk factor are increasing and can pose an
imminent threat to public health status. Health promotion strategy and primary prevention program
must take priority in national health policy specifically to ameliorate this issue.
We need baseline data on pre-diabetic state prevalence among Malaysians. Assessment of impaired
glucose tolerance (IGT) could be incorporated as part of the KOSPEN program instead of a large scale
population survey like NHMS.
Individual patients need to focus on self-care behaviour and us as health provider can facilitate.
Systematic monitoring of self-care variables along with medication compliance during clinic
appointment could improve outcomes.
Primary care service should establish a multidisciplinary team that deal with and focus on NCD.
Hence, one doctor one family concept should be fully implemented. Strategy for allocation of human
resources must take into account the number of available facility and the disease burden at each
locality. We could outsource fund for diabetes educator program from NGO like NADI.
Future reports ought to include data on diabetes educator and the medical officers, as they are key
human resources for diabetes care. Malaysia Diabetes Educators Society (MDES) may be of help with
regard to diabetic educator database. Future reporting must also include soft outcomes like quality
of life and hard outcomes including the mortality associated with DM. Analysis must narrow down to
each locality so as to identify niche issues of importance. Other suggestions for report improvement
include:
1. To include indicator on compliance to best practice (e.g. right treatment indication)
2. Number of equipment available in each clinic
3. To emphasis more on rate of change as a measure of improvements
4. Use of indicators that reflect performance in developing countries
5. To include indicator on rate of diabetic foot amputation by locality
Primary health care facilities including that of private sectors to fully utilise NDR and to update
patients progress on the registry to ensure completeness of data. NDR may also be expanded to
include data entry for other commonest chronic diseases like hypertension.
32
APPENDIX
33
Indicator: Number of endocrinologist (Table 6 & Table 7)
Data table 1: Number of Endocrinologist
State 2009 2010 2011 2013 2015

Johor 0 0 0 1 0
Kedah 0 0 0 0 0
Kelantan 0 0 0 0 0
WP Kuala Lumpur 3 5 5 8 8
Melaka 0 0 0 1 1
Negeri Sembilan 0 0 0 1 0
Private
Pahang 0 0 0 0 0
Perak 1 1 1 1 1
Perlis 0 0 0 0 0
Pulau Pinang 3 4 3 2 2
Sarawak 1 1 0 2 1
Terengganu 0 0 0 0 0
Sabah &WP Labuan 0 0 0 1 0
Selangor & WP Putrajaya 9 8 9 10 9
WP Putrajaya - 0 0 0 0
Selangor - 8 9 10 9
Malaysia 17 19 18 23 22
Johor 1 0 0 0 3
Kedah 0 0 0 1 1
Kelantan 3 3 4 2 4
WP Kuala Lumpur 13 13 13 12 14
Melaka 1 1 1 1 2
Negeri Sembilan 1 1 1 0 2
Pahang 0 0 0 0 2
Public
Perak 1 1 1 2 3
Perlis 0 0 0 0 0
Pulau Pinang 3 2 2 4 5
Sarawak 1 1 1 0 3
Terengganu 0 0 0 0 1
Sabah & WP Labuan 1 1 1 0 1
Selangor & WP Putrajaya 7 10 10 9 13
WP Putrajaya - 8 8 5 4
Selangor - 2 2 4 9
Malaysia 32 33 34 36 54
Data source:
NHEWS (hospital) 2008-2009 (page 102)
MEMS for data 2015
34
Indicator: Density of endocrinologist (Table 6 & Table 7)
Data table 2: Density of Endocrinologist
State 2009 2010 2011 2013 2015

Johor 0 0 0 0 0.08
Kedah 0 0 0 0.05 0.05
Kelantan 0.02 0.19 0.25 0.24 0.23
WP Kuala Lumpur 0.09 1.07 1.06 1.15 1.24
Melaka 0.01 0.12 0.12 0.12 0.34
Negeri Sembilan 0.01 0.1 0.1 0.09 0.18
Pahang 0 0 0 0.06 0.12
Perak 0.01 0.09 0.08 0.12 0.16
Perlis 0 0 0 0 0
Pulau Pinang 0.04 0.38 0.31 0.37 0.41
Sarawak 0.01 0.08 0.04 0.08 0.15
Terengganu 0 0 0 0 0.09
Sabah & WP Labuan 0 0.03 0.03 0.03 0.03
Selangor 0.03 0.18 0.2 0.24 0.29
WP Putrajaya - 11.05 10.47 6.06 4.82
Malaysia 0.02 0.18 0.18 0.2 0.24
2009 per 10 000 population
2010, 2011, 2013& 2015 per 100 000 population
Data source:
35
Indicatore: Number of FMS (Table 6)
Data table 3: Number of FMS
State 2008 2009 2010 2011 2012 2013 2014 2015

Perlis 2 3 3 3 2 4 4 4
Kedah 10 17 16 20 19 19 23 25
Pulau Pinang 4 8 10 10 11 11 13 15
Perak 7 12 12 13 17 20 22 21
Selangor 17 26 27 30 30 34 40 40
WP Putrajaya & WP K.L 5 14 14 15 12 15 19 19
Negeri Sembilan 9 11 12 12 14 15 17 16
Melaka 5 6 6 9 9 9 9 11
Johor 12 18 19 20 17 17 18 21
Pahang 9 15 14 16 17 18 17 19
Kelantan 11 14 15 15 17 18 19 20
Terengganu 10 16 17 19 17 18 21 21
Sarawak 2 8 8 10 19 13 13 27
Sabah 5 3 4 4 16 16 14 21
WP Labuan 0 0 0 0 1 1 1 1
Malaysia 108 171 177 196 218 228 250 281
Data source: Bahagian Pembangunan Kesihatan Keluarga (BPKK) updated until July 2015
Indicator: Number of KK (Table 6)
Data table 4: Number of KK
State 2008 2009 2010 2011 2012 2013 2014 2015

Perlis 9 9 9 9 9 9 9
Kedah 51 51 56 56 57 58 58
Pulau Pinang 26 27 29 29 30 30 30
Perak 73 73 79 83 83 84 85
Selangor 55 55 61 73 73 74 74
WP Putrajaya & WP K.L 14 15 17 17 17 16 16
Negeri Sembilan 38 41 46 46 46 46 47
Melaka 25 26 29 29 29 29 29
Johor 88 88 94 94 94 94 94
Pahang 64 64 76 79 82 84 84
Kelantan 53 53 59 69 69 80 80
Terengganu 39 39 45 45 46 46 46
Sarawak 194 194 197 196 198 203 204
Sabah 77 77 81 93 100 101 102
WP Labuan 1 1 1 1 1 1 1
Malaysia 807 813 879 919 934 955 959
36
Indicator: No of KK with FMS (Table 6)
Data table 5: No of KK with FMS
State 2008 2009 2010 2011 2012 2013 2014 2015

