Titis Kurniawan, MNS

Educations
1999 – 2004 Sarjana Keperawatan (PSIK – FK UNPAD)
2004 – 2005 Profesi Ners (Fakultas Ilmu Keperawatan UNPAD)
2009 – 2011 (Master of Nursing science) Adult Nursing Faculty of Nursing Prince of Songkla –
Thailand
2018 – Present (Doctoral Program) Faculty of Nursing Prince of Songkla – Thailand
2000 – Present Mentee mentoring berkelanjutan

Contact
Working Experiences
2005 – 2011 Staf Keperawatan Dasar F.Kep UNPAD
titis kurniawan 2011 – Present Staf Keperawatan Medikal Bedah F.Kep UNPAD
2016 – 2017 Manajer Kemahasiswaan & Hubungan Alumni F.Kep UNPAD
t.kurniawan@unpad.ac.id

Organization Achievements
2011 – 2016 & 2016 – 2018 (Ketua Ikatan Keluarga 2009 – 2011 DIKTI Scholarship Awardee
Alumni UPAD Komisariat F.Kep 2018 – Present Thai Education Hub for ASEAN Countries (TEH-AC) Awardee

2005 – Present (Member of PPNI (NIRA:

32730028935)
Research interest
2017 – present member of HIPMEBI
Chronic diseases, diabetes, self-management, continuity of care
 Literature said on…

Titis Kurniawan
Fakultas Keperawatan UNPAD - HIPMEBI
 DIABETES COMPLICATIONS
SCREENING

Why screening is significance?

What guidelines said about?

What evidences said about?

What should do next?

 DIABETES COMPLICATIONS
SCREENING

Through
1. History taking (e.g., asking about smoking, symptoms, etc.)
as an attempt to identify an 2. Physical examination (e.g., a blood pressure measurement, etc.),
asymptomatic, unrecognized disease 3. Laboratory test (e.g., serum cholesterol measurement, etc.)
before its clinical presentation or risk 4. Diagnostic test (X-Ray, ECG, Echocardiography, cardio magnetic resonance,
factor for it. etc.)

Outcome
• Prevent disease progression
• Treatment effectiveness
Follow up
• Level of risk classification
• Intervention/treatment
program
Resulting
1. Early detection
2. Early diagnoses
3. Early treatment

Makrilaris, K & Liatis, 2017. Cardiovascular Screening for the Asymptomatic Patient with Diabetes: More Cons Than Pros. Journal of Diabetes Research. 1-19
 DIABETES COMPLICATIONS
SCREENING

“Complication risk management”

 Why screening….?
DIABETES COMPLICATION F CTS
463
Million Global
PWD

59 - 70%
70% 29- 40% 20% 20% 20% 30%
Undiagnosed
Neuropathy Proteinuria Retinopathy Foot Ulcer Macro- Mental Erectile
Cause 4.2 million deaths vascular Problems dysfunction

 Asymptomatic
 Screen-able & Preventable
10.6 Rp. DM
COMPLICATION  Lack of knowledge &
Million
INDONESIAN PWD
awareness
130% vs. no complication Re-hospitalization & >> Mental Health
IDR 13 – 100 M/year ER visit

 Early detection
Undiagnosed  Lessen the risk for
complication
3rd highest death related NCD Inhibit effective Increase DALY
treatment Low QoL
IDF (2019). IDF Diabetes Atlas, 9th Edition.
Soewondo, P., Ferrario, A., & Tahapary, D. L. (2013). Challenges in diabetes management in Indonesia: a literature review. Globalization and Health, 9, 63–80. https://doi.org/10.1186/1744-8603-9-63
Cholil, AR., Lindarto, D., Pemayun, TGD., Wisnu, W., Kumala., & Putri HHS. (2019). DiabCare Asia 2012: diabetes management, control, and complications in patients with type 2 diabetes in Indonesia. Medical Journal of IIndonesia:
28; 47-56
Chen et al., 2015. Adherence to Diabetes Guidelines for Screening, Physical Activity and Medication and Onset of Complications and Death. J Diabetes Complications. 29(8): 1228–1233.
 What guidelines said about screening….?

