Establishing a Diabetes Registry Using the JADE-DIAMOND Electronic Portal (CN001)
Establishing a Diabetes Registry Using the JADE-DIAMOND Electronic Portal (CN001)
Quality diabetes care requires a team approach and informed decisions of patients and care
 providers. Several lines of evidence suggests that a protocol-driven care model delivered by
 trained staff with focus on periodic assessments, reinforcement of patient compliance and
 attainment of multiple treatment targets reduces risk of cardio-renal complications and early
 death in type 2 diabetes.

 The investigators hypothesize that the use of state of the art information technology to
 record, manage and analyze the large amount of clinical information generated during various
 consultation visits will improve the effectiveness and efficiency in implementing these care
 protocols through decision support and regular feedback to both patients and care team.
Diabetes is now a pandemic disease affecting 5-10% of global population. More than 60% of
 affected people will come from Asia with the number expected to increase from 85 million in
 2005 to 132 million in 2010 in Asia alone. On average, diabetes reduces life expectancy by
 10-12 years. While stroke, heart disease and kidney failure account for more than 50% of
 global deaths, 30-50% of patients with these conditions have diabetes as a major contributing
 factor. In contrast to the West, the main increase in diabetes prevalence in Asia will occur
 in the young to middle aged population. On average, 17 million people die from stroke and
 heart disease on a yearly basis. Of these, 11 million occur in Asia, affecting many young
 parents and economically active people.

 Despite their devastating nature, many diabetic complications can be prevented and managed
 effectively to preserve health, reduce disabilities and improve quality of life. However,
 there are multiple barriers in the implementation of quality diabetes care. These include
 insufficient knowledge base of health care professionals, fragmented nature of health care
 systems, lack of reimbursement for outpatient procedures including therapeutic patient
 education, poor compliance to treatment in part due to the silent nature of diabetes and
 associated complications as well as the complex nature of care protocols. The latter include
 periodic evaluation of clinical and laboratory parameters and the need for people with
 diabetes to adhere to long term medications and self care.

 While optimal management of risk factors and treatment to targets can substantially reduce
 the risk of diabetes associated complications, the challenge lies in the effective
 translation of this evidence to clinical practice. Since mid 1990s, inspired by the benefits
 of structured care, made possible during the conduct of clinical trials, the CUHK Diabetes
 Care & Research Group has developed prototypes of structured care protocols including an
 annual comprehensive assessment using a doctor-nurse-physician assistant team. Consistent
 with international data, these prototypes substantially improve rates of treatment compliance
 and attainment of multiple treatment targets resulting in reduced death and cardio-renal
 complication rates.

 The Joint Asia Diabetes Evaluation (JADE) Program is a web-based disease management program
 conceptualized, developed and tested by the Asia Diabetes Foundation (ADF) since 2007,
 supported by a MSD educational grant. The objectives of the JADE Program include:

 1. to promote collective learning and sharing of best practices in diabetes based on
 regionally relevant evidence

 2. to increase regional awareness about the magnitude of diabetes and its preventable
 nature through education, ongoing data collection and implementation of evidence-based
 guidelines

 3. to establish a regional diabetes registry

 4. to collect the evidence base to inform relevant stakeholders including public, people
 with diabetes, health care professionals, policy makers and payors to change policies
 and practices in order to make quality diabetes care accessible, sustainable and
 affordable.

 Using state of the art information technology, the JADE and DIAMOND electronic portal
 provides a virtual platform to enable care professionals to record, manage and analyse the
 large amount of information collected during various consultation visits. The Programs also
 incorporate risk equations developed and validated by the CUHK Diabetes Care & Research Group
 to help doctors assess their patients' future event rates. This information, displayed in
 charts and trend lines, can be communicated to patients and doctors to motivate behavioral
 changes and encourage dialogues to set treatment goals.

