The complex pathogenesis of diabetes is accompanied by pluralistic needs including care, drugs, education and ongoing support. The inter-individual variations in terms of risk factors and complications as well as their changes over time within the same individual require regular assessments and measurements to enable timely and personalized management. The silent and non-urgent nature of these risk factors and complications often result in clinical inertia and non-adherence which call for regular feedback with decision support. Given the multisystem nature of the disease which involves input from different disciplines, care fragmentation may easily occur if services are not well coordinated.
In the 1990s, Hong Kong faces a burgeoning epidemic of diabetes when hospitalizations and episodic clinic visits represent the mainstreams of care delivery. Motivated by the marked differences in clinical outcomes between patients receiving nurse-coordinated, protocol-guided care in a clinical trial setting and those receiving usual care, we decided to change the clinic setting, re-design the workflow and use trained nurses and protocols to provide regular services of comprehensive assessment followed by group education and care triage. This has formed the basis of the Hong Kong Diabetes Registry which has provided enormous insights on the natural history of diabetes and the highly modifiable nature of clinical outcomes using risk equations. In 2007, we digitalized the entire concept and developed the Joint Asia Diabetes Evaluation (JADE) Program which incorporates care protocols and validated risk engines to issue personalized reports with decision support to enable doctors establish registry for quality improvement. After more than 2 decades, these care models developed by combining research and practice, have informed decision makers to establish diabetes centres and career paths for diabetes nurse specialists in Hong Kong in both primary and hospital settings. On the other hand, the web-based JADE Program (www.adf.org.hk) has provided collaborative research opportunities for identifying gaps and evaluating pragmatic intervention programs using peer supporters and community healthcare workers to provide ongoing support.