Cancer screening Profil lipid; HDL, LDL, Trigliserida, hipertensi

Infection Pemeriksaan mata & funduskopi

Depression Pemeriksaan kaki komprehensif

Fungsi ginjal; kreatinin, GFR, albuminuria

Disfungsi ereksi

ADA, 2020. diabetes care standard

PERKENI, 2019. Konsensus Pencegahan dan pengelolaan DM
Diabetic Retinopathy Screening - Eyenuk, Inc. ~ Artificial Intelligence Eye Screening
What guidelines said about screening….?

 Pemeriksaan komprehensif segera setelah diagnosis (3 bulan) & Pemeriksaan retina mulai
DMT1 usia 11 tahun & 2 tahun setelah diagnosis (IDAI, 2015)
 Pemeriksaan mata komprehensif setelah 5 tahun setelah onset (ADA, 2020)

 Segera setelah diagnosis oleh spesialis mata (ADA, 2020; PERKENI, 2019)
DMT2  Pemeriksaan mata rutin tiap 2 tahun & bila pasien ada gejala retinopati diabetik
saat skrining awal dilakukan tiap tahun/lebih sering (ADA, 2020; PERKENI, 2019)

Ibu dg DMT1 & DMT2 yang berencana hamil harus periksa mata sebelum hamil, dan
diulang tiap trimester (ADA, 2020; PERKENI, 2019)

Rekomendasi & FOLLOW UP:

 Kontrol BG dan BP secara intensif
 Pasien dengan macular edema, NPDR berat atau PDR harus direfer ke ophthalmologist
 Tidak kontraindikasi dengan terapi aspirin
 What evidences said about screening….?
ENABLERS
 Adequate Knowledge, longer DM, presence of Adherence
neurological problem (Alwazae et al., 2019)  15,3% Indonesian population (Adriono et al., 2011)
 Patients fear of blindness, vision loss experiences,  30% Saudi population (Alwazae, et al., 2019)
33%  33% US low income/rural population (Kuo et al., 2020)
proximity of screening facility (Piyasena et al., 2019)
 Older age, female, non-English speaking (Kuo et al.,  81% Netherland population (van Eijk et al., 2012)
2020)  35% eye examination within last 2 years (Cholil et al.,
 Patient who receive DR education program 2019)
(Piyasena et al., 2019)

BARRIERS
Diabetic retinopathy barometer report
 21% ophthalmologist didn’t receive DR training  Lack of knowledge & financial (Adriono et al., 2011)
 28% healthcare provider didn’t have written protocol  Patient lack of knowledge, motivation, attitude as well as
 30% patients experience waiting appointment related barrier for provider lack of training, lack of infrastructure, cost
eye examination
 79% patients reported DR impaired ADL
service (Piyasena et al., 2019)
 69% patients experienced poor physical & mental health  Cost & accessibility (Keenum et al., 2016)

DR Barometer (idf.org)
Adriono G, Wang D, Octavianus C, Congdon N: Use of eye care services among diabetic patients in urban Indonesia. Arch Ophthalmol 2011, 129(7):930–935.
Alwazae M, Al Adel F, Alhumud A, et al. (December 23, 2019) Barriers for Adherence to Diabetic Retinopathy Screening among Saudi Adults. Cureus 11(12): e6454.
Kuo et al., 2020. Factors associated with adherence to screening guidelines for diabetic retinopathy among low-income metropolitan Patients, Missouri Medicine, 117(3); 258-264
Piyasena MMPN, Murthy GVS, Yip JLY, Gilbert C, Zuurmond M, Peto T, et al. (2019) Systematic review on barriers and enablers for access to diabetic retinopathy screening services in different income settings. PLoS ONE 14(4)
Van Eijk et al., 2012 Diabetic retinopathy screening in patients with diabetes mellitus in primary care: Incentives and barriers to screening attendance. Diabetes research and clinical practice. 10-16
Boehringer Ingelheim, Lilly launch campaign on Type 2 diabetes, heart disease link | Drug Store News
 What guidelines said about screening….?