 Apart from providing templates for documentation of risk factors and complications using
 standardized protocols, the JADE Program also incorporates different evidence-based care
 protocols with recommendations on follow up schedules and care processes in accordance to the
 patient's risk profile. Decision support in terms of prompts, charts, trend lines and
 practice tips are used to help doctors and patients to make informed decisions and to
 optimize care. The JADE Program also possesses matrixes which enable care providers to track
 clinical progress and risk factor control for benchmarking and quality improvement purposes.
 On the other hand, the DIAMOND Program provides the first step to entry of a quality
 assurance program by establishing a diabetes registry at a clinic level. The ongoing
 collection of these data provides an invaluable platform for collaborative epidemiological
 and interventional studies pertinent to Asian populations.

 In this multicentre study, we shall use a trio team consisting of a trained doctor, nurse and
 physician assistant (PA) to deliver protocol-driven diabetes care using a web-based disease
 management program, the Joint Asia Diabetes Evaluation (JADE) Program. To fully realize the
 functionality of the JADE Program requires changes in the practice environment and deployment
 of additional manpower (e.g. a nurse and a PA) to enter data and provide reminders to
 patients and doctors to improve adherence to protocols. In settings where these changes may
 not be immediately possible, periodic comprehensive assessment using the structured template
 in the JADE Program allows recognition of risk factors and complications for early
 intervention. The latter will allow data collected in a systematic manner which forms the
 basis of a DIAbetes MONitoring Database (DIAMOND) as a first step towards quality assurance.

 After explanation by trained doctors and nurses and with written informed consent, patients
 will be randomized to either the JADE or DIAMOND Program. The former encompasses all
 components of the structured care delivered by a trio-team of doctor, nurse and PA while the
 DIAMOND Program only consists of comprehensive assessments at baseline and 12-month with
 patients managed in the usual manner thereafter. At the end of 12 months, all patients will
 undergo repeat comprehensive assessments for comparison of rates of attainment of treatment
 targets, behavioral changes, quality of life and default rates.

 Aims of the study:

 1. To evaluate the reach, adoption and acceptability of the JD Program by patients and
 health care team;

 2. To compare the effectiveness of the JADE (structured care) versus DIAMOND (usual care)
 Programs in attainment of treatment targets, improvement of quality of life and changes
 in behaviors;

 3. To document the pattern of complications, risk factors, use of medications and quality
 of life in type 2 diabetic patients

 Study sites:

 1. Beijing People's Hospital, Beijing

 2. Peking Union Hospital, Beijing

 3. 1st Hospital, Peking University Hospital, Beijing

 4. China-Japan Friendship Hospital, Beijing

 5. Shanghai Sixth People's Hospital, Shanghai

 6. Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou
Inclusion Criteria:

 -  Type 2 diabetic patients attending hospitals or affiliated clinics led by PIs of the
 JADE Program who are living in the area with an intention to have 'regular' follow-up

 -  Aged >18 years

 -  Patients can have newly diagnosed or established disease, treated with lifestyle or
 blood glucose lowering drugs including oral agents with or without insulin

 -  For newly diagnosed type 2 diabetic patients, their plasma glucose levels should be:
 a) Fasting plasma glucose (PG) >7.0 mmol/L on 2 or more occasions, and/or b) Random
 (or post-OGTT 2h) PG >11.1 mmol/L on 2 or more occasions, and/or c) HbA1c >6.5%

 Exclusion Criteria:

 -  Type 1 diabetes defined as a history of ketosis at diagnosis [acute symptoms with
 heavy ketonuria (>3+) or ketoacidosis] or continuous requirement of insulin within one
 year of diagnosis

 -  Patients with reduced life expectancy (e.g. less than 6-months) due to recent
 diagnosis of advanced cancers (e.g. within last 2 years) and other life threatening
 conditions

 -  Patients with a mental condition rendering them unable to understand the nature,
 scope, and possible consequences of the study

 -  Patients actively enrolled in another intervention study

 -  Patients who are unwilling to return for regular follow up