Artikel Penelitian

Current Practice in the Management of Type 2 Diabetes in Indonesia: Results from the International Diabetes Management Practices Study (IDMPS)
Pradana Soewondo International Diabetes Management Practices Study (IDMPS) Study Group

Abstract: Increasing obesity, sedentary lifestyle and aging population have significantly contributed to the explosion of type-2 diabetes. In addition, the consequences of its complications have caused substantial morbidity and mortality. The major goal of diabetes treatment is to achieve good metabolic control, thus preventing the onset of the long-term complications. Unfortunately, there is still insufficient data on the quality of care of diabetic patients especially on type-2 diabetic patients in Indonesia. This study focused on diabetic patients seen by general practitioners, internists and endocrinologists, to assess its management, HbA1c achievement, and resources used. This study was part of The International Diabetes Management Practices Study (IDMPS) wave 2006, which was a cross-sectional study and also longitudinal follow up. Sixty eight physicians, consisted of 48 general practitioners (GPs)/internists and 20 endocrinologists, have reported 674 patients with type-2 diabetes mellitus who are currently receiving varied diabetes mellitus treatment. Among those patients, 21 patients only treated with lifestyle modification, 523 patients received only Oral Glycaemic Lowering Drug (OGLD), and 130 patients received insulin with or without OGLD. The average HbA1c in this study was 8.27% and only 37.4% reached the target value of HbA1c less than 7%. The majority of patients did not attain the recommended glycaemic target. This indicates the presence of a gap between recommendations of most recent guidelines and the actual practices. J Indon Med Assoc. 2011;61:47481 Keywords: Diabetes, Indonesia, Type of medication, Target achievement

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Current Practice in the Management of Type 2 Diabetes in Indonesia

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

Introduction

The incidence of diabetes mellitus, particularly type-2 diabetes is increasing dramatically across the world because of increasing obesity, sedentary lifestyle and population aging, and is the cause of substantial morbidity and mortality. This explosive increase in the prevalence of type-2 diabetes and the consequences of its complications and associated disorders represents the greatest health care challenge facing the world today. 1-6 The United Kingdom Prospective Diabetes Study (UKPDS) reported that early treatment and good control of diabetes can decrease the morbidity and mortality by decreasing its chronic complications.7 Each 1% reduction in updated mean HbA1c was associated with risk reductions of 21% for diabetes-related deaths, 14% for myocardial infarction, and 37% for microvascular complications.8 Therefore the major goal of treatment of diabetic patients is to achieve good (near normal) metabolic control, thus preventing the onset of the long-term complications. Unfortunately, there is still an insufficient data on the quality of diabetes care, especially on type-2 patients in non-Western countries, including Indonesia.9,10 IDMPS study is one of the largest population-based

studies of diabetic patients in developing countries. The aim was to assess the therapeutic management of type-2 diabetes mellitus in the current medical practice in 27 countries in Asia, Latin America and the Middle East and Africa. In Indonesia, the current diabetes practice was based on recommendation from the PERKENI (The Indonesian Society of Endocrinology). PERKENI had developed the type 2 diabetes guidelines since 1993 and it had been revised several times until 2006.11 In Indonesia, this study was one of few studies that was done to investigate the disease burden and quality of care in diabetes. The results would be very important to improve the quality of diabetes care in Indonesia. Method The IDMPS conducted in five waves which focuses on diabetes patients seen by general practitioners (GPs) and diabetic specialists who are experienced in insulin therapy. It provided an international perspective to identify practices variations across countries, and evaluated compliance to international guidelines of management of diabetes in differ475

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

Table 1. Distribution of Subjects Based on Demographic Characteristic Variable Lifestyle modification Gender Male (%) Female (%) Age Less than 40 yrs (%) 40 - 65 yrs (%) More than 65 yr (%)s Mean (SD) Median Family history of DM No (%) Yes (%) Duration of Diabetes Less than 1 yrs (%) 1 - 10 yrs (%) More than 10 yrs (%) Mean (SD) Median Smoking habit Smoker (%) Ex smoker (%) Non smoker (%) Obesity Under weight (%) Normal weight (%) Over weight (%) Obese (%) BMI Mean (SD) BMI Median Waist circumference Mean (SD) Median Systolic blood pressure Mean (SD) Median Diastolic blood pressure Mean (SD) Median Latest HbA1C Mean (SD) Median Fasting blood glucose Mean (SD) Median Type 2 OGLD