 Deteksi HT sejak awal diagnosis (persentil 95 atau 130/80 untuk

1. Australian
dewasa muda), dipantau tiap tahun (IDAI, 2015)
absolute cardiovascular disease risk calculator - National Vascular
 Profil lipid sejak usia 12 tahun, bila ada riwayat keluarga dengan Disease Prevention Alliance (cvdcheck.org.au
dislipidemia, penyakit kardiovaskular  penlaipsan sejak usia 2 tahun )
(IDAI, 2015). Bila normal pemantauan tiap 5 tahun 2. ASCVD Risk Estimator + (acc.org)
3. Calculator: Cardiovascular risk assessment (10-year, men: Patient e
ducation) -
 Pemeriksaan TD rutin tiap kunjungan, dan UpToDate
deteksi HT setiap tahun (ADA, 2020; PERKENI, 2019)
 Screening: tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate
 Screening rutin dan investigasi lanjut diperlukan bila pasien memiliki gejala; chest discomfort, dyspnoea, dan
gejala lain. (ADA, 2020). Pada pasien tanpa gejala tidak direkomendasikan menjalani screening ruting, selama
faktor risiko dikelola dengan baik (ADA, 2020)
 Profil lipid saat didiagnosa DM , bila normal diulang tiap 2 tahun , dan/atau 4-12 minggu pasca terapi
penurunan kadar lipid (ADA, 2020; PERKENI, 2019)

FOLLOW UP & TREATMENT

 Hypertension management (Set BP target individually, DASH, pharmacology therapy)
 Lipid management (penurunan LDL & trigliserida)
 Statin therapy
 Pengelolaan obesitas
 What evidences said about screening….?

Screening Adherence
 Physician did not rate themselves effectively help patient in preventing CVD and manage risk factors,
mostly perceived a need additional training, and perceived that patients themselves, time and insurance
coverage as barriers for adhering the CVD prevention guideline (Mosca et al., 2005)
 Review; more screened and referred patients based on the CVD risks in the current studies, but high
number of patients didn’t attend the follow up appointment (Willis et al., 2014)
 46% patients were screened fro macrovasular related complication (Ringborg, 2009)
 39% DM patient hold high risk for cardiovascular problem (Azavedo et al., 2018)

Follow up adherence
 More than 50% PWD + hyperlipidaemia received statin & 15% - 20% PWD + CHD received a combination
of statin & aspirin (Lin et al., 2012)
 Poor DM medication adherence increase mortality rate (45%) & incidence of CVD (41%)  only 34%
newly diagnosed DM have good medication adherence (Kim et al., 2018)

Diabetes & CVD: A Global Analysis - World Heart Federation (world-heart-federation.org) Packard & Hilleman (2016).
Lin et al., Utilization of statins and aspirin among patients with diabetes and hyperlipidemia: Taiwan, 1998e2006*. Journal of Chinese Medical Association. 75:567 - 572
Kim et al., 2018. Efect of medication adherence on long-term all-cause-mortality and hospitalization for cardiovascular disease in 65,067 newly diagnosed type 2 diabetes patients. Scientific reports; 8:12190): 1-7
Packard & Hilleman, 2016. Adherence to therapies for secondary prevention of cardiovascular disease: a focus on aspirin. Cardiovascular Therapeutics; 34: 415–422
Willis et al., 2014. The Effectiveness of Screening for Diabetes and Cardiovascular Disease Risk Factors in a Community Pharmacy Setting. PLoS ONE 9(4): e91157. doi:10.1371/journal.pone.0091157
Indonesian renal registry, 2018
What guidelines said about screening….?

 DMT1 > 5years  setidaknya setahun sekali

periksa urinary albumin (Spot UACR) & e-GFR
(ADA, 2020)
 DMT1 Nefropati ; pemeriksaan
mikroalbuminuria dimulai sejak usia 11 tahun
dan 2 tahun setelah terdiagnosis,. Pemantauan
 setiap tahun Rekomendasi & Follow Up
 Kontrol BG dan BP
 Diet rendah protein tdak direkomendasikan
 Penggunaan ACE inhibitor II hanya digunakan pada pasien
DM tanpa kehamilan dengan albuminuria sedang (30 -299
mg/24 jam) atau berat (> 300 mg/24 jam)
 Libatkan ahli nefrologi

 DMT2 segera setelah diagnosa, bila albuinuria

< 30 mg/24 jam ulangan setahun sekali
(ADA 2020; PERKENI, 2019)
 Bila albuminuria > 30 mg/g Cr or e-GFR < 60
mL/min/1.73 m2  monitor 2x/year (ADA,
2020)
 What evidences said about screening….?

