Harriet Chung

Effects of Telephone-Based Peer Support in Patients With Type 2 Diabetes Mellitus Receiving Integrated Care: A Randomized Clinical Trial

IMPORTANCE In type 2 diabetes mellitus (T2DM), team management using protocols with regular feedback improves clinical outcomes, although suboptimal self-management and psychological distress remain significant challenges. OBJECTIVE To investigate if frequent contacts through a telephone-based peer support program (Peer Support, Empowerment, and Remote Communication Linked by Information Technology [PEARL]) would improve cardiometabolic risk and health outcomes by enhancing psychological well-being and self-care in patients receiving integrated care implemented through a web-based multicomponent quality improvement program (JADE [Joint Asia Diabetes Evaluation]). DESIGN, SETTING, AND PARTICIPANTS Between 2009 and 2010, 628 of 2766 Hong Kong Chinese patients with T2DM from 3 publicly funded hospital-based diabetes centers were randomized to the JADE + PEARL (n = 312) or JADE (n = 316) groups, with comprehensive assessment at 0 and 12 months. INTERVENTIONS Thirty-three motivated patients with well-controlled T2DM received 32 hours of training (four 8-hour workshops) to become peer supporters, with 10 patients assigned to each. Peer supporters called their peers at least 12 times, guided by a checklist. MAIN OUTCOMES AND MEASURES Changes in hemoglobin A(1c) (HbA(1c)) level (primary), proportions of patients with attained treatment targets (HbA(1c) <7%; blood pressure <130/80 mm Hg; low-density lipoprotein cholesterol <2.6 mmol/L [to convert to milligrams per deciliter, divide by 0.0256]) (secondary), and other health outcomes at month 12. RESULTS Both groups had similar baseline characteristics (mean [SD] age, 54.7 [9.3] years; 57% men; disease duration, 9.4 [7.7] years; HbA(1c) level, 8.2% [1.6%]; systolic blood pressure, 136 [19] mm Hg; low-density lipoprotein cholesterol level, 2.89 [0.82] mmol/L; 17.4% cardiovascular-renal complications; and 34.9% insulin treated). After a mean (SD) follow-up period of 414 (55) days, 5 patients had died, 144 had at least 1 hospitalization, and 586 had repeated comprehensive assessments. On intention-to-treat analysis, both groups had similar reductions in HbA(1c) (JADE + PEARL, 0.30% [95% CI, 0.12%-0.47%], vs JADE, 0.29% [95% CI, 0.12%-0.47%] [P = .97]) and improvements in treatment targets and psychological-behavioral measures. In the JADE + PEARL group, 90% of patients maintained contacts with their peer supporters, with a median of 20 calls per patient. Most of the discussion items were related to self-management. CONCLUSIONS AND RELEVANCE In patients with T2DM receiving integrated care, peer support did not improve cardiometabolic risks or psychological well-being. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00950716.

The Clinical Utility of SUDOSCAN in Chronic Kidney Disease in Chinese Patients with Type 2 Diabetes

There are gaps between recommendations on regular screening for diabetic kidney disease (DKD) and clinical practice especially in busy and low resource settings. SUDOSCAN (Impeto Medical, Paris, France) is a non-invasive technology for assessing sudomotor function using reverse iontophoresis and chronoamperometry which detects abnormal sweat gland function. Vasculopathy and neuropathy share common risk factors and we hypothesized that SUDOSCAN may be used to detect chronic kidney disease (CKD). Between 2012 and 2013, SUDOSCAN was performed in a consecutive cohort of 2833 Hong Kong Chinese adults with type 2 diabetes. Chronic kidney disease was defined as estimated glomerular filtration rate <60 ml/min/1.73m2. In this cross-sectional cohort (mean age 58.6±9.5 years, 55.7% male, median disease duration 8 [interquartile range 3–14] years), 5.8% had CKD. At a cut-off SUDOSCAN-DKD score of 53, the test had sensitivity of 76.7%, specificity of 63.4% and positive likelihood ratio of 2.1 to detect CKD. The area under receiver operating characteristic curve for CKD was 0.75 (95% confidence interval 0.72–0.79). Patients without CKD but low score had worse risk factors and complications than those with high score. We conclude that SUDOSCAN may be used to detect patients at risk of impaired renal function as part of a screening program in Chinese population, especially in outreach or low resource settings.