Insulin +

Total

10 (50.0) 10 (50.0) 3 (14.3) 16 (76.2) 2 (9.5) 51.4 (10.8) 52.0 6 (30.0) 14 (70.0) 7 (33.3) 11 (52.4) 3 (14.3) 4.7 (4.6) 3.0 1 (4.8) 5 (23.8) 15 (71.4) 1 (4.8) 12 (57.1) 6 (28.6) 2 (9.6) 24.9 (4.9) 24.9 88.1 (11.1) 88.0 130.1 (22.6) 120.0 80.6 (9.1) 80.0 7.0 (1.2) 8.0 156.1 (47.9) 147.1

229 (43.9) 293 (56.1) 31 (5.9) 410 (78.4) 82 (15.7) 55.0 (10.1) 54.0 216 (41.3) 307 (58.7) 143 (28.5) 290 (57.9) 68 (13.6) 5.5 (6.1) 4.0 27 (5.2) 56 (10.7) 440 (84.1) 14 (2.7) 271 (52.6) 175 (34.0) 55 (10.7) 24.8 (3.8) 24.4 88.6 (11.4) 88.0 132.8 (19.8) 130.0 83.4 (9.7) 80.0 8.1 (2.1) 8.0 171.1 (77.1) 150.1

65 (50.8) 63 (49.2) 9 (6.9) 91 (70.0) 30 (23.1) 56.4 (10.4) 56.0 49 (37.7) 81 (62.3) 16 (12.6) 77 (60.6) 34 (26.8) 8.7 (7.3) 7.0 12 (9.2) 13 (10.0) 105 (80.8) 8 (6.2) 67 (51.9) 47 (36.4) 7 (5.5) 24.6 (4.8) 24.6 90.7 (11.8) 90.0 132.2 (23.1) 130.0 81.1 (9.4) 80.0 8.9 (2.4) 7.0 169.0 (75.2) 142.7

304 (45.4) 366 (54.6) 43 (6.4) 517 (76.7) 114 (16.9) 55.2 (10.2) 55.0 271 (40.3) 402 (59.7) 166 (25.6) 378 (58.2) 105 (16.2) 6.1 (6.4) 4.0 40 (5.9) 75 (11.0) 560 (83.1) 23 (3.5) 350 (52.6) 228 (34.3) 64 (9.7) 24.8 (4.0) 24.5 89.0 (11.5) 88.0 132.6 (20.5) 130.0 82.9 (9.7) 80.0 8.3 (2.2) 8.0 170.3 (76.1) 148.1

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

Table 2. Distribution of Subjects Based on Co-morbid and Complication Variable Lifestyle modification Hypertension Yes with treatment Yes but no treatment No hypertension Dislipidemia Yes with treatment Yes but no treatment No dislipidemia Late complication At least one No complication Type 2 OGLD

Insulin +

Total

8 (38.1) 0 13 (61.9) 8 (40.0) 4 (20.0) 8 (40.0) 9 (69.2) 4 (30.8)

230 (44.2) 17 (3.3) 273 (52.5) 179 (42.6) 36 (8.6) 205 (48.8) 290 (70.6) 121 (29.4)

59 (45.4) 5 (3.8) 66 (50.8) 53 (50.0) 12 (11.3) 41 (38.7) 97 (85.8) 16 (14.2)

297 (44.3) 22 (3.3) 352 (52.5) 240 (44.0) 52 (9.5) 254 (46.5) 396 (73.7) 141 (26.3)