CKD Risk Screening

 46% test for creatinin 14 days after diagnosed T2DM, Factor related
84.8% at least test creatinin within 1 year, 43% tested for  Having albuminuria, high serum creatinine, a
UACR (Folkertz, 2021) family history of kidney disease and being obese
 CKD prevalence 26% and only 28.9% patients who aware were significantly associated with CKD awareness
about CKD and its’ risk factors (Goro et al., 2019) (Fiseha, 2020)
 50% moderate risk for CKD and 20% high and very high risk  Lack of knowledge & awareness (Sherwood,
for CKD (Flood et al., 2018). Lack of awareness & 2016; Welch et al., 2016; Whaley-Connel et al.,
 Among 323 DM patient 26% had CKD and among these 2009)
patient only 10,6% aware about CKD (Fiseha, 2020) knowledge for
 Screened within 2 years (42.3%) (Choli et al., 2019) screening as well as
poor adherence on
the follow up
Follow up & Lowering CKD Risk Adherence treatment Follow up & Lowering CKD Risk Adherence
 < 50% received creatinin & UACR during follow up (Folkertz,  Diabetes found as the most concomitant long-term poor
2021) BP control (Li etal., 2016)
 Poor antihypertensive medication adherence found in 46%  Uncontrolled BP significantly related to poor knowledge,
participants, sub optimal blood pressure 48% (Li etal., 2016) medication non-adherence, uncontrolled BG, smoking,
 Medication Non-adherence 68%, BP uncontrolled 44%, BG and hypertension > 5 years (Dedefo et al., 2020)
 Forgetfulness, more medication prescribed, lower income
uncontrolled 43%. (Dedefo et al., 2020)
 61% adhere to antihypertensive therapy among DM-HT related to treatment adherence (Kefale, 2018)
patients (Kefale, 2018)

Folkerts, et al., 2021. Adherence to Chronic Kidney Disease Screening Guidelines Among Patients With Type 2 Diabetes in a US Administrative Claims Database. Mayo Clinic Proceedings. 96(4):975-986
Flood D, Garcia P, Douglas K, et al. (2018). Screening for chronic kidney disease in a community-based diabetes cohort in rural Guatemala: a cross-sectional study. BMJ Open. doi:10.1136/ bmjopen-2017-019778
Goro et al., (2019) Patient Awareness, Prevalence, and Risk Factors of Chronic Kidney Disease among Diabetes Mellitus and Hypertensive Patients at Jimma University Medical Center, Ethiopia. Hindawi Biomed International Research (
Li et al., 2016. Medication Adherence and Blood Pressure Control Among Hypertensive Patients With Coexisting Long-Term Conditions in Primary Care Settings. Medicine. 95(20):1-10
Dedefo et al., 2020. Blood Pressure Control among Hypertensive Diabetic Patients on Follow-Up at Chronic Clinic of Nekemte Referral Hospital in West Ethiopia. Hindawi International Journal of Hypertension. https://doi.org/10.1155/2020/7526257
Kefale B, Tadesse Y, Alebachew M, Engidawork E (2018) Management practice, and adherence and its contributing factors among patients with chronic kidney disease at Tikur Anbessa Specialized Hospital: A hospital-based cross-sectional study. PLoS ONE 13(7): e0200415. https://
doi.org/10.1371/journal.pone.0200415
Sherwood, 2016. Chronic kidney disease from screening, detection, and awareness, to prevention. Thelancet. 2288-289
 463
DFU F
12 -20% patients admitted in some
hospital develops DFU
Million Global
PWD nearly 40% DFU ended up with
amputation

CTS
6.3% global prevalence of Phenomena in Indonesian context(2,3,4,5)
DFU - Peripheral neuropathy 72.8%
20% PWD will develop ulceration - PAD 40.6%
- Delay treatment 2 – 6 weeks
15% DFU ended up with - Infection 100%, Wagner grade 3> 70%,
amputation
Gangrene 38.5%
Secondary Complications - Lack DM BG control & > 5years DM duration
- Disability and dependent - Premature death 10.7%
More prevalent in: - Depression
- Male -
- T2DM
Low QoL Cultural believe/Myths (6)
- Older
- Loss of productivity - No fish (itch), meat (odour), chicken (slimy) for
- Smoking - Premature death DFU patients
- Hypertension - Heat for treating Neuropathy
- Longer Duration - Benzene/Kerosene for (antimicrobial) wound
- DM retinopathy 5X bigger Expenditure than non-DFU
- Middle or low income
countries

IDF (2019). IDF Diabetes Atlas, 9th Edition.