Perlis 2 3 3 3 2 4 4 4
Kedah 10 17 16 20 19 18 23 23
Pulau Pinang 4 8 10 10 11 11 13 15
Perak 7 12 12 13 17 20 21 20
Selangor 17 26 26 29 30 33 34 36
WP Putrajaya & WP K.L 4 12 11 12 9 13 15 14
Negeri Sembilan 9 11 12 12 14 15 16 15
Melaka 5 6 6 9 9 8 9 10
Johor 12 18 19 20 17 17 18 18
Pahang 9 15 14 16 17 18 16 18
Kelantan 11 14 15 15 17 18 20 18
Terengganu 10 16 17 19 17 18 20 19
Sarawak 2 8 8 10 19 13 13 17
Sabah 5 3 4 4 16 16 13 14
WP Labuan 0 0 0 0 1 1 1 1
Malaysia 107 169 173 192 215 223 236 242
Indicator: Number of Malaysian Primary Care Clinics (Figure 7)
Data table 6: Number of Malaysian Primary Care Clinics per 10,000 Population in 2012
State Number of clinics Population Density

Malaysia 6557 29510000 2.2
Johor 802 3450400 2.3
Kedah 354 2001100 1.8
Kelantan 256 1651000 1.6
Melaka 215 843200 2.5
Negeri Sembilan 279 1057700 2.6
Pahang 280 1547100 1.8
Perak 593 2427000 2.4
Perlis 39 239400 1.6
Pulau Pinang 428 1623200 2.6
Sabah & WP Labuan 403 3523200 1.1
Sarawak 421 2569700 1.6
Selangor & WP Putrajaya 1596 5780700 2.8
Terengganu 193 1094100 1.8
WP Kuala Lumpur 698 1702100 4.1
Data source:
National Medical Care Statistics (Primary Care) 2014 (page 13 & 34)
37
Reference: Involved in calculation for admission rate
Data table 7: Population by states aged 15 years old and above
State 2010 2011 2012 2013 2014 2015

Malaysia 20766700 21271000 21733400 22430000 22935000 23410300
Johor 2448900 2500900 2546500 2575100 22935000 2717900
Kedah 1378300 1407900 1442300 1487100 2665100 1553500
Kelantan 1049000 1081000 1113700 1143900 1516400 1210300
WP Kuala Lumpur 1306000 1325600 1337200 1356100 1180000 1406200
Labuan 61700 63100 64100 65100 1368000 68500
Melaka 605500 618700 632900 645800 67200 678100
Negeri Sembilan 751400 771500 784300 801600 661000 822900
Pahang 1051800 1080700 1105800 1131900 811600 1176800
Perak 1733200 1768700 1802600 1838000 1157800 1888100
Perlis 173600 176100 178100 181100 1863300 186700
Pulau Pinang 1213400 1243100 1267100 1308200 183700 1350100
WP Putrajaya 50200 51800 51400 51700 1325500 52100
Sabah 2341000 2426600 2511500 2677100 51300 2784500
Sarawak 1768100 1814800 1859100 1936900 2735000 2010500
Selangor 4129800 4213900 4295000 4471700 4598200 4703900
Terengganu 704400 726700 741500 758800 783700 800500
Sabah & WP Labuan 2402700 2489700 2575600 2742200 2802200 2853000
Data source: Department of Statistics Malaysia
38
Indicator: Admission rate for uncontrolled DM without complications (Table 9 & Table 10)
Data table 8: Number of admission for uncontrolled DM without complications (aged 15 years
old and above)
State 2010 2011 2012 2013 2014 2015

Johor 3469 3255 2224 2149 2419 2069
Kedah 1482 1496 1117 813 1647 1290
Kelantan 726 707 681 708 869 581
WP Kuala Lumpur 1222 1239 106 497 1236 844
Labuan 0 0 135 52 0 0
Melaka 945 875 541 714 825 783
Negeri Sembilan 913 789 724 511 974 496
Pahang 1260 930 775 889 1121 864
Perak 2373 2808 1468 1609 1767 1404
Perlis 474 351 293 214 177 131
Pulau Pinang 1046 870 227 586 1435 988
WP Putrajaya 0 0 0 22 79 65
Sabah 1332 1425 1012 1185 0 0
Sarawak 806 805 601 847 763 695
Selangor 1392 1523 1441 1203 2808 1543
Terengganu 345 331 374 297 391 532
Sabah & WP Labuan 1332 1425 1147 1237 1390 1203
Malaysia 17785 17404 11719 12296 17901 13488
Data table 9: Admission rate for uncontrolled DM without complications
State 2010 2011 2012 2013 2014 2015

Johor 142 130 87 83 91 76
Kedah 108 106 77 55 109 83
Kelantan 69 65 61 62 74 48
WP Kuala Lumpur 94 93 8 37 90 60
Labuan 0 0 211 80 0 0
Melaka 156 141 85 111 125 115
Negeri Sembilan 122 102 92 64 120 60
Pahang 120 86 70 79 97 73
Perak 137 159 81 88 95 74
Perlis 273 199 165 118 96 70
Pulau Pinang 86 70 18 45 108 73
WP Putrajaya 0 0 0 43 154 125
Sabah 57 59 40 44 0 0
Sarawak 46 44 32 44 39 35
Selangor 34 36 34 27 61 33
Terengganu 49 46 50 39 50 66
Sabah & WP Labuan 55 57 45 45 50 42
Malaysia 86 82 54 55 78 58
39
Indicator: Admission rate for DM with short term complications (Table 9 & Table 10)
Data table 10: Discharge number for DM with short term complications (aged 15 years old and
above)
State 2010 2011 2012 2013 2014 2015

Johor 297 327 256 412 752 467
Kedah 310 213 216 130 322 391
Kelantan 173 178 120 180 192 246
WP Kuala Lumpur 155 180 19 81 303 312
WP Labuan 0 0 4 5 0
Melaka 133 217 99 184 171 273
Negeri Sembilan 133 124 95 119 175 157
Pahang 91 136 142 207 211 210
Perak 545 292 137 247 421 530
Perlis 22 11 22 38 38 45
Pulau Pinang 145 166 25 177 233 240
Sabah 139 160 121 154 0
Sarawak 169 150 148 202 260 378
Selangor 251 310 243 267 593 623
Terengganu 93 180 145 157 193 177
Sabah & WP Labuan 139 160 125 159 186 246
Malaysia 2656 2644 1792 2565 4079 4340
Data table 11: Admission rate for DM with short term complications
State 2010 2011 2012 2013 2014 2015

Johor 12 13 10 16 28 17
Kedah 22 15 15 9 21 25
Kelantan 16 16 11 16 16 20
WP Labuan 0 0 6 8 0 0
Melaka 22 35 16 28 26 40
Negeri Sembilan 18 16 12 15 22 19
Pahang 9 13 13 18 18 18
Perak 31 17 8 13 23 28
Perlis 13 6 12 21 21 24
Pulau Pinang 12 13 2 14 18 18
Sabah 6 7 5 6 0 0
Sarawak 10 8 8 10 13 19
Selangor 6 7 6 6 13 13
Terengganu 13 25 20 21 25 22
Sabah & WP Labuan 6 6 5 6 7 9
Malaysia 13 12 8 11 18 19
40
Indicator: Admission rate for DM with long term complications (Table 9 & Table 10)
Data table 12: Discharge number for DM with long term complications (aged 15 years old and
above)
State 2010 2011 2012 2013 2014 2015

