PT  - JOURNAL ARTICLE
AU  - Chan, Juliana C.N.
AU  - Lim, Lee-Ling
AU  - Luk, Andrea O.Y.
AU  - Ozaki, Risa
AU  - Kong, Alice P.S.
AU  - Ma, Ronald C.W.
AU  - So, Wing-Yee
AU  - Lo, Su-Vui
TI  - From Hong Kong Diabetes Register to JADE Program to RAMP-DM for Data-Driven Actions
AID  - 10.2337/dci19-0003
DP  - 2019 Nov 01
TA  - Diabetes Care
PG  - 2022--2031
VI  - 42
IP  - 11
4099  - http://care.diabetesjournals.org/content/42/11/2022.short
4100  - http://care.diabetesjournals.org/content/42/11/2022.full
SO  - Diabetes Care2019 Nov 01; 42
AB  - In 1995, the Hong Kong Diabetes Register (HKDR) was established by a doctor-nurse team at a university-affiliated, publicly funded, hospital-based diabetes center using a structured protocol for gathering data to stratify risk, triage care, empower patients, and individualize treatment. This research-driven quality improvement program has motivated the introduction of a territory-wide diabetes risk assessment and management program provided by 18 hospital-based diabetes centers since 2000. By linking the data-rich HKDR to the territory-wide electronic medical record, risk equations were developed and validated to predict clinical outcomes. In 2007, the HKDR protocol was digitalized to establish the web-based Joint Asia Diabetes Evaluation (JADE) Program complete with risk levels and algorithms for issuance of personalized reports to reduce clinical inertia and empower self-management. Through this technologically assisted, integrated diabetes care program, we have generated big data to track secular trends, identify unmet needs, and verify interventions in a naturalistic environment. In 2009, the JADE Program was adapted to form the Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) in the publicly funded primary care clinics, which reduced all major events by 30–60% in patients without complications. Meanwhile, a JADE-assisted assessment and empowerment program provided by a university-affiliated, self-funded, nurse-coordinated diabetes center, aimed at complementing medical care in the community, also reduced all major events by 30–50% in patients with different risk levels. By combining universal health coverage, public-private partnerships, and data-driven integrated care, the Hong Kong experience provides a possible solution than can be adapted elsewhere to make quality diabetes care accessible, affordable, and sustainable.