Effects of a Technology-Assisted Integrated Diabetes Care Program on Cardiometabolic Risk Factors Among Patients With Type 2 Diabetes in the Asia-Pacific Region

Lee‐Ling Lim ,Amy W C Fu,Andrea Luk ,Parinya Chamnan,Thị Thanh Huyền Vũ ,Aravind Sosale,Subir K Ray ,C Ronald ,Eric S.h Lau ,Yook Chin Chia ,Wayne H‐H Sheu ,Vanessa Lau,Nguyen Duc Cong ,Manoj Chawla ,Alice Pik Shan Kong ,Neeru Gera,Alexander Tong Boon Tan ,Yi‐Jen Hung ,Banshi Saboo ,Lee‐Ming Chuang ,Su-Yen Goh,Jothydev Kesavadev,Uday Phadke,Juliana C.n Chan

doi:10.1001/jamanetworkopen.2021.7557

Abstract

Many health care systems lack the efficiency, preparedness, or resources needed to address the increasing number of patients with type 2 diabetes, especially in low- and middle-income countries. To examine the effects of a quality improvement intervention comprising information and communications technology and contact with nonphysician personnel on the care and cardiometabolic risk factors of patients with type 2 diabetes in 8 Asia-Pacific countries. This 12-month multinational open-label randomized clinical trial was conducted from June 28, 2012, to April 28, 2016, at 50 primary care or hospital-based diabetes centers in 8 Asia-Pacific countries (India, Indonesia, Malaysia, the Philippines, Singapore, Taiwan, Thailand, and Vietnam). Six countries were low and middle income, and 2 countries were high income. The study was conducted in 2 phases; phase 1 enrolled 7537 participants, and phase 2 enrolled 13 297 participants. Participants in both phases were randomized on a 1:1 ratio to intervention or control groups. Data were analyzed by intention to treat and per protocol from July 3, 2019, to July 21, 2020. In both phases, the intervention group received 3 care components: a nurse-led Joint Asia Diabetes Evaluation (JADE) technology-guided structured evaluation, automated personalized reports to encourage patient empowerment, and 2 or more telephone or face-to-face contacts by nurses to increase patient engagement. In phase 1, the control group received the JADE technology-guided structured evaluation and automated personalized reports. In phase 2, the control group received the JADE technology-guided structured evaluation only. The primary outcome was the incidence of a composite of diabetes-associated end points, including cardiovascular disease, chronic kidney disease, visual impairment or eye surgery, lower extremity amputation or foot ulcers requiring hospitalization, all-site cancers, and death. The secondary outcomes were the attainment of 2 or more primary diabetes-associated targets (glycated hemoglobin A1c <7.0%, blood pressure <130/80 mm Hg, and low-density lipoprotein cholesterol <100 mg/dL) and/or 2 or more key performance indices (reduction in glycated hemoglobin A1c≥0.5%, reduction in systolic blood pressure ≥5 mm Hg, reduction in low-density lipoprotein cholesterol ≥19 mg/dL, and reduction in body weight ≥3.0%). A total of 20 834 patients with type 2 diabetes were randomized in phases 1 and 2. In phase 1, 7537 participants (mean [SD] age, 60.0 [11.3] years; 3914 men [51.9%]; 4855 patients [64.4%] from low- and middle-income countries) were randomized, with 3732 patients allocated to the intervention group and 3805 patients allocated to the control group. In phase 2, 13 297 participants (mean [SD] age, 54.0 [11.1] years; 7754 men [58.3%]; 13 297 patients [100%] from low- and middle-income countries) were randomized, with 6645 patients allocated to the intervention group and 6652 patients allocated to the control group. In phase 1, compared with the control group, the intervention group had a similar risk of experiencing any of the primary outcomes (odds ratio [OR], 0.94; 95% CI, 0.74-1.21) but had an increased likelihood of attaining 2 or more primary targets (OR, 1.34; 95% CI, 1.21-1.49) and 2 or more key performance indices (OR, 1.18; 95% CI, 1.04-1.34). In phase 2, the intervention group also had a similar risk of experiencing any of the primary outcomes (OR, 1.02; 95% CI, 0.83-1.25) and had a greater likelihood of attaining 2 or more primary targets (OR, 1.25; 95% CI, 1.14-1.37) and 2 or more key performance indices (OR, 1.50; 95% CI, 1.33-1.68) compared with the control group. For attainment of 2 or more primary targets, larger effects were observed among patients in low- and middle-income countries (OR, 1.50; 95% CI, 1.29-1.74) compared with high-income countries (OR, 1.20; 95% CI, 1.03-1.39) (P = .04). In this 12-month clinical trial, the use of information and communications technology and nurses to empower and engage patients did not change the number of clinical events but did reduce cardiometabolic risk factors among patients with type 2 diabetes, especially those in low- and middle-income countries in the Asia-Pacific region. ClinicalTrials.gov Identifier: NCT01631084.

Highlights

Large patient volume, multiple clinical needs, and insufficient patient engagement are major barriers to translating evidence into practice among patients with type 2 diabetes who require education and continuing care.[1,2] Lack of capacity is an additional challenge in low- and middle-income countries.[3]
Meaning The study’s findings indicate that the use of information and communications technology and nurses to empower and engage patients did not change the number of clinical events but did reduce cardiometabolic risk factors among patients with type 2 diabetes in low- and middle-income countries
In this 12-month clinical trial, the use of information and communications technology and nurses to empower and engage patients did not change the number of clinical events but did reduce cardiometabolic risk factors among patients with type 2 diabetes, especially those in low- and middle-income countries in the Asia-Pacific region

Summary

Introduction

Multiple clinical needs, and insufficient patient engagement are major barriers to translating evidence into practice among patients with type 2 diabetes who require education and continuing care.[1,2] Lack of capacity is an additional challenge in low- and middle-income countries.[3]. One in 5 patients with type 2 diabetes has multiple comorbidities (eg, myocardial infarction and stroke), and these comorbidities increase the risk of cardiovascular events and death by 2-fold to 7-fold in a dose-dependent manner.[5,6] these adverse events can be ameliorated or prevented through early detection and control of multiple risk factors,[7] substantial care gaps exist.[2,8,9] In high-income countries, 1 in 4 patients with type 2 diabetes is able to attain all primary diabetes-associated targets, which are conventionally defined as a glycated hemoglobin A1c (HbA1c) level lower than 7.0% (based on measurement standards from the National Glycohemoglobin Standardization Program10), a blood pressure (BP) level lower than 130/80 mm Hg, and a low-density lipoprotein (LDL) cholesterol level lower than 100 mg/dL (to convert to millimoles per liter, multiply by 0.0259).[6,8] In addition, 40% to 60% of patients with type 2 diabetes in highincome countries receive organ-protective drugs.[6,8] In Asia, which comprises many low- and middleincome countries, the proportion of patients with type 2 diabetes meeting all primary diabetesassociated targets has been reported to be lower than 10%, and only 30% to 40% of patients have received organ-protective drugs.[11]

Methods

Results

Discussion

Conclusion