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.

OBJECTIVE The implementation of the Chronic Care Model (CCM) improves health care quality. We examined the sustained effectiveness of multicomponent integrated care in type 2 diabetes. RESEARCH DESIGN AND METHODS We searched PubMed and Ovid MEDLINE (January 2000–August 2016) and identified randomized controlled trials comprising two or more quality improvement strategies from two or more domains (health system, health care providers, or patients) lasting ≥12 months with one or more clinical outcomes. Two reviewers extracted data and appraised the reporting quality. RESULTS In a meta-analysis of 181 trials (N = 135,112), random-effects modeling revealed pooled mean differences in HbA_1c of −0.28% (95% CI −0.35 to −0.21) (−3.1 mmol/mol [−3.9 to −2.3]), in systolic blood pressure (SBP) of −2.3 mmHg (−3.1 to −1.4), in diastolic blood pressure (DBP) of −1.1 mmHg (−1.5 to −0.6), and in LDL cholesterol (LDL-C) of −0.14 mmol/L (−0.21 to −0.07), with greater effects in patients with LDL-C ≥3.4 mmol/L (−0.31 vs. −0.10 mmol/L for 12 months (SBP −3.4 vs. −1.4 mmHg, P_difference = 0.034; DBP −1.7 vs. −0.7 mmHg, P_difference = 0.047; LDL-C −0.21 vs. −0.07 mmol/L for 12-month studies, P_difference = 0.049). Patients with median age <60 years had greater HbA_1c reduction (−0.35% vs. −0.18% for ≥60 years [−3.8 vs. −2.0 mmol/mol]; P_difference = 0.029). Team change, patient education/self-management, and improved patient-provider communication had the largest effect sizes (0.28–0.36% [3.0–3.9 mmol/mol]). CONCLUSIONS Despite the small effect size of multicomponent integrated care (in part attenuated by good background care), team-based care with better information flow may improve patient-provider communication and self-management in patients who are young, with suboptimal control, and in low-resource settings.

The validity of the 20-item Center for Epidemiological Studies Depression (CES-D) scale for depression screening in Hong Kong Chinese patients with type 2 diabetes remains unknown. We aimed to validate CES-D, compare its psychometric properties with the 9-item Patient Health Questionnaire (PHQ-9), and explore whether one of the two is more suitable for depression screening in Chinese patients with type 2 diabetes. Between June 2010 and July 2011, 545 consecutive Chinese patients with type 2 diabetes who underwent structured comprehensive assessments completed the CES-D and PHQ-9. Forty patients were retested within 2–4 weeks by telephone interview and 97 patients were randomly selected to undergo the Mini International Neuropsychiatric Interview (MINI) by psychiatrists for clinical diagnosis of depression. The internal consistency (Cronbach’s α) of CES-D was 0.85, with a test-retest correlation coefficient of 0.64. The area under the curve for CES-D compared to the clinical diagnosis of major depression was 0.85. A cut-off score of ≥21 for CES-D provided the optimal balance between sensitivity (78.3 %) and specificity (74.3 %) and identified 17.8 % (n = 97) of patients with depression. CES-D and PHQ-9 showed moderate agreement in depression screening (Cohen’s Kappa: 0.45). Compared to non-depressed patients, those who screened positive by PHQ-9 had a higher HbA1c whereas the glycemic differences were not significant when using CES-D. The CES-D is a valid screening tool for depression in Chinese type 2 diabetic patients although the PHQ-9 was more discriminative in identifying those with suboptimal glycemic control.