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Hong Kong quality improvement model provides targeted care with results


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Juliana CN Chan, MB, ChB, MD, FRCP
Juliana CN Chan, MB, ChB, MD, FRCP

A research-driven quality improvement initiative in Hong Kong has resulted in improved trends in A1C, blood pressure, and low-density lipoprotein cholesterol, as well as declining trends of cardiovascular events and death, especially among low-risk patients in the primary care setting.

Juliana CN Chan, MB, ChB, MD, FRCP, Professor of Medicine and Therapeutics at Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, discussed how the Hong Kong Diabetes Register (HKDR), Joint Asia Diabetes Evaluation (JADE) Program, and Risk Assessment and Management Program (RAMP) evolved to reform the delivery of diabetes care in China during Saturday’s ADA Diabetes Care Symposium.

“Every person with diabetes has a unique profile which needs to be defined to guide decision-making. The silent, progressive, and multisystem nature of diabetes, as well as the multiple biomedical and cognitive-psychological-behavioral needs of diabetes calls for regular assessments and feedback in order to avoid delayed interventions and poor adherence,” said Dr. Chan, recipient of the 2019 Harold Rifkin Award for Distinguished International Service in the Cause of Diabetes.

In 1989, in part due to insufficient manpower to address the rising number of patients with diabetes in Hong Kong, Dr. Chan’s team initiated a research-driven quality improvement program at the Prince of Wales Hospital, the teaching hospital of the Chinese University of Hong Kong.

“By changing the practice environment to implement protocol-driven risk assessment and stratification and care triage, using trained health-care professionals and personalized reports to provide feedback, we can reduce clinical inertia and improve self-management,” she said. “The establishment of a diabetes register also provides an audit to monitor performance indexes and detect default for recall.”

In 2007, Dr. Chan’s team set up a nonprofit research foundation, Asia Diabetes Foundation, as a knowledge transfer project and developed the web-based JADE Technology to guide data collection and enable users to develop a diabetes register for quality assurance and management purposes. In 2009, the nurse-coordinated RAMP program to enhance primary care clinics was adapted from the JADE program.

“To date, more than [400,000] people with diabetes have undergone these structured assessment and management programs in the public care setting, which have created a very comprehensive database with clinical profiles linked to lab, medication, procedure, and hospitalization data for service evaluation and knowledge discovery in a real-world setting,” she said.

Five years after implementation, the RAMP group had better control of all risk factors except for smoking rate, which remained similar, and lower Charlson Comorbidity Index score compared to the non-RAMP group. The high incidence of chronic kidney disease of 13 percent in the usual-care group was reduced to 7 percent in the RAMP group during this five-year period.

“Along with this risk reduction, the RAMP participants also had 50 percent reduction in all major event rates, including all-cause death, microvascular, and macrovascular complications,” she said.

Dr. Chan said through the creation of diabetes teams and by changing practice environments, RAMP program coordinators are able to use information technology to establish registers and generate data to inform patients, policymakers, and care providers.

“With ongoing professional education, as well as through learning on the job from their patients and other team members, these teams will be in a prime position to conduct community-based detection in a primary prevention program in order to treat early and safely, and to attain multiple targets,” Dr. Chan said.

Also presenting during the symposium were Struan Grant, PhD, Professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, who discussed TCF7L2 as a genetic window into the course and management of type 1 and type 2 diabetes, and Philip Home, DM, DPhil, Professor of Diabetes Medicine at Newcastle University, who examined glucose control targets in international and U.S. guidelines in an attempt to find common ground.