Zang et al., (2017). Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Anal of Medicine; 49(2).106 – 116
Zhang et al., (2020).. Global Disability Burdens of Diabetes-Related Lower-Extremity Complications in 1990 and 2016, Diabetes care
What guidelines said about screening….?

ADA (2020) & PERKENI (2019)

 Semua DMT2 pasien direkomendasikan melakukan pemeriksaan kaki
komprehensif setelah diagnosa
 DMT1; pemeriksaan kaki dimulai sejak 5 tahun setelah diagnosis (ADA,
2020) atau usia 11 tahun & 2 tahun setelah terdiagnosis (PERKEI, 2019)
 Pemantauan lanjutan setiap tahun (Komprehensif kaki (inspeksi, palpasi
pulsasi, ABI & neuropati sensorik; monofilamen test)
 Pemeriksaan kaki lengkap harus dilakukan pada ada pasien terindikasi
mengalami gangguan micro-vascular (ADA, 2020)
 Pasien dengan LOPS atau riwayat ulcerasi, pemeriksaan kaki tiap
kunjungan (ADA, 2020)
 What evidences said about screening….?

Foot Screening Factor related Foot examination

 60% DM patients perceived their feet are normal; 68% had neuropathy, 10% had low
 Having albuminuria, high serum creatinine, a
ABI, 6% had both, and had some foot conditions; dry skin, callus, foot deformity (Baba
family history of kidney disease and being obese
et al., 2014)
were significantly associated with CKD
 Only 16% patient chart noted foot exam (Pocuis et al., 2015) awareness (Fiseha, 2020)
 56.4% had undergone foot inspection, 39.5% monofilament test, 45.8% pulse check,  Foot screening significantly related history of
10% ABI. Complete foot examination 37%, ulcer stratification 12.4% (Alonso-Fernandez foot problems; foot deformities, neuropathy ,
et al., 2014) and PAD (alonso-Fernandez et al., 2014)

Foot care factor

Foot Care  Good awareness on foot care related to younger age, female, and lower HbA1c (Al-Dalawi &
 Good awareness on foot care 36% (Al- Al-Humairi, 2019)
Dalawi & Al-Humairi, 2019)  Poor foot care behaviour; Age, diabetes distress , foot care knowledge, family support &
 Poor Foot care & behaviours education level (Sari et al., 2020)
(Muhammad-Lutfi, et al., 2014; Sari et  Better foot care related to longer DM, better illnes perspective, better HbA1c, and less
al., 2020) depressive symptoms (Pereira et al., 2019)

Al-Dalawi & Al Humairi, 2019. Assessment of Awareness About Foot Care Among Diabetic Patients With or Without Foot Ulcer. Annals of Tropical Medicine & Public Health; 22(10): S290.
Sari, et al., 2020. Foot self-care behavior and its predictors in diabetic patients in Indonesia. BMC research Notes13(38); 1-6
Muhammad-Lutfi et al., 2014. Knowledge and Practice of Diabetic Foot Care in an InPatient Setting at a Tertiary Medical Center. Malaysian Orthopaedic Journal; 8(3; 22-26
Baba et al., 2014. Self‐awareness of foot health status in patients with Type 2 diabetes: the Fremantle Diabetes Study Phase II. Diabetic Medicine; 31(11)1939-1445
Pocuis et al., 2015. Exploring Diabetic Foot Exam Performance in a Specialty Clinic. Clinical nurisng Research. 26(1)
Alonso-Fernandez et al., 2014. Evaluation of diabetic foot screening in Primary Care. Endocrinologia and Nutricion. 61(6): 311-317
DEPRESSION IN DM
 28-30% diabetes suffer from moderate
– severe depression r/t being on
insulin therapy and being a current
smoke (Khan et al., 2019)
 44% mild depression (2% severe
depression) r/t being male, having
sexual dysfunction, > 5 years DM
(Asefa et al., 2020)

