Background and Objectives: In a previous randomized study, we reported the benefits of providing integrated care by the Joint Asia Diabetes Evaluation (JADE) Program consisting of comprehensive assessment (CA) and 3-4 monthly follow up (FU) assessments with personalized feedback reports and decision support on control of cardio-metabolic risk factors through reduced clinical inertia and improved self-care. Further, provision of additional peer support improved psychological well-being and all-cause hospitalization especially in those with negative emotions who tended to have co-morbidities. However, given the multicomponent nature of the program, the differential effects of peer support in different patient subgroups and independent effect of personalized FU reports had not been systematically evaluated.. In this thesis, I used a randomized and case-control design to examine the effects of providing regular FU reports and peer support on metabolic control, psychological health, and all-cause hospitalization in patients with diabetes. / Methods: Between February and December 2013, 1488 Chinese patients with diabetes aged 18-75 years underwent CA using the JADE portal and returned in 4 weeks in groups to receive their personalized CA report with explanation by nurses about their complications, risk factors and treatment targets. Amongst them, I selected 288 high risk patients defined as 1) HbA1c≥8%, 2) obesity (body mass index≥27.5 kg/m² and/or waist≥80cm (women) or ≥90cm (men), and/or 3) chronic kidney disease (CKD, eGFR<60ml/min/1.73m²) and offered them a telephone-based peer support program, to which 144 (50%) agreed (P+ group) and 144 (50%) refused (P- group). Within each group, they were also randomized to receive 2 JADE FU reports by mail after their clinic visits. These FU reports displayed their trends of ABC (HbA1c, BP, LDL-C) control and body weight with individualized reminders for self-care during a 12-month period. In the remaining patients (n=1200), half were randomized to receive 2 FU reports by mail (R+ group: n=600) while half received usual care (R- group: n=600). Amongst patients not offered peer support, 425 patients (50% received FU report) were matched to the P+ group (52% received FU report) on a 3:1 basis by age, gender, diabetes duration, and baseline HbA1c as a control group. The outcome measures were reduction in HbA1c and all-cause hospitalization at month 12. / Results: Amongst patients not offered peer support, after a median (IQR) follow-up period of 575 (519-646) days, the R+ group had greater reduction in HbA1c (mean [95% CI]: -0.24[-0.35,-0.14]% versus -0.15[-0.24,-0.06]%, p=0.030) with similar hospitalization rate and frequency compared with the R- group. Amongst patients offered peer support, the P+ group and P- group had similar baseline clinical and psychological-behavioral parameters. After 530 (463-575) days, the P+ group (n=138) tended to have greater reduction in HbA1c (-0.75[-0.97,-0.52]% versus -0.42[-0.68,-0.15]%, p=0.106) with significant improvements in mental health and quality of life than the P- group (n=131). In the case-control cohort for peer support,the P+ group tended to have greater reduction in HbA1c than the control group (n=425) (-0.75[-0.97,-0.52]% versus -0.49[-0.64, -0.35]%, p=0.119) with lower rate, frequency and length of hospitalization. On multivariable analysis of