Gender, diabetes education, and psychosocial factors are associated with persistent poor glycemic control in patients with type 2 diabetes in the Joint Asia Diabetes Evaluation (JADE) program.

Factors associated with persistent poor glycemic control were explored in patients with type 2 diabetes under the Joint Asia Diabetes Evaluation (JADE) program.

Effects of Providing Peer Support on Diabetes Management in People With Type 2 Diabetes

PURPOSE We examined the effects of participating in a “train-the-trainer” program and being a peer supporter on metabolic and cognitive/psychological/behavioral parameters in Chinese patients with type 2 diabetes. METHODS In response to our invitation, 79 patients with fair glycemic control (HbA1c <8%) agreed to participate in a “train-the-trainer” program to become peer supporters. Of the 59 who completed the program successfully, 33 agreed to be peer supporters (“agreed trainees”) and were each assigned to support 10 patients for 1 year, with a voluntary extension period of 3 additional years, while 26 trainees declined to be supporters (“refused trainees”). A group of 60 patients with fair glycemic control who did not attend the training program and were under usual care were selected as a comparison group. The primary outcome was the change in average HbA1c levels for the 3 groups from baseline to 6 months. RESULTS At 6 months, HbA1c was unchanged in the trainees (at baseline, 7.1 ± 0.3%; at 6 months, 7.1 ± 1.1%) but increased in the comparison group (at baseline, 7.1 ± 0.5%; at 6 months, 7.3 ± 1.1%. P = .02 for between-group comparison). Self-reported self-care activities including diet adherence and foot care improved in the trainees but not the comparison group. After 4 years, HbA1c remained stable among the agreed trainees (at baseline, 7.0 ± 0.2%; at 4 years: 7.2 ± 0.6%), compared with increases in the refused trainees (at baseline, 7.1 ± 0.4%; at 4 years, 7.8 ± 0.8%) and comparison group (at baseline, 7.1 ± 0.5%; at 4 years, 8.1 ± 0.6%. P = .001 for between-group comparison). CONCLUSIONS Patients with diabetes who engaged in providing ongoing peer support to other patients with diabetes improved their self-care while maintaining glycemic control over 4 years.

Healing effect of a two-herb recipe (NF3) on foot ulcers in Chinese patients with diabetes: a randomized double-blind placebo-controlled study.

In the present study, we examined the effect of a two‐herb traditional Chinese medicine (NF3), comprised of Astragali Radix and Radix Rehmanniae, on the healing of diabetic foot ulcer and the possible molecular mechanisms involved.

Health-Related Quality of Life in Chinese Patients with Type 2 Diabetes: An Analysis of the Joint Asia Diabetes Evaluation (JADE) Program

Objective: Diabetes is associated with impaired health-related quality of life (HRQoL) which predicts adverse clinical outcome. To examine clinical factors associated with HRQoL in a cross-sectional cohort of 14,826 Hong Kong Chinese patients with type 2 diabetes receiving outpatient care. Methods: Adult patients with type 2 diabetes who underwent comprehensive assessment of risk factors and complications using the web-based Joint Asia Diabetes Evaluation (JADE) Program also completed the EuroQol-5D (EQ-5D) questionnaire and visual analogue scale (VAS) for evaluation of HRQoL. Multiple linear regression analysis was used to identify clinical correlates with EQ-5D index and the association was expressed using β-coefficient whereby β>0 indicates positive correlation and β<0 indicates negative correlation. Results: More patients reported problems with pain/discomfort (24.8%) and anxiety/depression (20.3%) than other dimensions of mobility (7.1%), self-care (2.2%) and usual activities (4.3%). Age (β=-0.001), female gender (β=- 0.049), obesity (β=-0.007), hypoglycemia at least once monthly (β=-0.04), presence of cardiovascular disease (β=- 0.034), nephropathy (β=-0.014) and sensory neuropathy (β=-0.063) were independently correlated with lower EQ-5D index, while hypertension (β=0.017) and use of insulin (β=0.017) were correlated with higher EQ-5D index (p<0.05). Conclusion: In Hong Kong Chinese patients with type 2 diabetes, somatic and psychological complaints were common. Apart from demographic characteristics, risk factors, complications and treatment all influenced HRQoL.

Retinal Information is Independently Associated with Cardiovascular Disease in Patients with Type 2 diabetes.

