Aim

We evaluated the sustained effects of multicomponent risk assessment and data-driven care augmented by the web-based Joint Asia Diabetes Evaluation (JADE) Platform with a built-in template to guide comprehensive assessment (CA) for risk stratification on top of usual care in patients with type 2 diabetes (T2D) from Malaysia.

Methods

In 2012-2015, 1196 T2D patients participated in a 1-year JADE Program randomised to (1) CA-only, (2) receipt of a JADE personalised report (CA + R) to empower self-care, or (3) engagement by nurse phone calls (CA + R + T). In 2020-2022, patients underwent repeat CA for evaluation of attainment of ≥2 ABC targets (HbA1c <7%, Blood pressure <130/80 mmHg, low-density lipoprotein Cholesterol [LDL-C] <2.6 mmol/L) and diabetes-related endpoints.

Results

After 7.5 ± 0.5 (mean ± SD) years, 138 (11.5%) patients had died, 232 (19.4%) defaulted, and 826 (69.1%) patients returned. The deceased had more complications, while non-returnees were younger, with fewer complications but worse risk factor control than returnees at baseline. Using inverse probability weighting and logistic regression, attaining ≥2 ABC targets was associated with CA + R + T (vs. CA-only) with an odds ratio (OR, 95% confidence interval) of 1.57 (1.02-2.41, p = 0.041). Other predictors included age [1.05 (1.04-1.07, p < 0.001)], diabetes duration [0.97 (0.95-0.99, p = 0.003)], JADE risk category 3 [0.41 (0.26-0.66), p < 0.001] and risk category 4 (vs. category 1 and 2) [0.22 (0.12-0.38), p < 0.001]. Amongst participants without complications at baseline, CA + R + T was associated with an incidence rate ratio of 0.89 (0.78-1.00, p = 0.043) for any diabetes-related endpoints.

Conclusions

Technology-assisted multicomponent risk assessment and data-driven care for 1-year identified high-risk patients and improved outcomes after 7 years.

Keywords

data‐driven; diabetes; legacy effects; multicomponent care; technology; treatment targets.

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