Association of technologically assisted integrated care with clinical outcomes in type 2 diabetes in Hong Kong using the prospective JADE Program: A retrospective cohort analysis

Autoři: Lee-Ling Lim aff001;  Eric S. H. Lau aff001;  Risa Ozaki aff001;  Harriet Chung aff002;  Amy W. C. Fu aff002;  Wendy Chan aff004;  Alice P. S. Kong aff001;  Ronald C. W. Ma aff001;  Wing-Yee So aff006;  Elaine Chow aff001;  Kitty K. T. Cheung aff001;  Tiffany Yau aff001;  C. C. Chow aff001;  Vanessa Lau aff002;  Rebecca Yue aff004;  Shek Ng aff007;  Benny Zee aff007;  William Goggins aff007;  Brian Oldenburg aff008;  Philip M. Clarke aff009;  Maggie Lau aff010;  Rebecca Wong aff001;  C. C. Tsang aff010;  Edward W. Gregg aff011;  Hongjiang Wu aff001;  Peter C. Y. Tong aff004;  Gary T. C. Ko aff001;  Andrea O. Y. Luk aff001;  Juliana C. N. Chan aff001
Působiště autorů: Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China aff001;  Asia Diabetes Foundation, Shatin, Hong Kong SAR, China aff002;  Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia aff003;  Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China aff004;  Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China aff005;  Hospital Authority Head Office, Hong Kong SAR, China aff006;  Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China aff007;  Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia aff008;  Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom aff009;  Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong SAR, China aff010;  School of Public Health, Imperial College London, London, United Kingdom aff011
Vyšlo v časopise: Association of technologically assisted integrated care with clinical outcomes in type 2 diabetes in Hong Kong using the prospective JADE Program: A retrospective cohort analysis. PLoS Med 17(10): e1003367. doi:10.1371/journal.pmed.1003367
Kategorie: Research Article



Diabetes outcomes are influenced by host factors, settings, and care processes. We examined the association of data-driven integrated care assisted by information and communications technology (ICT) with clinical outcomes in type 2 diabetes in public and private healthcare settings.

Methods and findings

The web-based Joint Asia Diabetes Evaluation (JADE) platform provides a protocol to guide data collection for issuing a personalized JADE report including risk categories (1–4, low–high), 5-year probabilities of cardiovascular-renal events, and trends and targets of 4 risk factors with tailored decision support. The JADE program is a prospective cohort study implemented in a naturalistic environment where patients underwent nurse-led structured evaluation (blood/urine/eye/feet) in public and private outpatient clinics and diabetes centers in Hong Kong. We retrospectively analyzed the data of 16,624 Han Chinese patients with type 2 diabetes who were enrolled in 2007–2015. In the public setting, the non-JADE group (n = 3,587) underwent structured evaluation for risk factors and complications only, while the JADE (n = 9,601) group received a JADE report with group empowerment by nurses. In a community-based, nurse-led, university-affiliated diabetes center (UDC), the JADE-Personalized (JADE-P) group (n = 3,436) received a JADE report, personalized empowerment, and annual telephone reminder for reevaluation and engagement. The primary composite outcome was time to the first occurrence of cardiovascular-renal diseases, all-site cancer, and/or death, based on hospitalization data censored on 30 June 2017. During 94,311 person-years of follow-up in 2007–2017, 7,779 primary events occurred. Compared with the JADE group (136.22 cases per 1,000 patient-years [95% CI 132.35–140.18]), the non-JADE group had higher (145.32 [95% CI 138.68–152.20]; P = 0.020) while the JADE-P group had lower event rates (70.94 [95% CI 67.12–74.91]; P < 0.001). The adjusted hazard ratios (aHRs) for the primary composite outcome were 1.22 (95% CI 1.15–1.30) and 0.70 (95% CI 0.66–0.75), respectively, independent of risk profiles, education levels, drug usage, self-care, and comorbidities at baseline. We reported consistent results in propensity-score–matched analyses and after accounting for loss to follow-up. Potential limitations include its nonrandomized design that precludes causal inference, residual confounding, and participation bias.