the entire cohort (n=1488), peer support (β coefficient [95% CI] -0.31[-0.56, -0.06], p=0.015) and receiving FU reports (-0.14[-0.25, -0.04], p=0.009) were independent predictors for reduction in HbA1c. Peer support (OR [95% CI] 0.36[0.16, 0.79], p=0.011) and CKD with FU reports (0.40[0.18, 0.88], p=0.022) were also associated with reduced hospitalization. / Conclusion: In this real-world quality improvement program, both peer support and regular personalized feedback report by mail were associated with reduced HbA1c in patients with diabetes. Peer support was associated with lower risk of hospitalization, while feedback report was associated with reduced hospitalization only in patients with diabetes and comorbid CKD. / 背景及目的：在一項隨機對照研究中，我們發現通過亞洲糖尿病評估計劃JADE提供整合了全面糖尿病併發症篩查（CA）、定期隨訪（FU）評估、個體化回饋報告及決策支持的綜合護理可通过降低臨床惰性，促進自我管理從而改善糖尿病風險因素的控制。在此基礎上，同伴支持可進一步改善患者的心理健康，降低住院率， 并且在有負面情緒的人群中作用尤其明顯。然而，由於綜合護理由多部分組成，個體的作用並未被系統評估。本文分別採用隨機對照和病例對照研究，評估個體化隨訪報告和同伴支持對糖尿病患者代謝控制、心理健康及住院率的作用。 / 研究方法：2013 年2 月至12 月，1488 位年齡18 至75 歲的糖尿病患者進行了CA，並于4 周後領取個體化CA 報告，由護士說明其併發症和危險因子的控制以及治療有無達標。其中，我邀請了288 位有以下高危因素的患者參加一項基於電話的同伴支持計劃：1）糖化血紅蛋白（HbA1c）≥8%；2）肥胖（體重指數≥27.5 kg/m² 和/或女性腰圍≥80cm/男性腰圍≥90cm；和/或3）慢性腎臟病（CKD，腎小球濾過率<60 ml/min/1.73m²）。其中，144 位（50%）同意（P+ 組）參與，144 位（50%）（P- 組）拒絕參與。每組再隨機抽取一半患者郵寄2 份JADEFU 報告。該報告顯示了患者HbA1c、血壓、低密度膽固醇和體重的控制情況，並附有針對自我管理的個體化建議。餘下的1200 位患者中，隨機抽取一半患者（R+ 組，n=600）郵寄2 份JADE FU 報告，另外一半患者常規護理（R- 組，n=600）。未被邀請參加同伴支持計劃的1200 位患者中，425 位（50%有FU 報告）按年齡、性別、病程和基礎HbA1c 與P+組（52%有FU 報告）匹配成為對照組。研究指標為12 個月後HbA1c 和住院率的改變。 / 研究結果：未提供同伴支援的患者中，經過575（519-646）日的隨訪，R+組HbA1c 降低更多（ 均值[95% 置信區間]: -0.24[-0.35,-0.14]% versus-0.15[-0.24,-0.06]%, p=0.030），但住院率與R-組相同。提供同伴支持的患者中，P+組和P-組研究開始時臨床、心理和行為指標皆相似。530（463-575）日後，與P-組比較，P+組有HbA1c 降低更多的趨勢（-0.75[-0.97,-0.52] % versus-0.42[-0.68,-0.15]%, p=0.106），住院率相似，但心理健康和生活品質均有明顯改善。在病例對照研究中，與對照組比較（n=425），P+組（n=142） HbA1c降低更多（-0.92[-1.25, -0.59]% versus -0.39[-0.58, -0.21], p=0.004），且住院率、住院次數和時間皆有明顯降低。採用多變量回歸分析，同伴支持（β 係數[95% 置信區間] -0.31[-0.56, -0.06], p=0.015）和FU 報告（-0.14[-0.25, -0.04], p=0.009）均是降低HbA1c 的獨立預測因子。同伴支持（0.36[0.16, 0.79], p=0.011） 和CKD伴FU 報告（0.40[0.18, 0.88], p=0.022）與住院风险降低明顯相關。 / 結論：在此項品質改進計畫中，同伴支持和定期郵寄個體化隨訪報告均与糖尿病患者的糖化血紅蛋白降低相關。同伴支持伴隨住院风险降低，但個體化隨訪報告僅在糖尿病伴慢性腎臟病患者中与住院风险降低相關。 / Yin, Junmei. / Thesis Ph.D. Chinese University of Hong Kong 2015. / Includes bibliographical references (leaves 209-235). / Abstracts also in Chinese; appendix 4 in Chinese. / Title from PDF title page (viewed on 06, October, 2016). / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only.
| Identifer | oai:union.ndltd.org:cuhk.edu.hk/oai:cuhk-dr:cuhk_1291477 |
| Date | January 2015 |
| Contributors | Yin, Junmei (author.), Chan, Juliana C. N. (thesis advisor.), Chinese University of Hong Kong Graduate School. Division of Medical Sciences. (degree granting institution.) |
| Source Sets | The Chinese University of Hong Kong |
| Language | English, Chinese, Chinese |
| Detected Language | English |
| Type | Text, bibliography, text |
| Format | electronic resource, electronic resource, remote, 1 online resource (xviii, 252 leaves) : illustrations (some color), computer, online resource |
| Rights | Use of this resource is governed by the terms and conditions of the Creative Commons "Attribution-NonCommercial-NoDerivatives 4.0 International" License (http://creativecommons.org/licenses/by-nc-nd/4.0/) |
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