Johor 2042 2081 1637 1502 2075 2371
Kedah 2094 2008 1228 591 1425 1781
Kelantan 767 713 420 728 618 586
WP Kuala Lumpur 760 872 69 342 688 976
WP Labuan 0 0 17 17 0 0
Melaka 494 489 198 558 708 506
Negeri Sembilan 1039 921 751 730 948 939
Pahang 889 898 606 733 769 852
Perak 1180 1628 795 995 1902 1772
Perlis 159 242 237 320 230 182
Pulau Pinang 1108 1219 329 1199 1493 1564
WP Putrajaya 0 0 0 33 128 95
Sabah 286 312 238 374 0 0
Sarawak 583 475 445 506 609 574
Selangor 2273 2764 1101 1147 2439 2610
Terengganu 1294 1467 928 1139 863 667
Sabah & WP Labuan 286 312 255 391 421 578
Malaysia 14968 16089 8999 10914 15316 16053
Data table 13: Admission rate for DM with long term complications
State 2010 2011 2012 2013 2014 2015

Johor 83 83 64 58 78 87
Kedah 152 143 85 40 94 115
Kelantan 73 66 38 64 52 48
WP Labuan 0 0 27 26 0 0
Melaka 82 79 31 86 107 75
Negeri Sembilan 138 119 96 91 117 114
Pahang 85 83 55 65 66 72
Perak 68 92 44 54 102 94
Perlis 92 137 133 177 125 97
Pulau Pinang 91 98 26 92 113 116
WP Putrajaya 0 0 0 64 250 182
Sabah 12 13 9 14 0 0
Sarawak 33 26 24 26 31 29
Selangor 55 66 26 26 53 55
Terengganu 184 202 125 150 110 83
Sabah & WP Labuan 12 13 10 14 15 20
Malaysia 72 76 41 49 67 69
41
Indicator: Admission rate for DM (total) (Table 9 & Table 10)
Data table 14: Discharge number for DM (total) (aged 15 years old and above)
State 2010 2011 2012 2013 2014 2015

Johor 5808 5663 4117 4063 5246 4907
Kedah 3886 3717 2561 1534 3394 3462
Kelantan 1666 1598 1221 1616 1679 1413
WP Kuala Lumpur 2137 2291 194 920 2227 2132
WP Labuan 0 0 156 74 0 0
Melaka 1572 1581 838 1456 1704 1562
Negeri Sembilan 2085 1834 1570 1360 2097 1592
Pahang 2240 1964 1523 1829 2101 1926
Perak 4098 4728 2400 2851 4090 3706
Perlis 655 604 552 572 445 358
Pulau Pinang 2299 2255 581 1962 3161 2792
WP Putrajaya 0 0 0 60 236 205
Sabah 1757 1897 1371 1713 0 0
Sarawak 1558 1430 1194 1555 1632 1647
Selangor 3916 4597 2785 2617 5840 4776
Terengganu 1732 1978 1447 1593 1447 1376
Sabah & Labuan 1757 1897 1527 1787 1997 2027
Malaysia 35409 36137 22510 25775 37296 33881
Data table 15: Admission rate for DM (total)
State 2010 2011 2012 2013 2014 2015

Johor 237 226 162 158 197 181
Kedah 282 264 178 103 224 223
Kelantan 159 148 110 141 142 117
WP Kuala Lumpur 164 173 15 68 163 152
WP Labuan 0 0 243 114 0 0
Melaka 260 256 132 225 258 230
Negeri Sembilan 277 238 200 170 258 193
Pahang 213 182 138 162 181 164
Perak 236 267 133 155 220 196
Perlis 377 343 310 316 242 192
Pulau Pinang 189 181 46 150 238 207
WP Putrajaya 0 0 0 116 460 393
Sabah 75 78 55 64 0 0
Sarawak 88 79 64 80 83 82
Selangor 95 109 65 59 127 102
Terengganu 246 272 195 210 185 172
Sabah & WP Labuan 73 76 59 65 71 71
Malaysia 171 170 104 115 163 145
42
Indicator: % Patients who had funduscopy done within the last 1 year (Table 8)
% Patients who had foot examination done within the last 1 year
% Patients who had urine checked for micro-albumin within the last 1 year
% Patients who had HbA1c test done at least once within the last 1 year
Data table 16: Proportion of patients receiving clinical investigations [AuditDataset]
Investigation 2009 % 2010 % 2011 % 2012 %

BP 79202 98.8 63138 81.8 66940 93.4 116265 93.7
HbA1c 54431 67.9 48765 63.2 51018 71.2 96694 78
FBG 48019 59.9 46217 59.9 44565 62.2 71386 57.6
RBG 50744 63.3 43281 56.1 39169 54.7 74801 60.3
2HPP 9719 12.1 6150 8 4200 5.9 5862 4.7
Creatinine 65875 82.2 53067 68.8 51940 72.5 96248 77.6
Total cholesterol 66203 82.6 52724 68.3 53091 74.1 97362 78.5
LDL 51421 64.2 34220 44.3 35950 50.2 73332 59.1
HDL 52306 65.3 34461 44.7 36508 51 73772 59.5
TG 65648 81.9 52360 67.8 52506 73.3 97045 78.3
Urine protein 45794 57.2 44802 58.1 41830 58.4 80224 64.7
Urine microalbumin 36300 45.3 35859 46.5 36842 51.4 70273 56.7
Foot exams 58001 72.4 59643 77.3 50115 69.9 90558 73
Fundus 29263 36.5 29642 38.4 27806 38.8 54590 44
ECG 35926 44.8 35975 46.6 35848 50 67068 54.1
Patients audited 80,134 77,179 71,655 124,023
Data source:
NDR 2009-2012 (page 17)
43
Indicator: Rate of Retinopathy (Table 11)
Rate of Nephropathy
Rate of MI
Rate of Cerebrovascular disease
Rate of DFU
Rate of Amputation
Data table 17: Complications and co-morbidities in 2011 and 2012 [Audit Dataset]
2011 2012
Co-morbidities
n % n %
Nephropathy
Present 5429 7.6 9707 7.8
Absent 51350 71.7 99016 79.8
Unknown 14850 20.7 15256 12.3
Retinopathy
Present 4627 6.5 8255 6.7
Absent 50455 70.4 96872 78.1
Unknown 16547 23.1 18853 15.2
Ischaemic Heart Disease
Present 3467 4.8 6508 5.3
Absent 53387 74.5 101630 81.9
Unknown 14775 20.6 15842 12.8
Cerebrovascular Disease
Present 788 1.1 1550 1.3
Absent 56966 79.5 106953 86.2
Unknown 13875 19.4 15476 12.5
Diabetic Foot Ulcer
Present 841 1.2 1527 1.2
Absent 58044 81 108726 87.7
Unknown 12744 17.8 13725 11.1
Amputation
Present 387 0.5 721 0.9
Absent 58487 81.6 109652 88.4
Unknown 12755 17.8 13605 11
Data source:
NDR 2009-2012 (page 16)
44
Indicator: % Patient who achieved BP target ≤ 130/80mm/Hg (Table 12)
% Patient who had BMI < 23kg/m2
% Patient who achieved LDL target ≤ 2.6mmol/L
Data table 18: Target achievement based on clinical investigations [Audit Dataset]
2009 2010 2011 2012