ICT-assisted integrated care was associated with a reduction in clinical events, including death in type 2 diabetes in public and private healthcare settings.

Klíčová slova:

Cancer risk factors – diabetes mellitus – Hospitalizations – Chronic kidney disease – Patients – Physicians – Type 2 diabetes – Type 2 diabetes risk


1. Chan JC, Gregg EW, Sargent J, Horton R. Reducing global diabetes burden by implementing solutions and identifying gaps: a Lancet Commission. Lancet 2016;387:1494–1495 doi: 10.1016/S0140-6736(16)30165-9 27061676

2. Raz I, Riddle MC, Rosenstock J, Buse JB, Inzucchi SE, Home PD, et al. Personalized management of hyperglycemia in type 2 diabetes: reflections from a Diabetes Care Editors’ Expert Forum. Diabetes Care 2013;36:1779–1788 doi: 10.2337/dc13-0512 23704680

3. Manne-Goehler J, Geldsetzer P, Agoudavi K, Andall-Brereton G, Aryal KK, Bicaba BW, et al. Health system performance for people with diabetes in 28 low- and middle-income countries: A cross-sectional study of nationally representative surveys. PLoS Med 2019;16:e1002751 doi: 10.1371/journal.pmed.1002751 30822339

4. Luk AOY, Hui EMT, Sin MC, Yeung CY, Chow WS, Ho AYY, et al. Declining Trends of Cardiovascular-Renal Complications and Mortality in Type 2 Diabetes: The Hong Kong Diabetes Database. Diabetes Care 2017;40:928–935 doi: 10.2337/dc16-2354 28490423

5. Dzau VJ, McClellan MB, McGinnis JM, Burke SP, Coye MJ, Diaz A, et al. Vital Directions for Health and Health Care: Priorities From a National Academy of Medicine Initiative. JAMA 2017;317:1461–1470 doi: 10.1001/jama.2017.1964 28324029

6. Wilson ML, Fleming KA, Kuti MA, Looi LM, Lago N, Ru K. Access to pathology and laboratory medicine services: a crucial gap. Lancet 2018;391:1927–1938 doi: 10.1016/S0140-6736(18)30458-6 29550029

7. Khunti K, Wolden ML, Thorsted BL, Andersen M, Davies MJ. Clinical inertia in people with type 2 diabetes: a retrospective cohort study of more than 80,000 people. Diabetes Care 2013;36:3411–3417 doi: 10.2337/dc13-0331 23877982

8. Lim LL, Lau ESH, Kong APS, Davies MJ, Levitt NS, Eliasson B, et al. Aspects of Multicomponent Integrated Care Promote Sustained Improvement in Surrogate Clinical Outcomes: A Systematic Review and Meta-analysis. Diabetes Care 2018;41:1312–1320 doi: 10.2337/dc17-2010 29784698

9. Ko GT, Yeung CY, Leung WY, Chan KW, Chung CH, Fung LM, et al. Cost implication of team-based structured versus usual care for type 2 diabetic patients with chronic renal disease. Hong Kong Med J 2011;17 Suppl 6:9–12 22147352

10. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health 2018;6:e1196–e1252 doi: 10.1016/S2214-109X(18)30386-3 30196093

11. Chan JCN, Lim LL, Luk AOY, Ozaki R, Kong APS, Ma RCW, et al. From Hong Kong Diabetes Register to JADE Program to RAMP-DM for Data-Driven Actions. Diabetes Care 2019;42:2022–2031 doi: 10.2337/dci19-0003 31530658

12. OECD (2015), Fiscal Sustainability of Health Systems: Bridging Health and Finance Perspectives, OECD Publishing, Paris.

13. Health facts of Hong Kong. 2018 Edition. Department of Health, Hong Kong Special Administrative Region Government. [cited 2019 July 21].

14. World development indicators—GDP per capita (current US$). World Bank national accounts data and OECD National Accounts data files. [cited 2020 May 18].

15. Median monthly domestic household income of economically active households by household size (2019 Edition). General Household Survey, Census and Statistics Department, The Government of the Hong Kong Special Administrative Region. [cited 2020 May 18].