R e tin o p a th y N e u ro p a th y P r o te in u ria D ia ly s is F o o t u lc e r A m p u ta tio n A n g in a M y o c a rd in fa rc H e a rt fa ilu re S tro k e P e rip h e ra l V D 0 .0 1 0 .0 2 0 .0 3 0 .0 4 0 .0 5 0 .0 6 0 .0 7 0 .0

O G LD

In s u lin p lu s

D ie t/E x e rc is e

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Current Practice in the Management of Type 2 Diabetes in Indonesia the physicians. In addition, more than 60% of patients had never had diabetes education session. The patients who were given insulin were more frequent to attend the diabetes education session. (See table 3 for details). Diabetes mellitus has reduced the productivity of the
Table 3. Distribution of Subjects Based on Physicians Specialty, Diabetes Education and Follow up Visit Variable Lifestyle modification Specialty GPs/ internists 13 (61.9) Endocrinologists 8 (38.1) Diabetes education Given 8 (40.0) None 12 (60.0) Mean (SD) 6.8 (4.7) Median 3.0 Follow up in the last 3 months By GPs/ internists Followed up 1 (33.3) None 2 (66.7) By endocrinologists Followed up 13 (100.0) None 0 Type 2 OGLD Insulin + Table 5. Distribution of Subjects Based on the Target Achievement Variable Type 2 Lifestyle OGLD Insulin + modification

Total

Total

Target achieved Yes 5 (23.8) No 16 (76.2) Value of last HbA1c measurement Mean 7.04

203 (38.8) 44 (34.1) 320 (61.2) 85 (65.9)

252 (37.4) 421 (62.6)

8.12

8.76

8.27

387 (74.0) 136 (26.0)

71 (54.6) 59 (45.4)

471 (69.9) 203 (30.1) 225 (36.1) 399 (63.9) 4.2 (3.5) 3.0

168 (34.6) 49 (41.2) 317 (65.4) 70 (58.8) 4.1 (3.3) 4.3 (3.9) 3.0 7.0

105 (60.7) 68 (39.3) 332 (95.4) 16 (4.6)

23 (47.9) 25 (52.1) 96 (98.0) 2 (2.0)

129 (57.6) 95 (42.4) 446 (96.1) 18 (3.9)

sufferers. Only less than 35% of patients had a formal work, furthermore almost 10% of them had to take sick leave due to diabetes. (See table 4 for details). Success rate of the diabetic treatment is measured by achievement of HbA1c target less than 7%. This value was refered to international diabetes societies (ADA, EASD) which have made global recommendations aiming to achieve optimal levels of glycaemic control. The HbA1c average was 8.27% and only 37.4% had reached the HbA1c target of <7%. The OGLD-only-treated groups achieved better HbA1c level compare to insulin-treated group. (See table 5 for details) Discussion
Table 4. Distribution of Subjects Based on Working Productivity and Hospitalization Variable Type 2 Lifestyle OGLD Insulin + modification

Total

Working productivity Unemployed 13 (61.9) Normal work 8 (38.1) Sick leave 0 Unable to work 0 Hospitalized Yes 2 (12.5) No 14 (87.5) Mean (SD) 2.5 (2.1) Median 1.0

283 (54.2) 195 (37.4) 32 (6.1) 12 (2.3)

63 (48.5) 31 (23.8) 32 (24.6) 4 (2.3)

359 234 64 16

(53.3) (34.8) (9.5) (2.4)