% Mean % Mean % Mean % Mean
Treatment
Clinical test achieved test 95% CI achieved test 95% CI achieved test 95% CI achieved test 95% CI
target
target result target result target result target result
Urine
Negative N/A N/A N/A 64.3 N/A N/A 71.1 N/A N/A 71.9 N/A N/A
microalbumin
≤130/80
BP 41.2 N/A N/A 45 N/A N/A 42 N/A N/A 40.9 N/A N/A
mmHg
Total <4.5
24.1 5.3 (5.3-5.3) 25.8 5.3 (5.2-5.3) 26.3 5.2 (5.2-5.2) 28.5 5.2 (5.2-5.2)
cholesterol mmol/l
≤2.6
LDL 30.6 3.2 (3.2-3.2) 33.6 3.2 (3.2-3.2) 34.5 3.2 (3.1-3.2) 37.8 3.1 (3.1-3.1)
mmol/l
<23
BMI 2 17.2 28 (27.7-28.3) 15.9 30 (28.1-31.9) 16.3 27.4 (27.4-27.5) 16.6 27.4 (27.3-27.4)
kg/m
<90 cm
35.3 93.4 (93.2-93.5) 34.2 94 (93.8-94.1) 35.1 93.6 (93.5-93.8) 33.8 94 (93.9-94.1)
Waist (Male)
circumference <80 cm
15.6 90.1 (89.9-90.2) 14.8 90.2 (90.1-90.4) 15.2 90.4 (90.3-90.6) 14.4 90.7 (90.6-90.8)
(Female)
Data source:
NDR 2009-2012 (page 21)
This report is intended only for the use of the individual entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure.
45
Indicator: % Patient who achieved HbA1c target < 6.5% (Table 12)
Data table 19: Proportion of patients achieving HbA1c treatment target (HbA1c <6.5%) and mean HbA1c by state [Audit Dataset] (All age group)
2009 2010 2011 2012

% % % %
Mean Mean Mean Mean
achieved 95% CI achieved 95% CI achieved 95% CI achieved 95% CI
HbA1c HbA1c HbA1c HbA1c
target target target target
Malaysia 19.4 8.3 (8.3-8.3) 24.8 8 (8.0-8.0) 22.6 8.2 (8.2-8.2) 23.8 8.1 (8.1-8.1)
Kelantan 14.7 8.9 (8.8-8.9) N/A N/A 19.9 8.6 (8.5-8.7) 14.9 8.8 (8.7-8.9)
Terengganu 23 8.6 (8.5-8.7) 22.2 8.4 (8.3-8.5) 18.2 8.7 (8.6-8.8) 17.6 8.8 (8.7-8.9)
Pulau Pinang 18.2 8.3 (8.2-8.4) 21.9 8 (8.0-8.1) 22 8.1 (8.0-8.1) 21 8 (7.9-8.0)
Johor 18.7 8.3 (8.3-8.4) 20.6 8.2 (8.2-8.3) 18.5 8.4 (8.4-8.5) 21.9 8.1 (8.1-8.2)
Kedah 15.9 8.6 (8.5-8.7) N/A N/A 25 8.4 (7.1-9.6) 22.4 8.3 (8.2-8.3)
Pahang 18.8 8.6 (8.5-8.7) 25.2 8.2 (8.2-8.3) 20.1 8.4 (8.4-8.5) 22.4 8.3 (8.3-8.4)
Selangor 22.3 8.2 (8.1-8.3) 30.5 7.8 (7.7-7.8) 22.3 8.2 (8.2-8.3) 23 8.3 (8.3-8.4)
Perak 18.3 8.3 (8.2-8.3) 26.1 8 (7.9-8.1) 24.6 8.1 (8.0-8.2) 24.3 8.2 (8.2-8.3)
Negeri Sembilan 18.7 8.2 (8.2-8.3) 22.7 8 (8.0-8.1) 24.2 8.1 (8.1-8.2) 24.4 8 (7.9-8.0)
Melaka 19.5 8.2 (8.1-8.3) 20.7 8.1 (8.0-8.2) 24.5 7.9 (7.9-8.0) 25.2 7.8 (7.8-7.8)
Perlis 29.1 7.8 (7.6-7.9) 27.9 8.1 (8.0-8.3) 27.7 8.1 (7.9-8.2) 29.2 8.1 (8.0-8.2)
WP Kuala
19 8.1 (8.1-8.2) 30.4 7.7 (7.6-7.7) 25.3 8 (7.9-8.0) 30.5 7.7 (7.7-7.8)
Lumpur
WP Putrajaya 16.1 7.8 (7.6-8.1) 26.2 7.7 (7.5-7.8) 17.2 8 (7.9-8.2) 31.1 7.9 (7.8-8.1)
Sabah 38.4 7.4 (7.2-7.6) 36.1 7.2 (7.1-7.3) 31.3 7.5 (7.4-7.6) 33.4 7.4 (7.4-7.5)
Sarawak 34.4 7.5 (7.4-7.7) 26.3 7.8 (7.6-8.0) 30 7.7 (7.5-7.9) 39.1 7.4 (7.3-7.6)
WP Labuan N/A N/A N/A 39.4 7.3 (7.1-7.5) 32.1 7.4 (7.0-7.8) 54 6.9 (6.7-7.1)
Data source:
NDR 2009-2012 (page 19)
46
Data table 20: Prevalenve of overall, known and undiagnosed diabetes (aged 18 years old and
above)
Diabetes Mellitus (%)

Overall Known Undiagnosed
2006 2011 2015 2006 2011 2015 2006 2011 2015
Malaysia 11.6 15.2 17.5 7 7.2 8.3 4.5 8 9.2
Johor 11.1 13.4 19.8 7 7.6 8.8 4.1 5.9 11
Kedah 13.6 22.5 25.4 9.3 9.1 9.3 4.3 13.4 16.1
Kelantan 11.7 19.7 18.5 6.8 8 7.1 4.9 11.7 11.3
Melaka 15.2 17.1 16.7 11.4 10.4 8.3 3.9 6.6 8.4
Negeri Sembilan 15.3 22 19.3 8.8 11.5 10.5 6.6 10.5 8.8
Pahang 12.1 16.7 14.8 8.1 8.6 6.3 4 8.1 8.6
Pulau Pinang 14.9 15 18.1 8.9 8.5 9 6 6.4 9.1
Perak 12.6 16.2 19.4 7.6 10.1 11.9 5 6.1 7.4
Perlis 13.5 24.8 20.6 8 8.7 10.9 5.5 16.1 9.7
Selangor 12 16.5 15.5 8.3 6.5 7.8 3.8 10.1 7.7
Terengganu 11.1 11.6 18.6 5.7 7.1 8.7 5.4 4.5 9.9
Sabah 4.9 9 14.2 2.4 2.6 5.9 2.5 6.4 8.3
Sarawak 10 12.3 14.8 4.1 5.1 8.3 6 7.3 6.6
WP Kuala Lumpur 12.6 11.3 17.4 6.6 7.2 8.1 6 4.1 9.3
WP Labuan 7.9 4.8 3.2
WP Putrajaya 8.8 19.2 4.6 5.3 4.2 13.9
Data source:
NHMS 2006 Vol.2 (page 254)
NHMS 2011 Vo.2 (page 13)
47
Indicator: Prevalence of impaired fasting glucose (Table 4 & Table 5)
Data table 21: Prevalenve of impaired fasting glucose (aged 18 years old and above)
Impaired Fasting Glucose (FBG 5.6 – 6.1 mmol/L)

