Diabetes melitus tipe 2 (DMT2) dengan komplikasi merupakan salah satu tantangan utama pelayanan kesehatan di rumah sakit rujukan tersier karena bersifat kronis, kompleks, dan membutuhkan pelayanan berkesinambungan lintas disiplin. Rumah Sakit Prof. dr. I G.N.G. Ngoerah, Bali (RS Ngoerah) sebagai rumah sakit rujukan nasional menghadapi tuntutan untuk tidak hanya menyediakan layanan klinis lanjutan, tetapi juga memastikan mutu, efisiensi, dan kesinambungan pelayanan melalui tata kelola yang kuat dan terintegrasi. Penelitian ini bertujuan mengembangkan governansi klinis pelayanan kronis terintegrasi bagi pasien DMT2 dengan komplikasi di Poliklinik RS Ngoerah, agar pelayanan berkesinambungan dan berkualitas. Penelitian menggunakan pendekatan mixed methods dengan kerangka analisis Teori Donabedian (struktur/input–proses–outcome/output) serta prinsip governansi klinis dan pelayanan penyakit kronis. Data diperoleh melalui analisis dokumen, survei, dan wawancara mendalam dengan berbagai pemangku kepentingan layanan. Hasil penelitian menunjukkan bahwa secara struktural RS Ngoerah telah memiliki sumber daya manusia, fasilitas, dan layanan subspesialistik yang memadai. Namun, keunggulan struktur tersebut belum sepenuhnya diikuti oleh proses pelayanan yang terintegrasi dan berkesinambungan. Pelayanan pasien DMT2 dengan komplikasi masih didominasi pendekatan episodik, terfragmentasi antar unit, serta belum didukung oleh alur pelayanan kronis terintegrasi, sistem rujuk balik yang efektif, dan pemanfaatan data klinis longitudinal secara optimal. Ketidakselarasan antara struktur/input, proses, dan outcome/output ini berdampak pada belum optimalnya efektivitas layanan, efisiensi biaya, dan pengalaman pasien. Analisis tata kelola menunjukkan bahwa interaksi unsur man, machine, dan method belum berjalan secara sinergis. Kompetensi tenaga kesehatan yang tinggi belum sepenuhnya didukung oleh sistem informasi terintegrasi dan metode pelayanan kronis yang baku. Dari perspektif availability, affordability, dan accessibility, layanan komprehensif tersedia secara klinis, namun masih terdapat hambatan dalam akses berkelanjutan dan kesesuaian pembiayaan dengan kebutuhan pelayanan kronis jangka panjang. Berdasarkan temuan tersebut, penelitian ini merekomendasikan pengembangan model governansi klinis pelayanan kronis terintegrasi yang menekankan integrasi struktur/input–proses–outcome/output, penguatan kepemimpinan klinis, standarisasi alur pelayanan kronis lintas unit, pemanfaatan sistem informasi klinis terintegrasi, serta mekanisme evaluasi berbasis outcome klinis dan pengalaman pasien dalam bentuk unit pelayanan diabetes terpadu (diabetes integrated care unit). Model ini diharapkan mampu meningkatkan efektivitas, efisiensi, dan kesinambungan pelayanan pasien DMT2 dengan komplikasi di RS Ngoerah Bali, sekaligus menjadi rujukan penguatan tata kelola pelayanan penyakit kronis di rumah sakit rujukan lainnya.

Type 2 diabetes mellitus (T2DM) with complications represents one of the major challenges in healthcare delivery at tertiary referral hospitals due to its chronic nature, clinical complexity, and the need for continuous, multidisciplinary care. Prof. dr. I G.N.G. Ngoerah Hospital, Bali (Ngoerah Hospital), as a national referral hospital, is therefore required not only to provide advanced clinical services but also to ensure the quality, efficiency, and continuity of care through a robust and integrated governance framework. This study aimed to develop an integrated chronic care governance model for patients with T2DM and complications attending the outpatient clinics of Ngoerah Hospital, Bali, in order to support high-quality and continuous care delivery. A mixed-methods approach was employed, guided by the Donabedian framework (structure/input–process–outcome/output) and informed by principles of clinical governance and chronic disease management. Data were collected through document review, surveys, and in-depth interviews with key healthcare stakeholders. The findings indicate that, from a structural perspective, Ngoerah Hospital has adequate human resources, facilities, and subspecialty services to support comprehensive diabetes care. However, these structural strengths have not been fully translated into integrated and continuous care processes. Care for patients with T2DM and complications remains predominantly episodic, fragmented across service units, and insufficiently supported by integrated chronic care pathways, effective referral-back mechanisms, and optimal use of longitudinal clinical data. This misalignment between structure/input, process, and outcomes/output has contributed to suboptimal service effectiveness, cost efficiency, and patient experience. Governance analysis further reveals that the interaction among the elements of manpower, machinery, and methods has not yet functioned synergistically. While healthcare professionals demonstrate a high level of clinical competence, this capacity is not adequately supported by integrated health information systems and standardized chronic care methods. From the perspectives of availability, affordability, and accessibility, comprehensive services are clinically available; however, barriers persist in ensuring sustained access and alignment between financing mechanisms and the long-term needs of chronic care. Based on these findings, this study recommends the development of an integrated chronic care governance model that emphasizes alignment across structure, process, and outcomes; strengthens clinical leadership; standardizes multidisciplinary chronic care pathways; optimizes the use of integrated clinical information systems; and implements evaluation mechanisms based on clinical outcomes and patient experience, as in diabetes integrated care unit. Such a model is expected to enhance the effectiveness, efficiency, and continuity of care for patients with T2DM and complications at Ngoerah Hospital, while also serving as a reference for strengthening chronic disease care governance in other tertiary referral hospitals.