41 (12.5) 26 (28.0) 288 (87.5) 67 (72.0) 1.2 (0.4) 1.0 (0.2) 1.0 2.5

69 (15.8) 369 (84.2) 1.1 (0.5) 1.0

Indonesia is entering the epidemiological transition period, many degenerative diseases have recently showed significant increases. The latest national household survey in 2007 reported that the incidence of diabetes in Indonesia had increased. The Indonesian national prevalence of diabetes was 5.7%, but 73.7% of them were undiagnosed.8 Previous study on diabetes care in Indonesia was the DiabCare Asia study series. The latest DiabCare study (n=1785) was in 2008. It was a cross sectional, hospital based study involving 18 hospitals from all around Indonesia; performed a collection of data on demography, diabetes status, management and complications. 9 IDMPS, an international study on diabetes management practice, was a cross sectional and a longitudinal study which mostly done in private practice. The IDMPS recorded resource use associated with type 2 diabetes in such a wide range using a standardized protocol in developing countries in Asia, Latin America and the Middle East and Africa. 10 Consequently our study could add significant information regarding the quality of existing diabetes care in Indonesia. Based on demographic characteristics, various epidemiological studies reported that women have a slightly higher risk of contracting diabetes.11 Not surprisingly, this study has recruited a little bit more female type-2 diabetes patients compared to male patients (54.6% vs 45.4%). This finding supported the basic health research finding in 2007 which reported that the prevalence of diabetes in female and male were 6.4% and 4.9% respectively. The mean age of IDMPS study patients was 55.2 (SD 10.2) years old, quite high, given the life expectancy in the developing world. Furthermore, only 6.4% were aged less than 40 years old. Nevertheless, most patients (76.7%) were in 40-65 years old age group, younger than in the developed countries. This finding is in concordance with the finding from the basic health survey in 2007, which showed that the diabetes prevalence in that age group was between 10.5%-13.5%. The DiabCare study found the mean age of diabetes patients was 58.91 (SD 9.74) years old.10 Genetic trait might play important role among Indonesian diabetics. Most subjects (59.7%) reported to have family history of diabetes. Genetic susceptibility was also reported as one of risk factor for increasing diabetes preva-

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Current Practice in the Management of Type 2 Diabetes in Indonesia lence in Asia. Chan et al12 reported that cigarette smoking was one of risk factors for the increasing diabetes prevalence in Asia.12 This study found 5.9% and 11% of patients were active smokers and ex smokers respectively, which was lower than national figure of smokers (45.8% of adult male population).13 Obesity is also confirmed as a common risk factor for diabetes in Asia.11 This study found that 34.3% and 9.7% of diabetes patients were overweight and obese respectively. The mean of BMI was 24.8 (SD 4) kg/m2, and the mean waist circumference was 89.0 (SD 11.5) cm. The DiabCare study reported lower mean BMI, which was 23.4 kg/m2. This study found high HbA1c level (8.3%) and high fasting glucose level (170.3 mg/dL). These findings were in line with the DiabCare study, who reported HbA1c level of 8.1% and fasting blood glucose of 142.2 mg/dL. The OGLDonly treated groups achieved better HbA1c level compare to insulin-treated group. This might be caused by the bias of indication, in which patients with better glycemic control were still given the OGLD, while patients with worse glycemic control were switched to insulin regimen or were given insulin from the start. In addition, there might be a lack of optimal insulin titration in the real life setting. The DiabCare study reported that the mean of SBP was 131.4 (SD18.1) mmHg. There were 57.4% of patients received anti hypertension medication. Our study reported the same finding that the mean of SBP was 132.6 (SD 20.5) mmHg. Nevertheless our study reported lower percentage of hypertension treatment, 47.6% had hypertension, 44.3% received treatment, while 3.3% without treatment. The DiabCare study reported that there were 54% and 14.1% of patients had LDL and TG above target respectively. In addition, 11.3% male and 21.1% female had HDL above target. Among those patients, 34% of them received lipid lowering treatment. 10 Our study reported 53.5% patients with dyslipidemia, but only 44% received treatment while 9.5% were without treatment. These findings show us that the metabolic control of diabetic patients were not good enough to prevent diabetic chronic complications. In all countries of Asia region including China, Hong Kong, Indonesia, India, South Korea, Malaysia, Taiwan and Thailand, the presence of microvascular complications (47%) was also identified as a significant predictor of resource use, but to a lesser extent than macrovascular complications (20%).14 Our study found microvascular complications, such as neuropathy, retinopathy and nephropathy, more often than the macrovascular complications. This finding supports previous findings on the DiabCare study. Our study reported that neuropathic symptoms are frequent initial causes of medical consultation that lead to diagnosis. Therefore neuropathy was the most prevalent diabetic complication among subjects in Indonesia followed by retinopathy, and nephropathy. Our study also found that the rate of screening for diaJ Indon Med Assoc, Volum: 61, Nomor: 12, Desember 2011