To evaluate the association between a series of retinal information and cardiovascular disease (CVD) and to evaluate whether this association is independent of traditional CVD risk factors in type 2 diabetes patients, we undertook an age-sex matched case-control study with 79 CVD cases and 150 non-CVD controls. All the participants underwent standardized physical examinations and retinal imaging. Retinal information was extracted from the retinal images using a semi-automatic computer program. Three stepwise logistic regression models were evaluated: model 1 with cardiovascular risk factors only; model 2 with retinal information only and model 3 with both cardiovascular risk factors and retinal information. The areas under the receiver operating characteristic curves (AUCs) were used to compare the performances of different models. Results showed that the AUCs were 0.692 (95%CI: 0.622−0.761) and 0.661 (95%CI: 0.588−0.735) for model 1 and model 2, respectively. In addition, model 3 had an AUC of 0.775 (95%CI: 0.716−0.834). Compared to the previous two models, the AUC of model 3 increased significantly (p < 0.05 in both comparisons). In conclusion, retinal information is independently associated with CVD in type 2 diabetes. Further work is needed to validate the translational value of applying retinal imaging analysis into clinical practice.

Healing effect of a two-herb recipe (NF3) on foot ulcers in Chinese patients with diabetes: A randomized double-blind placebo-controlled study (包含两种草本中药的配方（NF3）对中国糖尿病患者足部溃疡的治疗作用：一项随机双盲安慰剂对照的研究)†

In the present study, we examined the effect of a two‐herb traditional Chinese medicine (NF3), comprised of Astragali Radix and Radix Rehmanniae, on the healing of diabetic foot ulcer and the possible molecular mechanisms involved.

Regular mailing of personalized feedback reports improved glycemic control in diabetes – a randomized controlled trial

Background To examine the effects of mailing regular personalized follow-up(FU) reports on metabolic control and hospitalization in patients managed by the Joint Asia Diabetes Evaluation(JADE) Program. Methods: In 2013, 1200 Chinese patients with diabetes (95.8% type 2 diabetes, mean age:58.3 ± 12.6 years, disease duration:10.1 ± 8.2 years, HbA1c: 7.4 ± 1.4%, 35% insulin-treated) underwent comprehensive assessment(CA) with usual clinic FU visits. 600 patients were randomized to receive 2 FU reports(R+) by mail and 600 without(R-). The FU reports showed trends of HbA1c, blood pressure, low-density lipoprotein cholesterol and body weight with recommended targets and reminders on self-care triggered by attained targets. The primary outcome was change in HbA1c and frequency of hospitalization at month 12. Results Both groups had similar baseline HbA1c(R+:7.3 ± 1.45% versus R-:7.4 ± 1.31%, p = 0.362). After 575(519-646) [median (IQR)] days, HbA1c fell by -0.2% (95% CI [-0.27,-0.13], p < 0.001) in the whole cohort, with greater reduction in the R+ (-0.24[-0.35,-0.14]%) than the R- group (-0.15[-0.24, -0.06]%, p = 0.03). Linear regression confirmed independent effect of FU reports on reducing HbA1c (β coefficient: -0.23[-0.39,-0.07], p = 0.004). Fewer patients with chronic kidney disease (CKD) in the R+ group (42.3% versus 69.2%, p = 0.047) had hospitalizations with lower frequency (relative risk [95%CI], 0.50[0.28,0.91], p = 0.021) and shorter length of stay (0.49[0.23,0.94], p = 0.023) than the R- group, after adjustment for confounders including age, gender, diabetes duration, glycemic control, BMI, self-care behaviors, and complications with log-transformed follow up time as offset value. Conclusions Regular personalized feedback reports improved glycemic control in patients with diabetes and reduced hospitalization in those with CKD.

Healing effect of a two-herb recipe (NF3) on foot ulcers in Chinese patients with diabetes: A randomized double-blind placebo-controlled study (包含两种草本中药的配方（NF3）对中国糖尿病患者足部溃疡的治疗作用：一项随机双盲安慰剂对照的研究): TCM and diabetic foot ulcer

In the present study, we examined the effect of a two‐herb traditional Chinese medicine (NF3), comprised of Astragali Radix and Radix Rehmanniae, on the healing of diabetic foot ulcer and the possible molecular mechanisms involved.