 ADA RECOMMENDATIONS:
 Psychosocial screening and follow-
up; attitudes about diabetes,
expectations for medical
management and outcomes, affect
or mood, general and diabetes-
related, DM distress, eating
disorder, etc.
 More conducted on elderly
 Time of screening; initial
visit/diagnoses, change the
diseases/treatment status
 What evidences said about screening….?

DM during Pandemic Covid-19

 Kematian Covid-19 dengan comorbid DM di China 7.3% di Italia
36%, INDONESIA 11,6%
 Pasien DM diharuskan mematuhi promkes
 Menjalankan self-management DM dengan baik
 Hindari kunjungan klinik langsung
 Manfaatkan “Mobile JKN Fasilitas Kesehatan”

Tele-health & screening DM complications

 Tele-Diabetology  effectively improve screening & diabetes care
accessibility (Mohan, et al., 2014)

Perkeni, 2020. Pernyataan Resmi dan Rekomendasi Penanganan Diabetes Mellitus di era Pandemi COVID-19
Mohan et al., 2014. Tele-diabetology to Screen for Diabetes and Associated Complications in Rural India: The Chunampet Rural Diabetes Prevention Project Model. Journal of Diabetes
Science and Technology. 8(2) 256–261
Pradeepa et al., 2019. Use of Telemedicine Technologies in Diabetes Prevention and Control in Resource-Constrained Settings: Lessons Learned from Emerging Economies .
Diabetes Technology & TherapeuticsVol. 21, No. S2
 Screening in Indonesian context….?

Patients side
 Patient reported hypoglicemia  Never
check BG (43.7%), Never visit hospital (57%)
 60% patient had HbA1C > 7% (Soewondo et
al., 2013)
10.6  High number of patients and high Rate of
Million undiagnosed patient
INDONESIAN PWD
 Cultural issues; no symptom = normal =
healthy = delay seeking care untile “severe”
(Wahyuni, 2020)
 Delay seeking behaviours; self-medication,
Undiagnosed search alternative “cocok” (Wahyuni 2020)
68,7% obesity
50% hypertension Healthcare staff side
>50% dyslipidaemia  Physician dominated role, lack of other healthcare staffs
3 highest death related NCD
rd
role. HCP also perceived lack of skills and inadequate  National Guideline
specific DM related training including complications  National policy on DM
screening (Ligita et al., 2018) management; Prolanis, BPJS

IDF (2019). IDF Diabetes Atlas, 9th Edition. Infodatin (2018)

Mihardja et al., 2014. Prevalence and clinical profile of diabetes mellitus in productive aged urban Indonesians. Journal of Diabetes Investigation. 5(5); 507-512
Widyahening et al., 2014. "Awareness, agreement, adoption and adherence to T2DM guidelines: A survey of Indonesian primary care physician" BMC Family Practice; 15(72); 1-8
Ligita et al., 2018.
Wahyuni et al., 2020. Health-Seeking Behavior of People in Indonesia: A Narrative Review. Journal of Epidemiology and Global Health. 10(1); 6-15
Wahyuni et al., 2020. Lay perceptions and illness experiences of people with type 2 diabetes in Indonesia: a qualitative study, Health Psychology and Behavioral Medicine, 8:1, 1-15,
 What should do next….?

Membangun “Awareness”
Semua pihak; pasien, keluarga, masyarakat,
LSM, petugas kesehatan, dan pemerintah
01
Pedoman
Pelibatan seluruh tenaga kesehatan &
penanganan kolaboratif, serta
03 penambahan aspek skrining dan
penanganan masalah psikososial DM

Peningkatan Kapasitas SDM Kesehatan Infrastruktur Yankes

Dokter, Perawat, Farmasi, Dietician, Diabetes
02 04 Kelengkapan peralatan skrining dan juga
penanganan lanjutan, termasuk TELE-HEALTH
educator,
03
Thank You