betic complications were still low, the same finding from the DiabCare study. Diabetes management needs an implementation of strategies of prevention or delay of macro- and microvascular complications and adequate control of hyperglycaemia. Our study reported that diabetes caused 9.5% of sick leave 2.4% loss of employment. Diabetes also caused hospitalization in 15.8% of patients. These two findings suggested that diabetes is associated with a significant amount of direct and indirect expenses. The substantial impact of complications on resource use clearly provides an economic rationale for concerted efforts for earlier diagnosis and implementation of appropriate treatment, considering that most Indonesian diabetic cases were undiagnosed. In addition, for prevention of further complications, we need to perform diabetic complications screening among all diabetic patients. 15 Most of the type-2 diabetes cases in this study were treated by GPs/internists. Nevertheless, the patients who were treated by endocrinologist were more likely to visit the physicians frequently. This findings might be explained by the fact that most of the patients who visited endocrinologist had already had advanced diabetes, been given complex treatment regimen and insulin therapy. The Indonesian GPs/internists preferred to prescribe their diabetic patients with OGLD that is much simpler compared to the use of insulin. On the other hand, the endocrinologists tend to be more courageous to try various regimen types. They prescribed insulin for some of type-2 diabetes patients with or without OGLD. In ensuring that diabetes patients will comply with their life time medication, education session was organized by specially trained diabetes educators during their clinic visits. The diabetes educator provided important information about the disease, the need for life time medication, and trained the patients in managing the disease properly. Patients who were only prescribed OGLD got the least education session compared to those relied to insulin or those were given only lifestyle modification. 16 The endocrinologists have more contacts with the diabetes patients for the last three months compared with the GPs/internists, especially among the type-2 diabetes patients who relied on lifestyle modification. The GPs/internists have been visited more by type-2 diabetes patients who used only OGLD as their treatment. However, the average of last HbA1c in this study was 8.27% and among all patients, it appeared that only 37.4% of type-2 diabetes patients reached the target value of HbA1c less than 7%. It was lower than China which has the highest number (44%) of patients reached the target value of HbA1c in Asia, followed by South Korea (40%).12 IDMPS demonstrated that a minority of patients meet glycemic targets. As reported in regions in the world, lack of glycemic control was a strong predictor of resource use, with patients not at guideline-recommended HbA1c target significantly more likely to
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Current Practice in the Management of Type 2 Diabetes in Indonesia consume healthcare resources. 12 The highest number (58%) of patients reached glycemic control was achieved in Panama, meanwhile Egypt achieved the lowest number (16%).12 The DiabCare study (n=1785) in 2008, a hospital based study involving 18 hospitals from all around Indonesia, reported that only 34.45% of diabetic patients reach the A1c target less than 7%. Our study showed that the mean of HbA1c levels were different across treatment regiment, in which the A1c level were lowest among lifestyle modification group and highest among insulin group. Nevertheless, the proportion of subjects achieved the A1c target was highest among OGLD group and lowest among lifestyle modification group. Nevertheless, lifestyle modification is the basic foundation in diabetes management. Lifestyle modifications should be implemented across all diabetes treatment regiments to achieve glycemic control and to prevent diabetic complications. Finally, Diabetes is a chronic health condition with comorbidities and it is also associated with micro and macrovascular complications. We can learn from this study that diabetes lead to a huge resource use and also associated with significant direct and indirect cost.17 These consequences could be reduced through early diagnosis, prompt treatment, effective metabolic control and screening for diabetic complications. Even we have already had type 2 diabetes guidelines since 1993, nevertheless the comprehensive management of type 2 diabetes in Indonesia was not as we expected. Our study showed that we still need to improve quality of diabetes care in Indonesia. An integrated public health approach and family medicine approach are crucial to raise awareness of the wide reaching economic consequences of diabetes-related complications, to increase family support and participation, to educate patients and healthcare workers and to allocate appropriate resources for disease management. Conclusion In Indonesia, the majority of type-2 diabetic patients were treated by GPs/internists. Most patients were given OGLD alone. The average HbA1c in this study was high and the majority of patients did not attain the recommended glycemic target. This indicates the presence of a gap between recommendations of most recent guidelines and the actual practices. An integrated public health and family medicine approach are crucial in improving quality of diabetes care in Indonesia. Acknowledgement The author is especially grateful to all investigators who have participated in IDMPS study: Prof. Dr. Askandar Tjokroprawiro, SpPD, KEMD. Prof. Dr. RR Djokomoeljanto, SpPD, KEMD. Prof. DR. Dr. Karel Pandelaki, SpPD.KEMD, Prof. Dr. Ketut Suastika, SpPD. KEMD, Prof. DR. Dr. Agung
480

