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Background 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. Conclusions ICT-assisted integrated care was associated with a reduction in clinical events, including death in type 2 diabetes in public and private healthcare settings. Lee-Ling Lim and colleagues reveal how personalised medical guidance can reduce clinical outcomes for diabetes patients in Hong Kong. Author summary Why was this study done? The public healthcare systems are overburdened with manpower shortage, long waiting time, infrequent structured evaluation, and insufficient patient engagement, while structured patient assessment and education is often not provided in the private sector due to high costs and/or lack of capacity. In 2007, we developed the web-based Joint Asia Diabetes Evaluation (JADE) Program, a multicomponent data-driven integrated care program, to close care gaps in both private and public sectors in Hong Kong. It combines the use of nonphysician personnel (e.g., nurses), information and communications technology (ICT), and structured evaluation with issue of personalized JADE reports to empower patients and promote shared decision-making. In 2007, we also established a community-based, nurse-led diabetes center to complement public and private care in Hong Kong by increasing community access to JADE-assisted evaluation for personalized empowerment and engagement. What did the researchers do and find? This retrospective analysis involved 16,624 patients with type 2 diabetes enrolled from the public and private sector in Hong Kong between 2007 and 2015. We categorized these patients into 3 groups, namely non-JADE, JADE, and JADE-Personalized (JADE-P), and compared their risk for clinical events after 6 years of follow-up. Compared with the JADE group (publicly funded evaluation with JADE reports and group education), the non-JADE group (publicly funded evaluation only) had 19%–34% higher risk of clinical events, including hospitalization. Compared with the JADE group, the JADE-P group (self-paid evaluation with JADE reports, personalized empowerment, and annual telephone reminder for engagement) had 23%–36% lower risk of clinical events, including hospitalization and death. What do these findings mean? Multicomponent, data-driven integrated care, assisted by nonphysician personnel and ICT, is associated with a reduction in clinical events and death in patients with type 2 diabetes. Its implementation in the private sector is an affordable option for patients who opt for a more user-friendly and personalized care and may reduce the burden of hospitalization in the public sector. |