Background: Type 2 diabetes mellitus (T2DM) is a non-communicable disease with one of the highest health burdens in Indonesia, with prevalence nearly doubling over a decade, from 6.9% (2013) to 11.7% (2023), placing Indonesia as the country with the fifth-highest number of diabetes patients in the world (20.4 million in 2024). T2DM patients face a threefold higher risk of cardiovascular disease and a tenfold higher risk of kidney disease, with complication-related costs accounting for approximately 74% of total direct medical costs covered by BPJS Kesehatan. The effectiveness of prevention programs such as Prolanis depends heavily on understanding the factors that accelerate complication onset. Therefore, this study aimed to determine the survival of T2DM patients enrolled in the National Health Insurance (JKN) program with respect to complication onset, along with its associated determinants. Methods: This study used BPJS Kesehatan Sample Data from 2020, employing a retrospective closed-cohort design with an observation period of 2020–2025. Analyses were conducted using the Kaplan-Meier method and Cox Proportional Hazard regression. Results: Of 2,704 T2DM patients included in the study, 54.1% experienced complications, with a 4-year survival rate of 0.473 (95% CI: 0.45–0.49) and a median time-to-event of 3.639 years. The Kaplan-Meier and log rank analysis found out that age at diagnosis (p = 0,041), hypertension (p < 0,0001), and dyslipidemia (p < 0,0001) variables significantly differs the time of complication onset among T2DM patients. Based on the Cox Proportional Hazard analysis, factors that significantly accelerated complication onset were having hypertension (aHR=1,370; 95% CI: 1,231–1,525) and having dyslipidemia (aHR=1,522; 95% CI: 1,363–1,647), while being ≥65 of age when first diagnosed is a protective factor (aHR=0,868; CI: 0,771 – 0,978). Conclusion: Survival from complications among JKN-enrolled T2DM patients in Indonesia remains relatively low, with hypertension and dyslipidemia as the main determinants. Comprehensive efforts to prevent and manage these comorbidities are therefore needed, including through optimized risk stratification within the Prolanis program. Keywords: Type 2 Diabetes Mellitus, Survival Analysis, Complications, National Health Insurance, BPJS Sample Data

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Latar belakang: Diabetes melitus (DM) tipe 2 merupakan penyakit tidak menular dengan beban kesehatan tertinggi di Indonesia, dengan prevalensi yang meningkat hampir dua kali lipat dalam satu dekade, dari 6,9% (2013) menjadi 11,7% (2023), serta menempatkan Indonesia sebagai negara dengan jumlah penderita diabetes tertinggi kelima di dunia (20,4 juta jiwa pada 2024). Penderita DM tipe 2 menghadapi risiko tiga kali lebih tinggi mengalami penyakit kardiovaskular dan sepuluh kali lebih tinggi mengalami penyakit ginjal, dengan beban biaya komplikasi yang mencakup sekitar 74% dari total biaya medis langsung yang ditanggung BPJS Kesehatan. Efektivitas program pencegahan seperti Prolanis sangat bergantung pada pemahaman mengenai faktor-faktor yang mempercepat terjadinya komplikasi. Oleh karena itu, penelitian ini dilakukan untuk mengetahui kesintasan komplikasi pasien DM tipe 2 peserta Jaminan Kesehatan Nasional (JKN) beserta faktor-faktor yang memengaruhinya. Metode: Penelitian ini menggunakan Data Sampel BPJS Kesehatan tahun 2020 dengan desain studi kohort tertutup retrospektif dan masa pengamatan pada 2020—2025. Analisis dilakukan menggunakan metode Kaplan-Meier dan uji Cox Proportional Hazard. Hasil: Dari 2.704 pasien DM tipe 2 yang diikutsertakan, terdapat 54,1% kejadian komplikasi, dengan 4-year survival rate sebesar 0,473 (95% CI: 0,45–0,49) dan median time-to-event 3,639 tahun. Pada faktor sosiodemografi, faktor usia saat diagnosis secara signifikan memengaruhi survival rate (p = 0,041) walau perlu diinterpretasikan dengan kehati-hatian. Pada faktor klinis, pasien DM tipe 2 dengan hipertensi (p < 0,0001) dan dislipidemia (p < 0,0001) secara signifikan memiliki 4-year survival rate lebih rendah. Berdasarkan analisis multivariat, faktor yang secara signifikan mempercepat kejadian komplikasi hipertensi (aHR=1,370; 95% CI: 1,231–1,525), dislipidemia (aHR=1,522; 95% CI: 1,363–1,647), sedangkan berumur ≥65 saat diagnosis (aHR=0,868; CI: 0,771 – 0,978) merupakan faktor protektif. Kesimpulan: Kesintasan komplikasi pasien DM tipe 2 peserta JKN di Indonesia masih tergolong rendah, dengan hipertensi dan dislipidemia sebagai determinan utama. Oleh karena itu, diperlukan penguatan upaya pencegahan dan pengendalian komorbiditas secara komprehensif, salah satunya melalui optimalisasi stratifikasi risiko dalam program Prolanis. Kata kunci: Diabetes Melitus Tipe 2, Analisis Kesintasan, Komplikasi, Jaminan Kesehatan Nasional (JKN), Data Sampel BPJS Kesehatan