2006 2011 2015
Malaysia 4.2 4.9 4.7
Johor 2.9 3.5 7.2
Kedah 4.4 7.8 6.4
Kelantan 4.5 7.6 6.6
Melaka 3.8 4.4 3.5
Negeri Sembilan 2.6 7 6.4
Pahang 3.4 5.2 4.3
Pulau Pinang 6.1 2.9 4.2
Perak 5 3.6 5.3
Perlis 3.4 11.9 4
Selangor 4.6 6.3 4.3
Terengganu 4 4.5 3.5
Sabah 2.7 4.4 3.3
Sarawak 4.8 3.5 2.9
WP Kuala Lumpur 6.1 2.2 3.8
WP Labuan 4.5
WP Putrajaya 1.2 6.5
Data source:
48
Indicator: Prevalence of obesity (Table 4 & Table 5)
Data table 22: Prevalence of obesity among adults (aged 18 years old and above)
Obesity (BMI ≥ 27.5 kg/m2)

2006 2011 2015
Malaysia 14 27.2 30.6
Johor 14.1 28.6 29.8
Kedah 15.5 28.2 33.2
Kelantan 12.5 29.4 28.8
Melaka 17.4 29.3 36
Negeri Sembilan 18.6 28.2 35.6
Pahang 15.3 28.2 32.5
Perak 12.9 30.1 29.5
Perlis 17.2 34.6 36
Selangor 16 28.2 32.7
Terengganu 15.2 28.1 32.5
Sabah 9.7 21.1 23.9
Sarawak 11.5 26.7 32.3
WP Labuan 14.6
WP Putrajaya 27.4 43
Data source:
49
Indicator: Prevalence of pre-obese (Table 4 & Table 5)
Data table 23: Prevalence of pre-obese among adults (aged 18 years old and above)
Pre-obese (BMI 23-27.4 kg/m2)

2006 2011 2015
Malaysia 29.1 33.3 33.4
Johor 28.9 33 33.5
Kedah 31.1 34 32.4
Kelantan 28.3 35.2 30.7
Melaka 31.1 33.7 33.6
Pahang 28.8 32.2 31.5
Perak 27.6 31.4 34.7
Perlis 32.1 29.1 30.7
Selangor 31 32.3 33.4
Sabah 24.9 34.5 36.9
Sarawak 28.7 32.4 31
WP Labuan 30.6
Data source:
50
Data table 24: Prevalence of overweight among adults (aged 18 years old and above)
Overweight (BMI ≥ 23kg/m2)

2006 2011 2015
Malaysia 29.1 33.3 33.4
Johor 28.9 33 33.5
Kedah 31.1 34 32.4
Kelantan 28.3 35.2 30.7
Melaka 31.1 33.7 33.6
Pahang 28.8 32.2 31.5
Perak 27.6 31.4 34.7
Perlis 32.1 29.1 30.7
Selangor 31 32.3 33.4
Sabah 24.9 34.5 36.9
Sarawak 28.7 32.4 31
WP Labuan 30.6
Data source:
51
Indicator: Prevalence of insufficient physical activity (Table 4 & Table 5)
Data table 25: Prevalence of Insufficient Physical Activity
Insufficient Physical Activity (%)

2006 2011 2015
Malaysia 43.7 35.2 33.5
Johor 45.6 41.4 32.9
Kedah 36.8 34.4 33.6
Kelantan 34.2 45 25.8
Melaka 39.3 39.7 37.8
Pahang 31.4 42.1 26
Perak 43.7 33.2 28.1
Perlis 49.1 32.4 27.8
Selangor 52.1 38.7 39.9
Terengganu 32.3 41 30.7
Sabah 42.5 24.8 30.1
Sarawak 48 32.4 40.8
WP Labuan 49.2
Data source:
52
Indicator: Male waist circumference > 90cm (Table 4)
Female waist circumference > 80cm
Data table 26: Prevalence of abdominal obesity
Abdominal obesity (%)

2006 2011 2015
Malaysia - 45.4 48.6
Johor - 47.7 52.8
Kedah - 58.6 47.4
Kelantan - 36.8 39
Melaka - 45 54.2
Negeri Sembilan - 45.5 45.7
Pahang - 41.3 48.8
Pulau Pinang - 44.4 56.8
Perak - 56.5 48.6
Perlis - 57.7 51.6
Selangor - 45.1 47.2
Terengganu - 34.7 46.5
Sabah & WP Labuan - 34.6 46.4
Sarawak - 45.2 48
WP Kuala Lumpur - 46.1 51.8
WP Putrajaya - 41.3 61.3
Male 7.2 37.4 38.2

Female 26 54.1 60.2
Cut off points (>102 cm in men and >88 cm in woman) for data 2006
Cut off points (>90 cm in men and >80 cm in woman) for data 2011 & 2015
Data source:
53
Data table 27: Characteristics of T2DM patients enrolled from 2009 to 2012 [Registry Dataset]
Ethnicity
No of patients Male Mean Foreigner/
95% CI Other Malaysian
State (%) (%) Age Malay (%) Chinese (%) Indian (%) Unknown
(%)
(%)
Johor 92,750 (14.2) 38,386 (41.4) 59.8 59.7-59.9 58,306 (62.9) 22,724 (24.5) 11,219 (12.1) 397 (0.4) 104 (0.1)
Kedah 42,344 (6.5) 16,482 (38.9) 59.1 59.0-59.2 31,515 (74.4) 5,059 (11.9) 5,274 (12.5) 453 (1.1) 43 (0.1)
Kelantan 27,002 (4.1) 9,692 (35.9) 59.3 59.2-59.4 25,497 (94.4) 1,066 (3.9) 145 (0.5) 278 (1.0) 16 (0.1)
Melaka 42,974 (6.6) 18,640 (43.4) 61.0 60.9-61.1 28479 (66.3) 9,883 (23.0) 4,264 (9.9) 292 (0.7) 56 (0.1)
Negeri Sembilan 57,869 (8.9) 25,288 (43.7) 60.4 60.3-60.5 33,317 (57.6) 10,810 (18.7) 13,347 (23.1) 314 (0.5) 81 (0.1)
Pahang 38,119 (5.8) 15,972 (41.9) 58.9 58.8-59.1 29,700 (77.9) 5,450 (14.3) 2,664 (7.0) 201 (0.5) 104 (0.3)
Perak 74,492 (11.4) 31,604 (42.4) 61.1 61.1-61.2 38,867 (52.2) 18,869 (25.3) 16,113 (21.6) 588 (0.8) 55 (0.1)
Perlis 13,388 (2.1) 5,311 (39.7) 58.9 58.7-59.1 11,521 (86.1) 1,217 (9.1) 326 (2.4) 314 (2.3) 10 (0.1)
Pulau Pinang 40,439 (6.2) 17,271 (42.7) 60.6 60.5-60.7 17,758 (43.9) 14,534 (35.9) 7,876 (19.5) 210 (0.5) 61 (0.2)
Sabah 11,302 (1.7) 4,933 (43.6) 58.8 58.6-59.0 560 (5.0) 3,594 (31.8) 104 (0.9) 6,888 (60.9) 156 (1.4)
Sarawak 43,333 (6.6) 17,046 (39.3) 59.3 59.2-59.4 12,030 (27.8) 14,850 (34.3) 254 (0.6) 16,088 (37.1) 111 (0.3)
Selangor 106,101 (16.2) 45,019 (42.4) 58.5 58.4-58.6 55,245 (52.1) 19,664 (18.5) 29,603 (27.9) 1067 (1.0) 522 (0.5)
Terengganu 22,272 (3.4) 8,275 (37.2) 58.3 58.2-58.5 21,786 (97.8) 427 (1.9) 21 (0.1) 23 (0.1) 15 (0.1)
WP Kuala Lumpur 37,713 (5.8) 16,261 (43.1) 60.5 60.4-60.7 17,258 (45.8) 11,587 (30.7) 8,448 (22.4) 317 (0.8) 103 (0.3)
WP Labuan 524 (0.1) 202 (38.5) 55.8 54.8-56.8 363 (69.3) 72 (13.7) 4 (0.8) 77 (14.7) 8 (1.5)
WP Putrajaya 2,704 (0.4) 1,408 (52.1) 54.5 54.1-54.9 2,494 (92.2) 62 (2.3) 128 (4.7) 12 (0.4) 8 (0.3)
Total 653,326 (100) 271790 (41.6) 59.7 59.7-59.7 384,696 (58.9) 139,868(21.4) 99,790 (15.3) 27,519 (4.2) 1,453 (0.2)
Data source:
NDR 2009-2012 (page 13)
54
Data table 28: Diabetes among adults aged 20-79 years
Country 2015
Australia 5.1 Korea, Rep. 7.2

