RT Journal Article
SR Electronic
T1 From Hong Kong Diabetes Register to JADE Program to RAMP-DM for Data-Driven Actions
JF Diabetes Care
JO Diabetes Care
FD American Diabetes Association
SP 2022
OP 2031
DO 10.2337/dci19-0003
VO 42
IS 11
A1 Chan, Juliana C.N.
A1 Lim, Lee-Ling
A1 Luk, Andrea O.Y.
A1 Ozaki, Risa
A1 Kong, Alice P.S.
A1 Ma, Ronald C.W.
A1 So, Wing-Yee
A1 Lo, Su-Vui
YR 2019
UL http://care.diabetesjournals.org/content/42/11/2022.abstract
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.