Pranoto, SpPD. KEMD, Prof. DR. Dr. Djoko Hardiman, SpPD. KEMD, Prof. Dr. Asman Manaf, SpPD. KEMD, Prof. Dr. Syafril Syahbuddin, SpPD. KEMD, Dr. K. Heri Nugroho, SpPD. KEMD, Dr. Aris Wibudi, SpPD. KEMD, Dr. Ida Ayu Kshanti, SpPD. KEMD, Dr. Wira Gotera, SpPD. KEMD, Dr. Sony Wibisono, SpPD. KEMD, Dr. Dharma Lindarto, SpPD. KEMD, Dr. Gatut Semiardji, SpPD. KEMD, Dr. Roy P. Sibarani, SpPD. KEMD, Dr. Alwi Shahab, SpPD. KEMD, Dr. Tony Suhartono, SpPD. KEMD, Dr. Sri Murtiwi, SpPD. KEMD, Dr. Mardianto, SpPD. KEMD, Dr. Tjokorda Gde Pemayun, SpPD. KEMD, Dr. Zulfahmi Wahab, SpPD, Dr. Nono Matarungan, SpPD, Dr. Dedy K.Kurniawan, SpPD, Dr. ND Pangesti, SpPD,Dr. Tuty Kuswardhani, SpPD. KGer, Dr. Ratna Saraswati, SpPD, Dr. Suroto Lim, SpPD, Dr. Marwani Bratasaputra, SpPD, Dr. Maria Riastuti, SpPD, Dr. Eva Decroli, SpPD, Dr. Irfani Riza, SpPD, Dr. Imam Faturakhman, SpPD, Dr. Paul Harijanto, SpPD, Dr. Ratni Rahim, SpPD, Dr. Yuanita Langi, SpPD, Dr. Hadi Sulistyanto, SpPD, Dr. Eddy Prijambodo, SpPD, Dr. Jerahim Tarigan, SpPD, Dr. Luthfan B.Purnomo, SpPD, Dr. Rizky Perdana, SpPD, Dr. Abdullah Ammarie, SpPD, Dr. Zuhrial Zubir, SpPD, Dr. Imam Suprianto, SpPD, Dr. Sapto Priatmo, SpPD, Dr. Dasril Effendi, SpPD, Dr. Sunu Sugiyanto, SpPD, Dr. Kuntjoro Yakti, SpPD, Dr. Budi Santoso, SpPD, Dr. Sulistyawati Ohnio, SpPD, Dr. Pendrik Tandean, SpPD, Dr. Zulkhair Ali, SpPD. KGH, Dr. Bimanesh Sutarjo, SpPD. KGH, Dr. Abdurrahim Lubis, SpPD. KGH, Dr. Anton Cahaya, Dr. Budi Ikhwansyah, Dr. Ervin Tampubolon, Dr. Gunawan Arsyadi, Dr. Atyah Rasyid, Dr. G. Kunar Abadi, Dr. Davis Ajiaribowo, Dr. Zulkarnaen, Dr. Sutrisno, Dr. Jalil Alfani, Dr. Djoko Rahardjo, Dr. Sulhani Nurul Aini, Dr. Husaini Umar. References
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