Austria 6.9 Luxembourg 4.7
Belgium 5.1 Mexico 15.8
Canada 7.4 Netherlands 5.5
Chile 10 New Zealand 7.3
Czech Republic 7.4 Norway 6
Denmark 7.2 Poland 6.2
Estonia 4.4 Portugal 9.9
Finland 6 Slovak Republic 7.8
France 5.3 Slovenia 7.8
Germany 7.4 Spain 7.7
Greece 5.2 Sweden 4.7
Hungary 7.3 Switzerland 6.1
Iceland 6.1 Turkey 12.8
Ireland 4.4 United Kingdom 4.7
Israel 7.5 United States 10.8
Italy 5.1 OECD-34 7.01
Japan 5.7
Age standardized
Source: International Diabetes Federation 2015 (page 116)
55
Data table 29: Prevalence of overweight (BMI ≥ 25kg/m2) and obesity (BMI ≥ 30kg/m2)
(population aged 18+ years)
Country 2014

Belgium 20.2 Mexico 28.1
Canada 28 Netherlands 19.8
Chile 27.8 New Zealand 29.2
Czech Republic 26.8 Norway 23.1
Finland 20.6 Slovak Republic 25.7
Hungary 24 Switzerland 19.4
Iceland 22.8 Turkey 29.5
Israel 25.3 United States 33.7
Italy 21 OECD-34 23.0
Japan 3.3
Data source: Global status report on Noncommunicable Diseases 2014 (page 232)
Data table 30: Prevalence of insufficient physical activity (adults 18 years old and above)
Country 2010

Belgium 33.2 Mexico 26
Canada 23.2 Netherlands 15.5
Chile 21.3 New Zealand 39.8
Czech Republic 23.8 Norway 25.8
Finland 23.5 Slovak Republic 17.8
Hungary 18.1 Turkey 32.8
Italy 33.2 United States 32.4
Japan 33.8 OECD-31 23.5
Data source: Global status report on Noncommunicable Diseases 2014 (page 172)
56
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Integrative Model. Medical Care, 975-992.
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(2014). Putrajaya.
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Kesihatan Kementerian Kesihatan Malaysia. Retrieved 17 November, 2016, from
KOSPEN: http://www.infosihat.gov.my/infosihat/projekkhas/kospen.php
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58
GLOSSARY
Accessibility Accessibility refers to physical access to the health service, or where the
service can be delivered to people. It involves the overall organisation of
the health system and especially, its procurement, supply and dispensing
systems. In order to embrace the notion of access to treatment,
accessibility in this publication is also understood as encompassing
factors such as access to prescribers and proper education and
information. (International Diabetes Federation 2015)
Acute Coronary ACS encompasses clinical features comprising chest pain or

Syndrome (ACS) overwhelming shortness of breath, is defined by accompanying clinical,
ECG and biochemical features. ACS comprises the following: 1. Unstable
Angina Pectoris (UAP) 2. Non-ST-elevation Myocardial Infarct (NSTEMI)
3. ST-elevation Myocardial Infarct (STEMI). (NCVD-ACS 2009-2010)
Admission Admission (or inpatient admission) is the formal acceptance by a hospital

of a patient who will occupy a hospital bed, crib or bassinet for
observation, care, diagnosis or treatment and will have a medical record
maintained for him/her. (NHEWS 2012 – 2013)
Amputation Amputation is the intentional surgical removal of a limb or body part. It is

performed mainly to remove diseased tissue. In this publication,
amputation refers to particularly of the lower limbs.
Average annual AAR is calculated by taking the geometric mean of the annual percentage
rate of change difference between the baseline achievement (beginning value) and the
current achievement (ending value) with the assumption that the
achievements have been compounding discretely over the specified
period.
Benchmark A benchmark refers to the performance that has been achieved in the
recent past by other comparable organizations, or what can be
reasonably inferred to have been achieved in the circumstances (OECD).
(http://www.who.int/hac/about/definitions/en/)
Cardiovascular Cardiovascular diseases cover a range of illnesses related to the

diseases circulatory system, including ischemic heart disease and cerebrovascular
diseases such as stroke (Health at a Glance 2015: OECD Indicators)
Crude measure Crude measures are methods that attempt to rely on non-fully-specified
features of the world to ensure that an underdefined or underpowered
solution does manage to solve the problem.
(http://lesswrong.com/lw/ly9/crude_measures/)
Current smoker Smoker who daily or occasionally smokes any tobacco product.
Daily smoker Person who currently smokes any tobacco product every day.
DALY The Disability Adjusted Life Year or DALY is a health gap measure that
extends the concept of potential years of life lost due to premature death
(PYLL) to include equivalent years of ‘healthy’ life lost by virtue of being
59
in states of poor health or disability.
(http://www.who.int/hac/about/definitions/en/)
Demography Demography is a statistical and mathematical study of the size,

composition, spatial distribution of human population, and of changes
overtime in these aspects through the operation of the five processes of
fertility, mortality, marriage, migration and social mobility. (Bogue,
Donald, 1969. Principles of Demography, Wiley, New York.)
Diabetes Acute and chronic conditions caused by diabetes. Chronic complications

