A Randomized Quality Improvement Study Using the Web-based Multi-component Joint Asia Diabetes Evaluation (JADE) Program 

Juliana CN Chan1,2, Yook-Chin Chia3,4, Wayne Sheu5, Duc-Cong Nguyen6, Parinya Chamnan7, Su-Yen Goh8, Subir Ray9, Sagarsankar Mukherjee10, Amy W Fu1, Eric S Lau1, Lee-Ling Lim1,2,3, Andrea O Luk1,2 on behalf of the JADE Study Group 

1Asia Diabetes Foundation, Hong Kong; 2The Chinese University of Hong Kong, Hong Kong; 3University of Malaya, Malaysia; 4Sunway University, Malaysia; 5Taichung Veterans General Hospital, Taiwan; 6Thong Nhat Hospital, Vietnam; 7Sanpasitthiprasong Hospital, Ubon Ratchathani, Thailand; 8Singapore General Hospital, Singapore; 9Relief Polyclinic, India; 10Dr. Mrs. Sagarika Mukherjee, India.

Background:
Insufficient time, infrequent assessment of risk factors, lack of continuation and variations of care, treatment non-adherence and frequent default result in poor clinical outcomes in type 2 diabetes (T2D). The multi-component JADE program uses a nurse to assist doctors collect clinical information guided by the JADE portal with built-in care protocols, validated risk engines, personalized report and reminders triggered by attained HbA1c, blood pressure(BP), LDL-C and body weight (BW) to help doctors identify treatment gaps and improve patient self management. Using this team approach augmented by information technology, we have reported the utility of the JADE Program in reducing clinical inertia, treatment non-adherence, cardiometabolic risk factors and defaults rates in Chinese patients with T2D.1-3

Objective:
We examined the feasibility, acceptability and effectiveness of implementation of the JADE Program using a nurse coordinator in a wide range of private, public and subsidized care settings in Asia.

Methods:
Each site was given access to the JADE Portal and a grant to support a nurse to recruit 600 patients with T2D for eye, feet, blood and urine examination (J) at baseline and 1 year.  At each site, half of the patients had at least 2 phone or face-to-face follow-up contacts by the nurse during the 1-year period. In phase 1 study, all patients were given the JADE personalized report with or without nurse contact (J+R+N vs J+R). In phase 2 study, only patients who had additional nurse visit were given the JADE report (J+R+N vs J-R).

Results:
Between 2012 and 2015, 15192 T2D patients were recruited from 48 sites in Asia (India, Indonesia, Malaysia, Philippines, Singapore, Taiwan, Thailand, Vietnam) with analyzable baseline data [male (55.1%), age (mean±SD: 56.9±11.5 years), disease duration [median (IQR): 8 (4-14) years], current smokers (9.4%), history of arteriosclerotic-cardiovascular disease including heart failure (15.7%), chronic kidney disease (18.5%), cancer (1.9%), HbA1c<7% (30.2%), BP<130/80mmHg (23.8%), LDL-C<2.6mmol/L (57.5%), use  of statins (38.4%) and RAS inhibitors (32.6%)]. We used reduction (Δ) in HbA1c≥0.5%, Δ systolic BP≥5 mmHg, Δ LDL-C≥0.5 mmol/L and Δ BW ≥3% as Key Performance Indexes (KPI). At 12 months, 8488 (55.9%) patients returned for repeat assessment.  Of these, 5137 (74.4 %) had achieved at least 1 KPI, more so in the J+R+N group compared to the J group (Table 1). The J+R+N group also had a lower default rate than the J group in both phase 1 and phase 2 sites with defaulters being younger, having fewer complications/morbidities but worse risk factor control (Table 2). Structured assessment improved risk factor control which was enhanced by issue of a personalized report, while patient engagement by nurses between medical clinic visits reduced default rate.

Conclusion:
In real world practice, more than 1 in 3 Asian patients with T2D had complications with suboptimal control of cardiometabolic risk factors, under-usage of organ-protective drugs and frequent default. Care organization using a doctor-nurse team to perform structured assessment, augmented by informational technology, with personalized reporting and empowerment improved shared decision making and quality of care. 

Receipt of grants or research support:
The JADE program was supported by Asia Diabetes Foundation. Prof. Juliana CN Chan received research support from AstraZeneca, Bayer, Boehringer Ingelheim, MSD, Sanofi and Pfizer.

References:
1. Chan JC et al. JAMA internal medicine. 2014;174:972-981. 
2. Tutino GE et al. Diabetic medicine. 2017;34:440-450. 
3. Yin J et al. Journal of diabetes. 2017;9:536-538.

A randomized quality improvement study using the web-based multi-component Joint Asia Diabetes Evaluation (JADE) program