16. Hong Kong Hospital Authority. Hospital Authority Annual Report 2017–2018, 2018. [cited 2019 July 29].

17. Office for National Statistics. UK Health Accounts: 2016. Released date 25 April 2018. [cited 2019 Oct 16].

18. Hong Kong’s Domestic Health Accounts. Estimates of Health Expenditure, 1989/90–2017/18 (SHA 2011), Food and Health Bureau, The Government of the Hong Kong Special Administrative Region. [cited 2020 May 18].

19. Wu H, Lau ESH, Ma RCW, Kong APS, Wild SH, Goggins W, et al. Secular trends in all-cause and cause-specific mortality rates in people with diabetes in Hong Kong, 2001–2016: a retrospective cohort study. Diabetologia 2020;63(4):757–66 doi: 10.1007/s00125-019-05074-7 31942668

20. Chan J, So W, Ko G, Tong P, Yang X, Ma R, et al. The Joint Asia Diabetes Evaluation (JADE) Program: a web-based program to translate evidence to clinical practice in Type 2 diabetes. Diabet Med 2009;26:693–699 doi: 10.1111/j.1464-5491.2009.02751.x 19573118

21. Luk AOY, Ke C, Lau ESH, Wu H, Goggins W, Ma RCW, et al. Secular trends in incidence of type 1 and type 2 diabetes in Hong Kong: A retrospective cohort study. PLoS Med. 2020;17:e1003052 doi: 10.1371/journal.pmed.1003052 32078650

22. Report of Population Health Survey 2014/2015. Surveillance and Epidemiology Branch, Centre for Health Protection, Department of Health, Government of the Hong Kong Special Administrative Region. Copyright 2017. [cited 2020 May 18].

23. Chan JC, Sui Y, Oldenburg B, Zhang Y, Chung HH, Goggins W, et al. Effects of telephone-based peer support in patients with type 2 diabetes mellitus receiving integrated care: a randomized clinical trial. JAMA Intern Med 2014;174:972–981 doi: 10.1001/jamainternmed.2014.655 24781960

24. Chan JCN, So WY, Ma RCW, Tong PCY, Wong R, Yang X. The complexity of vascular and non-vascular complications of diabetes: The Hong Kong Diabetes Registry. Curr Cardiovasc Risk Rep 2011;5:230–9 doi: 10.1007/s12170-011-0172-6 21654912

25. Chan JC, Ozaki R, Luk A, Kong AP, Ma RC, Chow FC, et al. Delivery of integrated diabetes care using logistics and information technology—the Joint Asia Diabetes Evaluation (JADE) program. Diabetes Res Clin Pract 2014;106 Suppl 2:S295–304 doi: 10.1016/S0168-8227(14)70733-8 25550057

26. Lim LL, Fu AWC, Lau ESH, Ozaki R, Cheung KKT, Ma RCW, et al. Sudomotor dysfunction independently predicts incident cardiovascular-renal events and all-cause death in type 2 diabetes: the Joint Asia Diabetes Evaluation register. Nephrol Dial Transplant 2019;34(8):1320–1328 doi: 10.1093/ndt/gfy154 29939305

27. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009;150:604–612 doi: 10.7326/0003-4819-150-9-200905050-00006 19414839

28. Austin PC. An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies. Multivariate Behav Res 2011;46:399–424 doi: 10.1080/00273171.2011.568786 21818162

29. Marshall M, Pronovost P, Dixon-Woods M. Promotion of improvement as a science. Lancet 2013;381:419–421 doi: 10.1016/S0140-6736(12)61850-9 23374480

30. Braithwaite J. Changing how we think about healthcare improvement. BMJ 2018;361:k2014 doi: 10.1136/bmj.k2014 29773537

31. Lapidos A, Lapedis J, Heisler M. Realizing the Value of Community Health Workers—New Opportunities for Sustainable Financing. N Engl J Med 2019;380:1990–1992 doi: 10.1056/NEJMp1815382 31116918

32. Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995–2050. Lancet 2019;393:2233–2260 doi: 10.1016/S0140-6736(19)30841-4 31030984

33. Khunti K, Seidu S, Kunutsor S, Davies M. Association Between Adherence to Pharmacotherapy and Outcomes in Type 2 Diabetes: A Meta-analysis. Diabetes Care 2017;40:1588–1596 doi: 10.2337/dc16-1925 28801474

34. Fisher EB, Chan JC, Nan H, Sartorius N, Oldenburg B. Co-occurrence of diabetes and depression: conceptual considerations for an emerging global health challenge. J Affect Disord 2012;142 Suppl:S56–66 doi: 10.1016/S0165-0327(12)70009-5 23062858

35. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 2002;25:1159–1171 doi: 10.2337/diacare.25.7.1159 12087014

36. Verlato G, Muggeo M, Bonora E, Corbellini M, Bressan F, de Marco R. Attending the diabetes center is associated with increased 5-year survival probability of diabetic patients: the Verona Diabetes Study. Diabetes Care 1996;19:211–213 doi: 10.2337/diacare.19.3.211 8742563

37. Barker I, Steventon A, Deeny SR. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data. BMJ 2017;356:j84 doi: 10.1136/bmj.j84 28148478

38. Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018;8:e021161 doi: 10.1136/bmjopen-2017-021161 29959146

39. Johnson FR, Manjunath R, Mansfield CA, Clayton LJ, Hoerger TJ, Zhang P. High-risk individuals’ willingness to pay for diabetes risk-reduction programs. Diabetes Care 2006;29:1351–1356 doi: 10.2337/dc05-2221 16732020

40. Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:2091–2138 doi: 10.1016/S0140-6736(18)32281-5 30496107

41. Tutino GE, Yang WY, Li X, Li WH, Zhang YY, Guo XH, et al. A multicentre demonstration project to evaluate the effectiveness and acceptability of the web-based Joint Asia Diabetes Evaluation (JADE) programme with or without nurse support in Chinese patients with Type 2 diabetes. Diabet Med 2017;34:440–450 doi: 10.1111/dme.13164 27278933

42. Yin J, Luk A, Wong R, Chung H, Kong A, Ozaki R, et al. Regular mailing of personalized feedback reports improves glycemic control in diabetes: A randomized controlled trial. J Diabetes 2017;9:536–538 doi: 10.1111/1753-0407.12527 28083979

43. International Diabetes Federation. IDF Diabetes Atlas, 9th edn. Brussels, Belgium: International Diabetes Federation, 2019.

44. Chan JC, Luk A, So WY, Zee B. Designing a sustainable public-private-partnership program to enhance diabetes care and evaluating its impact using an outcomes simulation model. [cited 2019 July 29].

45. Wu H, Lau ESH, Yang A, Ma RCW, Kong APS, Chow E, et al. Trends in diabetes-related complications in Hong Kong, 2001–2016: a retrospective cohort study. Cardiovasc Diabetol. 2020;19:60 doi: 10.1186/s12933-020-01039-y 32398003

Článek vyšel v časopise

PLOS Medicine

2020 Číslo 10
Nejčtenější tento týden
Nejčtenější v tomto čísle

Zvyšte si kvalifikaci online z pohodlí domova

Důležitost adherence při depresivním onemocnění
nový kurz
Autoři: MUDr. Eliška Bartečková, Ph.D.

Koncepce osteologické péče pro gynekology a praktické lékaře
Autoři: MUDr. František Šenk

Sekvenční léčba schizofrenie
Autoři: MUDr. Jana Hořínková, Ph.D.

Hypertenze a hypercholesterolémie – synergický efekt léčby
Autoři: prof. MUDr. Hana Rosolová, DrSc.

Multidisciplinární zkušenosti u pacientů s diabetem
Autoři: Prof. MUDr. Martin Haluzík, DrSc., prof. MUDr. Vojtěch Melenovský, CSc., prof. MUDr. Vladimír Tesař, DrSc.

Všechny kurzy
Zapomenuté heslo

Zadejte e-mailovou adresu, se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.


Nemáte účet?  Registrujte se