complications include retinopathy (eye disease), nephropathy (kidney disease),
neuropathy (nerve disease), cardiovascular disease (disease of the
circulatory system), periodontitis (inflammation of the tissue
surrounding the tooth), foot ulceration and amputation. (International
Diabetes Federation 2015)
Diabetes Mellitus A metabolic disorder of multiple etiologies characterized by chronic high

blood glucose levels with disturbance of carbohydrate, fat and protein
metabolism resulting from defects in insulin secretion, insulin action or
both (NHMS Vol.2 2006)
Undiagnosed Not known to have diabetes and has a fasting capillary blood glucose
equal to or more than 6.1 mmol/L (or non-fasting blood glucose of more
than 11.1 mmol/L)(NHMS Vol.2 2011)
Known Self-reported by subject, as having diagnosed with diabetes previously by

medical personnel (NHMS Vol.2 2011)
Endocrinologist Endocrinologists treat people who suffer from hormonal imbalances,

typically from glands in the endocrine system.
(http://www.hormone.org/contact-a-health-professional/what-is-an-
endocrinologist)
Family Medicine Family medicine is the medical specialty which provides continuing,
Specialist comprehensive health care for the individual and family. It is a specialty
in breadth that integrates the biological, clinical and behavioural sciences.
The scope of family medicine encompasses all ages, both sexes, each
organ system and every disease entity.
(http://www.aafp.org/about/policies/all/family-medicine-
definition.html)
Foot examinations Check feet and toes, inspecting the tops, sides, soles, heels, and the area in
between the toes. (http://www.healthline.com/health/diabetes-foot-
care)
Funduscopy Ophthalmoscopy (also called fundoscopy) is a test that allows a doctor to

see inside the back of the eye (called the fundus) and other structures
using a magnifying instrument (e.g. ophthalmoscope) and a light source.
HbA1c Glycosylated haemoglobin A1c (HbA1c) refers to haemoglobin which

glucose is bound. Glycosylated haemoglobin is tested to determine the
average level of blood glucose over the past two to three months
(International Diabetes Federation 2015)
60
Health care facility Health-care facilities are hospitals, primary health-care centres, isolation
camps, burn patient units, feeding centres and others.
(http://www.who.int/environmental_health_emergencies/services/en/)
Hospital An institution with primary function to provide inpatient diagnostic and

therapeutic services for a variety of medical conditions both surgical and
non-surgical. (NHEWS 2012-2013)
Impaired Fasting Impaired fasting glucose (IFG) is categorized based on capillary whole
Glucose blood glucose level within 5.6-6.1mmol/L range taken from subject
without diabetes who fasted for at least 8 hours. (NHMS 2011)
Incidence The number of new cases of a disease among a certain group of people for
a certain period of time. (International Diabetes Federation 2015)
Inpatient care In-patient care refers to care for a patient who is formally admitted (or
‘hospitalised’) to an institution for treatment and/or care and stays for a
minimum of one night in the hospital or other institution providing in-
patient care. (https://stats.oecd.org/glossary/detail.asp?ID=1364)
Insufficient No activity is reported OR some activities are reported but not enough to
physical activity meet moderate or high categories (IPAQ)
Kempen Cara Kempen Cara Hidup Sihat is another initiative of the Ministry of Health to
Hidup Sihat develop a healthy lifestyle through physical activity among Malaysians,
especially the youth.
(http://www.infosihat.gov.my/infosihat/projekkhas/kempen_nak_sihat.
php)
KOSPEN The program "Komuniti Sihat Perkasa Negara" (KOSPEN) is an initiative

that was triggered by the Health Minister of Malaysia, Datuk Seri S.
Subramaniam in July 2013 in order to address the problem of increasing
burden of NCDs (Non Communicable Diseases, NCDs) in the country
through empowerment and community participation in the expansion of
public health programs by combining existing government mechanisms,
particularly at the grassroots.
(http://www.infosihat.gov.my/infosihat/projekkhas/kospen.php)
Microalbuminuria Microalbuminuria is defined as an abnormal increase in albumin

excretion rate within the specific range of 30–299 mg of albumin/g of
creatinine. In diabetes, microalbuminuria is an early sign of diabetic
kidney disease. (https://www.ncbi.nlm.nih.gov/pubmed/15538104)
Myocardial Occurs when the flow of blood to the heart is blocked, most often by a
infarction build-up of fat, cholesterol and other substances, which form a plaque in
the arteries that feed the heart (coronary arteries). The interrupted blood
flow can damage or destroy part of the heart muscle. (Health at a Glance
2015: OECD Indicators)
Nephropathy Damage, disease, or dysfunction of the kidney, which can cause the
kidneys to be less efficient or to fail altogether. (International Diabetes
Federation 2015)
61
Obesity Obesity is a complex, multifactorial condition characterized by excess
body fat (CPG 2004- BMI ≥ 27.5 kg/m2; WHO 1998- BMI ≥ 30 kg/m2).
Generally, men with >25% body fat and women with >35% body fat are
considered obese (CPG Management of Obesity, 2004).
Overweight BMI 23-27.49 kg/m2. (NHMS Vol.2 2015)
Performance Selection and use of quantitative measures of capacities, processes, and

measure outcomes to develop information about critical aspects of activities,
including their effect on the public. (Guidebook for Performance
Measure)
Population aging Population ageing defined as a process which increases the proportion of
old people within the total population. (United Nations, Department of
Economic and Social Affairs, Population Division (2013). World
Population Ageing 2013)
Prevalence The proportion or number of individuals in a population that has a

disease or condition at a particular time (be it a point in time or time
period). (International Diabetes Federation 2015)
Primary care Basic or general healthcare focused on the point at which a patient ideally
first seeks assistance from the medical care system. (NHEWS (Primary
Care) 2008-2009)
Quality of care Quality of care can be defined as the degree to which health services for
individuals and populations increase the likelihood of desired health
outcomes and are consistent with current professional knowledge.
(Health Care Quality Indicators Project Conceptual Framework Paper,
OECD)
Retinopathy A disease of the retina of the eye which may cause visual impairment and
blindness. (International Diabetes Federation 2015)
Urbanization Urbanization is a process of global scale changing of the social and

environmental landscape. Urbanization is a result of population
migration from rural areas in addition to natural urban demographic
growth.
(http://www.who.int/globalchange/ecosystems/urbanization/en/)
Urine test Urine test is tests performed in a clinical laboratory or at home using self-
test kits and a sample of the patient's urine. Urine tests can be performed
for a variety of reasons, but in people with diabetes, they are most
commonly used to look for ketones or microalbumin.
(http://www.medicinenet.com/urine_tests_for_diabetes/article.htm#uri
ne_tests_for_diabetes_facts)
62
INDICATOR OPERATIONAL DEFINITION
No Indicator Numerator Denominator Constant
Density of Number of Total midyear

1 per 100 000
endocrinologist endocrinologist population
Number of public and Total midyear

2 Primary care facility per 10 000
private health clinics population
% Patients who had Number of DM patients Total number of DM

3 funduscopy done who had funduscopy done patients by end of per 100
within 1 last year within 1 last year index year
% Patients who had

Number of DM patients Total number of DM
foot examination
4 who had foot examination patients by end of per 100
done within the last 1
done within 1 last year index year
year
% Patients who had Number of DM patients

