National Taiwan University Hospital Diabetes Care Team
A leading academic diabetes program in Taiwan built on multidisciplinary integration, smart medicine, and patient-centered continuity of care
Diabetes is not a disease managed by glucose numbers alone. High quality diabetes care requires coordinated control of glycemia, cardiovascular risk, kidney disease, eye complications, neuropathy, peripheral vascular disease, inpatient safety, and increasingly, liver-metabolic risk. For readers unfamiliar with National Taiwan University Hospital, the defining strength of its diabetes care program is that it functions not as a single clinic, but as a hospital-wide, multidisciplinary platform that integrates physicians, diabetes educators, nurses, dietitians, pharmacists, case managers, social workers, information specialists, laboratory medicine, and quality management into one coordinated model of care. This structure allows NTUH to deliver continuous care across outpatient, inpatient, education, screening, follow-up, and innovation pathways.
NTUH has a long standing foundation in diabetes care. According to the hospital’s official webpage, the hospital established a “Diabetes Health Promotion Institute (DHPI)” in 1991, later renamed as a diabetes health promotion institution, with the goal of strengthening diabetes education and self management support for patients and families. The diabetes education group is supported by the Department of Internal Medicine, Department of Nursing, Department of Nutrition, and Department of Pharmacy, and is also part of the Taipei Diabetes Shared Care Network. NTUH currently provides outpatient care to more than 28,000 patients with diabetes annually, reflecting both large-scale service capacity and decades of accumulated clinical experience.
From an organizational perspective, NTUH has built an institutional governance model for diabetes care. Based on the hospital’s diabetes disease-care certification self-assessment materials, the program is supported at the vice superintendent level for hospital wide coordination and resource integration, while we oversee clinical planning, quality improvement, education, and research. The team conducts quarterly core team meetings, monthly “difficult case” conferences, continuous glucose monitoring case reviews, insulin pump discussions, and weekly academic conferences. This means the NTUH diabetes program is not simply a service line; it is a structured quality system with leadership accountability, data review, and continuous improvement.
In terms of workforce and expertise, NTUH demonstrates the breadth expected from a top academic medical center. The core team includes 13 endocrinologists, 3 nephrologists, 4 cardiologists, 7 certified diabetes educators, 11 dietitians, and 3 pharmacists. In addition, more than 600 other healthcare professionals participate in diabetes-related care processes across emergency medicine, surgery, ophthalmology, neurology, family medicine, geriatrics, anesthesiology, imaging, laboratory medicine, and obstetrics and gynecology. All core members hold relevant professional licenses and have completed Shared Care Network certification and/or Certified Diabetes Educator credentials. This extensive staffing model supports both high-volume care and rapid multidisciplinary consultation.
One of NTUH’s most important strengths is its one-stop complication screening and integrated risk assessment model. Team members are trained in non-mydriatic fundus photography, peripheral vascular and neuropathy assessment, and interpretation of continuous glucose monitoring data. As a result, complication screening, metabolic review, and treatment adjustment can be incorporated into a unified care pathway rather than fragmented across isolated visits. For patients, this translates into fewer delays, better coordination, and earlier identification of high-risk conditions.
Quality improvement at NTUH is strongly data-driven. The team reviews hemoglobin A1c performance, Shared Care Network enrollment, and key process indicators every quarter together with the hospital’s quality management unit. According to the 2026 annual work plan, targeted indicators include Shared Care Network enrollment of 42% under the National Health Insurance Administration benchmark, or 22% under certification standards, retinal screening of 40%, urine microalbumin testing of 70%, lipid testing of 80%, and HbA1c testing of 95%. In disclosed 2025 performance data, urine microalbumin testing reached about 70.82%, and HbA1c/glycated albumin monitoring reached about 92.06%, showing that the program not only defines measurable targets but also systematically tracks performance gaps and implements corrective strategies.
NTUH also extends diabetes care beyond traditional glucose management into inpatient safety and emerging comorbidity prevention. The hospital has collaborated with pharmacy, quality management, and information services to build a perioperative SGLT2 inhibitor alert system designed to reduce the risk of diabetic ketoacidosis in patients who should discontinue these agents before surgery. In parallel, the team has proposed and advanced an FIB-4 alert system aligned with the ADA 2025 Standards of Care to help identify patients with type 2 diabetes at risk for MASLD related liver fibrosis. The system is designed to trigger risk-based recommendations such as hepatology referral, FibroScan evaluation, interval FIB-4 score follow-up, and consideration of glucose-lowering therapies with evidence for MASLD benefit. These initiatives show how NTUH is using digital tools to move from reactive diabetes management toward proactive whole-person metabolic risk control.
For inpatients, NTUH has introduced an inpatient diabetes education consultation service. Patients newly diagnosed with diabetes, requiring insulin, or experiencing poor control can be proactively seen by diabetes educators for medication instruction, self-management education, and post-discharge referral into the shared-care system. In the outpatient setting, shared decision-making for injectable therapies is also being actively implemented. Hospital materials show that from January to November 2025, 336 patients received documented education for first-time injectable therapy use. This illustrates NTUH’s emphasis on therapeutic adoption, self-care competence, and continuity across settings.
Education and social impact are also central to the NTUH model. The hospital has developed 13 themed digital diabetes courses and requires team members to complete at least four hours of diabetes-related training annually. New staff are expected to obtain relevant Shared Care Network and diabetes educator qualifications within defined timeframes. Beyond hospital staff development, NTUH supports the training of diabetes educators, shared-care professionals, and medical students from both within and outside the institution. It also organizes World Diabetes Day events, youth camps, patient support clubs, and group education activities, extending the program from tertiary medical care into public education and community empowerment.
The Joint Commission of Taiwan lists National Taiwan University Hospital among certified institutions for disease-specific diabetes care. For external audiences, this matters because it signals that NTUH’s diabetes program is not only large and experienced, but also externally recognized, quality-assured, and continuously improving. With an annual outpatient volume exceeding 28,000 patients, a multidisciplinary network involving more than 600 healthcare professionals, and forward-looking digital systems such as SGLT2i and FIB-4 score alerts, the NTUH Diabetes Care Team represents a highly developed academic diabetes care model in Taiwan and Asia, combining clinical depth, organizational coordination, innovation, and patient centered continuity.