Evaluation of Morbidities, Endpoints and Reaching Targets in Diabetic Patients Managed by an All-encompassing Program Led by a Diabetes Specialist Team (EMERALD)

Aim: To examine the effects of 1-year team-based multi-component intervention care (MIC) program in obese T2D with poor glycemic control

Hypothesis: The change from a traditional clinic consultation to an individualized, multicomponent care program will improve cardiometabolic parameters in suboptimally treated obese type 2 diabetic participants.

Study design: This is a pilot translational study aiming to compare the effects of a multi-component care program with personalized drug regimen augmented by behavioural therapy with psychological support and peer influence, led by a diabetes specialist team on metabolic and psychobehavioural health in obese type 2 diabetic participants versus usual care (UC).

Settings: The participants would be identified from the Prince of Wales Hospital (PWH). The recruitment period would be 2 years. Since 1995, the PWH runs a comprehensive complication screening program in the ambulatory Diabetes Centre. On a weekly basis, 50-100 patients undergo assessments for risk factors and complications by nurses and healthcare assistants using standard protocols. On average, 8-12 patients attend each session. Since 2007, these data are entered into a web-based Joint Asia Diabetes Evaluation (JADE) Program which incorporates a validated risk engine to generate an integrated report with risk categories, care protocols, trends of risk factor control and decision support to empower both doctors and patients to make informed decisions. After the assessments, During the first two months of intervention, each group would have three 3.5-hour face-to-face workshops with the nurses (week 0, 4 and 8). This would be reduced to 2-hour per workshop 4-monthly thereafter in the following ten months (week 24, 40, 56) i.e. a total of six sessions per group in 1-year intervention. At each workshop, the nurses would use role plays, quizzes, reflective stories and on-site fitness classes to instill these key principles. Each workshop would use similar strategies including goal-setting, health behaviors tracking and peer sharing on personal progress. During this 1-year MIC program, 4 out of 6 workshops would be conducted when participants would be waiting to see endocrinologists (at week 24, 40 and 56). The consultations would be around 15-minute for each participant per visit. In the first two months of intervention, each MIC group also would receive three 20-minute telephone reminders from HCA at 4-weekly intervals (week 0, 4, 8). The call frequency would be reduced to 4-monthly intervals in the following ten months (week 24, 40, 56) i.e. a total of six calls per group. Group members would also be acted as peer supporters for one another in groups of 3 to 4 patients with at least one telephone reminder between workshops. The calls would be guided by structured log sheets focusing on adherence to lifestyle modification, medications and action plan, as well as to identify patients who would require ad-hoc support from the nurses.

The MIC group would return to UC after exit from the 1-year intervention. During the ensuing two years, the MIC group would receive mailing of three simplified JADE follow-up reports at month 18, month 24 and month 30 where the HCA entered BP, HbA1c, body weight and LDL-cholesterol retrieved from the clinic notes or laboratory measurements to provide feedback to the patients. They would be invited to an annual 4-hour group gathering where doctors and nurses would invite patients who achieve and/or maintain risk factor control to share their success stories and provide motivational support to the group.