Total number of DM
urine checked for who had urine checked
5 patients by end of per 100
micro-albumin for micro-albumin within
index year
within the last 1 year 1 last year
% Patients who had Number of DM patients

Total number of DM
HbA1c test done at who had HbA1c test done
least once within the at least once within 1 last
index year
last 1 year year
Admission rate for

Number of DM patients Total midyear
uncontrolled DM
7 with uncontrolled DM population of 15 per 100 000
without
without complications years old and above
complications
Admission rate for Number of DM patients Total midyear

8 DM with short term with short term population of 15 per 100 000
complications complications years old and above
Admission rate for Number of DM patients Total midyear

9 DM with long term with long term population of 15 per 100 000
complications complications years old and above
Total number of DM-

Admission rate for Total midyear
related (uncontrolled+
10 DM related hospital population of 15 per 100 000
short term+ long term)
admission years old and above
hospital admission
Total number of DM
Number of DM patients
11 Rate of retinopathy patients by end of per 100
with retinopathy
index year

12 Rate of nephropathy per 100
with nephropathy patients by end of
63
index year
Total number of DM
13 Rate of MI patients by end of per 100
who have had MI
index year
Rate of Number of DM patients Total number of DM

14 cerebrovascular who have had patients by end of per 100
disease cerebrovascular disease index year
Total number of DM
15 Prevalence of DFU patients by end of per 100
with DFU
index year

16 Rate of amputation who have had lower limb patients by end of per 100
amputation index year
% Patient who Number of DM patients Total number of DM

17 achieved BP target ≤ who achieved BP target ≤ patients by end of per 100
130/80mm/Hg 130/80mm/Hg index year
% Patient who Number of DM patients Total number of DM

18 achieved HbA1c who achieved HbA1c patients by end of per 100
target < 6.5% target < 6.5% index year
Total number of DM
% Patient who had Number of DM patients
BMI < 23kg/m2 who had BMI < 23kg/m2
index year
% Patient who Total number of DM
who achieved
20 achieved LDL target ≤ patients by end of per 100
2.6mmol/L index year
LDL ≤ 2.6mmol/L
Number of persons with

Total midyear
BMI ≥27.5 kg/m2 OR
21 Prevalence of obesity population of 18 per 100
years old and above
BMI ≥ 30.0 kg/m2 (WHO)
Total midyear
Prevalence of Number of persons with
22 population of 18 per 100
overweight BMI 23 – 27.49 kg/m2
years old and above
Number of persons not

Prevalence of known to have diabetes Total midyear
23 impaired fasting but had a fasting capillary population of 18 per 100
glucose (IFG) blood glucose between years old and above
5.6 -6.6 mmol/L.
Prevalence of Number of persons with Total midyear

24 insufficient physical low physical activity level population of 16 per 100
activity assessed by IPAQ years old and above
64
Total number of persons Total midyear
Prevalence of overall
25 with undiagnosed DM and population of 18 per 100
DM
known DM years old and above
Number of persons not

known to have diabetes Total midyear
Prevalence of
26 but had a fasting capillary population of 18 per 100
undiagnosed DM
blood glucose of ≥ 6.1 years old and above
mmol/L.
Total midyear
Prevalence of known Number of persons with
27 population of 18 per 100
DM known diabetes
years old and above
65
66

Diabetes Care Performance Report 2016

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This report is intended only for the use of the individual entity to which it is addressed and may contain

Malaysian Healthcare Performance Unit

Tel : (603) 8000 8000

YBhg Datuk Dr Noor Hisham Abdullah

YBhg Datuk Dr Shahnaz Murad

Y.Bhg. Datuk Dr Lokman Hakim b. Sulaiman

Y.Bhg. Dato' Dr Hj Azman bin Abu Bakar

Dr Md. Khadzir bin Sheikh Hj. Ahmad

Professor Niek Klazinga

Dato’ Dr Hassan Merican Omar Naina Merican Dr Bariyah Kadas

Dato’ Dr Norhizan Ismail Dr Lokman Rejali

Dr Wan Abdul Rahim Wan Muhammad Dr Amirullah Ahmad Arshad

Dr Hjh Fatimah Othman Dr Mohd Zaki Abdul Hamid

Dr Fatimah Muda Dr G. R. Letchuman Ramanathan

Dr Fathullah Iqbal Abdul Rahim Datin Dr Siti Haniza Bt Mahmud

Dr Vickneshwari Ayadurai Dr Nazrila Hairizan Bt Nasir

Dr Muhammad Fadhli Mohd Yusoff Dr Omar B Mihat

Dr.Fatanah Binti Ismail Puan Viola Michael

Malaysian Healthcare Performance Unit

Team lead: Members:

Dr. Jamaiyah Haniff Dr Nor Aini Abdullah

List of tables ...................................................................................................................................................................... vii

Table 1: Data availability, coverage, and levels of disaggregation of selected performance

Figure 1: Breakdown of cases by age group, 2009-2012 ............................................................................. 13

AAR Average Annual Rate

Malaysian diabetic scenarios

Age-standardized prevalence of obesity in Malaysia is almost double the prevalence of obesity in

Resources and facilities

3. KK to population ratio 2015 1: 32 519 - - -

4. Number of KK with FMS 2015 242 ↑6.2 2009-2015 -

5. Primary care facility per 10 000

2. % Patients who had foot

3. % Patients who had urine checked

4. % Patients who had HbA1c test

Outcome (Hospital admission per 100 000 population)

2. DM with short term complicationspp 2015 19 ↑ 7.7 2010-2015 -

3. DM with long term complicationspp 2015 69 ↓ 1.0 2010-2015 -

1. Rate of retinopathyp 2012 7.9% ↓6.5 2011-2012 -

2. Rate of nephropathyp 2012 8.9% ↓6.6 2011-2012 -

3. Rate of myocardial infarctionp 2012 6.0% ↓1.3 2011-2012 -

4. Rate of cerebrovascular diseasep 2012 1.4% ↑4.7 2011-2012 -

5. Rate of diabetic foot ulcerp 2012 1.4% ↓3.0 2011-2012 -

6. Rate of amputationp 2012 0.7% ↓0.6 2011-2012 -

Outcome (Clinical target achievements in primary care)

2. % Patients who achieved HbA1c 1

4. % Patients who achieved LDL target

3. Prevalence of IFG 2015 4.7% ↑ 1.3 2006-2015 -

4. Prevalence of insufficient physical

1. To describe the magnitude of current diabetic burden in Malaysia

In this report, performance is measured in four ways:

1. Whether or not Malaysia has reached a specific achievement target/standard.

↑ Increased since previous year Desirable change

A note about making comparisons (limitation):

 All indicators are presented in crude measure without adjustment to baseline

Indicator Time period Coverage Data source Domain

4. Prevalence of impaired fasting glucose NHMS

5. Prevalence of insufficient physical activity NHMS

6. Diabetes age-adjusted comparative National IDF

7. Obesity age-standardized adjusted National WHO

8. Insufficient physical activity age- National WHO

11. Primary care clinics to population ratio NHEWS

12. Endocrinologist density per 100 000 MEMS

Indicator Time period Coverage Data source Category

13. Proportion of diabetics who have had: