Skip Navigation
Skip to contents

Diabetes Metab J : Diabetes & Metabolism Journal

Search
OPEN ACCESS

Articles

Page Path
HOME > Diabetes Metab J > Volume 41(2); 2017 > Article
Review
Clinical Care/Education A Clinical Practice Guideline to Guide a System Approach to Diabetes Care in Hong Kong
Ip Tim Lau1,2orcid
Diabetes & Metabolism Journal 2017;41(2):81-88.
DOI: https://doi.org/10.4093/dmj.2017.41.2.81
Published online: April 14, 2017
  • 3,849 Views
  • 56 Download
  • 34 Web of Science
  • 34 Crossref
  • 35 Scopus

1Department of Medicine, Tseung Kwan O Hospital, Hong Kong.

2Central Committee on Diabetic Services, Hong Kong Hospital Authority, Hong Kong.

Corresponding author: Ip Tim Lau. Department of Medicine, Tseung Kwan O Hospital. 2 Po Ning Lane, Tseung Kwan O, Hong Kong. lauit@ha.org.hk
• Received: November 30, 2016   • Accepted: January 2, 2017

Copyright © 2017 Korean Diabetes Association

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • The Hospital Authority of Hong Kong is a statutory body that manages all the public medical care institutions in Hong Kong. There are currently around 400,000 diabetic patients under its care at 17 hospitals (providing secondary care for 40%) and 73 General Outpatient Clinics (providing primary care for 60%). The patient population has been growing at 6% to 8% per year over the past 5 years, estimated to include over 95% of all diagnosed patients in Hong Kong. In order to provide equitable and a minimal level of care within resources and local system factors constraints, a Clinical Practice Guideline on the management of type 2 diabetes mellitus was drawn in 2013 to guide a system approach to providing diabetes care. There is an algorithm for the use of various hypoglycemic agents. An organizational drug formulary governs that less expansive options have to be used first. A number of clinical care and patient empowerment programs have been set up to support structured and systematic diabetes care. With such a system approach, there have been overall improvements in diabetes care with the percentage of patients with glycosylated hemoglobin <7% rising from 40% in 2010 to 52% in 2015.
The prevalence of diabetes mellitus has continued to rise worldwide with the latest estimation by the International Diabetes Federation that, by the year 2040, one in 10 adults or 642 million people will have diabetes [1]. Tackling its rise and the health burden arising from the disease is a major challenge to almost all health care systems. Hong Kong, returned to the sovereignty of China as a Special Administrative Region from the United Kingdom, is no exception. Being the most developed region of China, its prevalence of diabetes is higher than the national average. The direct medical cost for managing diabetes and its complications was estimated to take up 3.9% of the total healthcare expenditure and 6.4% of the public health expenditure [2].
Hong Kong has a dual track system with public and private care along each other. For historical reasons, specialist and inpatient care is mainly provided by the public sector (90%), which also provides 29% of primary outpatient care through the General Outpatient Clinics (GOPCs). However, in the, hitherto, absence of an universal health insurance or co-payment scheme, much of the primary care provided by the public sector actually involves caring for people with chronic diseases, since most of them find long term treatment of their conditions by private doctors difficult to afford. The Hospital Authority (HA) of Hong Kong is a statutory body set up to provide all public health care services in the territory. It manages 41 hospitals and institutions, 47 Specialist Outpatient Clinics, which together provide inpatient and specialist care; and 73 GOPCs where primary care for the early stages of chronic diseases for most patients is delivered. These hospitals and clinics are organised into seven geographical clusters to provide a continuum of primary and specialist services to the citizens. The expenditure of the HA is largely dependent on government funding which amounts to HK$50.76 billion (~USD 6.5 billion) and constitutes less than half of the 5.4% of the gross domestic product (GDP) that is spent on health care in Hong Kong (Table 1). A recent Bloomberg news coverage ranked the health care system of Hong Kong the most efficient in the world [3]. Therefore, it is obvious that the HA has been running on a very tight budget.
The prevalence of diabetes in Hong Kong is about 10% [4]. With a population of 7.4 million, it is estimated that there are about 740 thousand diabetic patients, 40% to 50% of whom are undiagnosed. However, the number of diabetic patients under the care of the HA has been rising steadily from 397 thousand in 2009/2010 to 408 thousand in 2015/2016 (Fig. 1). Annually, 33 to 35 thousand new diabetic patients are added to the public health care system (Fig. 2). The rise is likely contributed to by earlier diagnosis among the undiagnosed because of increased awareness of diabetes in the community; attraction of more patients from the private to the public sector; an increase in the prevalence of diabetes due to an increase in the incidence among younger people, etc. Thus, diabetes is a major burden to the HA because it is estimated that more than 90% of the known diabetic patients are under its care.
With the background of forerunners in research and service development, the HA started a journey of a system approach to providing diabetes care across the whole public health care system in 2009. A Central Committee on Diabetic Services was set up to steer the development. The following strategies have been adopted:
  1. Service data were captured and analysed through the electronic Clinical Management System.

  2. Clinical modules in the Clinical Management System to facilitate clinical care for diabetes and capture diabetes specific clinical data.

  3. Corporate Clinical Practice Guideline (CPG) on the management of type 2 diabetes: first published 2013; currently being reviewed to be updated in 2017.

  4. Large scale programmes to enhance diabetes care including a territory-wide multi-disciplinary Risk Assessment and Management Program for diabetes (RAMP-DM) and a structured Patient Empowerment Program (PEP) in the GOPCs.

  5. Regular monitoring of performance indicators.

The intent of the guideline was to describe the minimal level of care to be provided across the different care levels in the HA, with due consideration of available evidence and local systems factors. On the other hand, a service framework outlining the cycle of periodic assessment, risk stratification for different management and patient empowerment strategies and regular follow-up at the different care levels was included (Fig. 3). Importantly, patient empowerment is considered an integral component of diabetes care. An algorithm was drawn to guide the use of the various glucose lowering agents (Fig. 4). The management of hypertension and dyslipidemia was discussed with a view to minimizing cardiovascular risk. Although the targets for glycosylated hemoglobin (HbA1c), blood pressure and low density lipoprotein cholesterol (LDL-C) are to be individualized, those recommended by international guidelines in 2013 were adopted for suitable patients (Table 2). There is also guidance on the management of the various chronic complications of diabetes. Criteria for referral to specialists such as endocrinologists, ophthalmologists, orthopaedic, and vascular surgeons were outlined.
A special note should be made regarding the use of drugs, including glucose lowering agents, in the HA. There is a corporate drug formulary in which drugs are classified into general, special, and self-financed items. General drugs can be freely used by all doctors; special drugs can only be used for specific clinical indications by designated specialists; self-financed items are purchased by their patients out-of-pocket if the clinical indications are not met or present. The formulary effectively governs that less expensive options have to be used first unless or until they are not tolerated or effective, which helps contain the drug expenditure. The formulary is periodically reviewed to take into consideration new clinical evidence, changes in prize and introduction of new drugs or formulations. Thus, metformin, sulphonylureas, and human insulin are general drugs, to which pioglitazone was recently added as its price has come down. DDP-4 and sodium/glucose cotransporter 2 inhibitors are special drugs that can only be used when the combination of metformin and sulphonylureas with or without pioglitazone fail to control glycemia. Insulin analogues can only be used for patients with repeated hypoglycemia while on human insulin or patients with established cardiovascular and renal complications. Glucagon-like peptide-1 analogues are self-financed items because of the high prices.
In 2009, the HA introduced a multidisciplinary RAMP-DM to improve the quality of care for patients receiving diabetic care in the GOPCs [5]. All patients with type 2 diabetes mellitus who are independent in their activities of daily living and being followed up regularly at the GOPCs are eligible for the RAMP. Enrolled patients undergo a comprehensive risk assessment with checking of relevant clinical parameters including HbA1c, blood pressure, LDL-C, and screening for diabetes-related complications according to a standardized protocol. After the assessment, patients are classified into different risk groups according to the Joint Asia Diabetes Evaluation (JADE) criteria [6] and are offered different management options to receive appropriate interventions and education provided by a team of multidisciplinary healthcare professionals. Low risk patients continue with the usual GOPC care; medium risk patients are given additional intervention by a nurse with special training in diabetes; and high risk/very high risk patients are reviewed by a specialist family physician for intensification. About two-thirds of the diabetic patients under the care of the GOPCs (277,309 in 2015/2016) have been enrolled.
The effect and effectiveness of the RAMP-DM has been evaluated by three prospective cohort studies. Thus, it was found that there was a significant decrease in HbA1c (−0.20%, P<0.01), systolic blood pressure (SBP; −3.62 mm Hg, P<0.01), 10-year cardiovascular disease (CVD) risks (total CVD risk, −2.06%, P<0.01; coronary heart disease [CHD] risk, −1.43%, P<0.01; stroke risk, −0.71%, P<0.01) at 12 months in a random sample of 1,248 patients enrolled to RAMP-DM compared with an age-, sex-, and HbA1c-matched group of unenrolled 1,248 patients under the usual primary care. There was a rise in the percentage of patients reaching treatment targets of HbA1c (5.4%, P<0.01), and SBP/diastolic blood pressure (5.77%, P<0.01) and a lower cardiovascular events incidence (1.21% vs. 2.89%, P=0.003) [7]. More significantly, in another prospective cohort study of 18,188 propensity score matched RAMP-DM participants and patients receiving the usual primary care with a median follow-up of 36 months (9,094 subjects in each group), there were significantly lowered adjusted hazard ratios (HRs) in the RAMP-DM group compared with the usual care group in all-cause deaths (0.363; 95% confidence interval [CI], 0.308 to 0.428; P<0.001); CHD (0.570; 95% CI, 0.470 to 0.691; P<0.001); stroke (0.652; 95% CI, 0.546 to 0.780; P<0.001); and congestive heart failure (0.598; 95% CI, 0.446 to 0.802; P=0.001) [8]. Further, a third study comparing RAMP-DM participants with subjects under the usual primary care (14,835 in each group) with a median follow-up of 36 months, RAMP-DM participants had a lower incidence of microvascular complications (760 vs. 935; adjusted HR, 0.73; 95% CI, 0.66 to 0.81; P<0.001) and lower incidences of all specific microvascular complications except neuropathy (adjusted HR, 0.94; 95% CI, 0.61 to 1.45; P=0.778). Adjusted HRs for the RAMP-DM versus control group for end stage renal disease, sight threatening diabetic retinopathy or blindness, and lower-limb ulcers or amputation were 0.40 (95% CI, 0.24 to 0.69; P<0.001), 0.55 (95% CI, 0.39 to 0.78; P=0.001), and 0.49 (95% CI, 0.30 to 0.80; P=0.005), respectively [9]. Although these are not randomized controlled trials, the careful matching, large numbers of patients and long duration of follow-up meant that a program of risk assessment and stratification followed by appropriate intervention is likely to be high effective in improving long term clinical outcomes.
Life style modification through patient empowerment has long been considered an important and integral component of management of diabetes. Diabetic self-management education, whether delivered on an individual or group setting, has been shown to improve glycemic and cardiovascular risk factor control [101112]. In 2010, the Hong Kong Hospital Authority launched the PEP as a territory-wide primary care component with the purpose of improving the quality of care. The curriculum of the PEP, designed by a group of specialist diabetes nurse educators, was delivered in six sessions by trained healthcare workers in community centers run by non-government organizations. There was a generic component covering behavior modification, healthy diet and regular exercise habit, goal setting and problem solving skills, sharing on self-monitoring experience, stress coping management, psychosocial support and networking, and communications with healthcare professionals. A second, disease-specific component dealt with specific knowledge about diabetes, medications, and management of hypo- and hyperglycemia.
In an observational matched cohort study comparing a random sample of PEP participants with a group of matched control, each consisting of 1,141 subjects, the PEP group had an average decrease of 0.138% in the HbA1c level (95% CI, −0.252 to −0.024; P=0.017) more than the control group. The PEP group also achieved a significant decrease in the mean LDL-C value (0.254 mmol/L, P<0.001), and the decrease was significantly more (−0.136 mmol/L; 95% CI, −0.223 to −0.048; P<0.001) than that of the control group [13]. More importantly, three prospective cohort studies, each comparing a group of more than 12,000 PEP participants with a group of matched control of the same number of patients with a median follow-up of more than 21 months, have been published. PEP participants had a lower rate of all-cause mortality (HR, 0.564; 95% CI, 0.445 to 0.715; P<0.001), first CVD (HR, 0.807; 95% CI, 0.696 to 0.935; P=0.004), and stroke (HR, 0.702; 95% CI, 0.569 to 0.867; P=0.001) than those without PEP [14]. PEP participants were associated with a lower incidence of first microvascular event (HR, 0.85; 95% CI, 0.78 to 0.94; P=0.001) and nephropathy (HR, 0.71; 95% CI, 0.62 to 0.80; P<0.001) than non-PEP participants, after adjusting for confounding variables [15]. There were a significantly lower number of emergency department visits (incidence rate ratio, 0.903; P<0.001): 40.4 visits per 100 patients annually among the PEP group versus 36.2 per 100 patients annually in the control group; and significantly fewer hospitalization episodes (incidence rate ratio, 0.854; P<0.001): 20.0 hospitalizations per 100 patients annually in the PEP group versus 16.9 hospitalizations per 100 patients annually in the control group [16]. To date, the PEP is the first structured diabetic self-management education program shown to improve mortality, macro- and microvascular complications, and utilization of health services.
In order to monitor the overall improvement in diabetic control, the percentage of all the patients under the care of the Hospital Authority with HbA1c below 7% has been captured from the laboratory information system of the corporate electronic Clinical Management System. The percentage improved from 33% in 2008/2009 to over 50% in 2015/2016 (Fig. 5), reflecting that the strategies have been effective in improving the overall control. This will probably translate into a decrease in the incidence of complications. The experience of Hong Kong demonstrated that a system approach, comprising a CPG to guide clinical care, a system for ensuring that the key care processes of assessment, risk stratification and appropriate multidisciplinary interventions are implemented, is required to tackle the problem.
Charged with the responsibility for providing a health care safety net for all citizens of Hong Kong, the HA has to provide efficient and effective care for the majority of people with diabetes in the city within a very tight budget. However, since all the public hospitals and clinics are under its management, it has the advantage of being able to adopt a system approach to organize diabetes care across the different levels of health care settings for the whole continuum of the disease. The organizational CPG sets the standard of care, covering the following areas: (1) diagnosis; (2) minimal processes in outpatient management; (3) patient self-education as an integral component of management; (4) glucose lowering therapy; (5) control of cardiovascular factors; (6) regular screening for diabetic complications at 1 to 3 years' intervals; and (7) inpatient management of hyperglycemic emergencies and perioperative situations. A number of programs have been set up to support systemic and structured care, including a 6-class interactive PEP for early disease run by non-governmental organizations; education through telephone calls by trained nurses; a structured complication assessment program; an insulin initiation program at the GOPCs; control intensification at diabetes centers at hospitals. Various key performance and clinical indicators are regularly monitored across different hospitals and clinics to assure quality. The provision of diabetes care by the HA is an integral and representative component of the highly efficient and regarded public health care system of Hong Kong, which many economies, including mainland China [17], can learn from.

CONFLICTS OF INTEREST: No potential conflict of interest relevant to this article was reported.

  • 1. International Diabetes Federation. IDF diabetes atlas. 7th ed. Brussels: International Diabetes Federation; 2015.
  • 2. Chan BS, Tsang MW, Lee VW, Lee KK. Cost of type 2 diabetes mellitus in Hong Kong Chinese. Int J Clin Pharmacol Ther 2007;45:455-468. ArticlePubMed
  • 3. Bloomberg. U.S. Health-care system ranks as one of the least-efficient: America is number 50 out of 55 countries that were assessed updated 2016 Sep 29. Available from: http://www.bloomberg.com/news/articles/2016-09-29/u-s-health-care-system-ranks-as-one-of-the-least-efficient.
  • 4. Wong KC, Wang Z. Prevalence of type 2 diabetes mellitus of Chinese populations in Mainland China, Hong Kong, and Taiwan. Diabetes Res Clin Pract 2006;73:126-134. ArticlePubMed
  • 5. Fung CS, Chin WY, Dai DS, Kwok RL, Tsui EL, Wan YF, Wong W, Wong CK, Fong DY, Lam CL. Evaluation of the quality of care of a multi-disciplinary risk factor assessment and management programme (RAMP) for diabetic patients. BMC Fam Pract 2012;13:116ArticlePubMedPMCPDF
  • 6. Chan J, So W, Ko G, Tong P, Yang X, Ma R, Kong A, Wong R, Le Coguiec F, Tamesis B, Wolthers T, Lyubomirsky G, Chow P. The Joint Asia Diabetes Evaluation (JADE) Program: a web-based program to translate evidence to clinical practice in type 2 diabetes. Diabet Med 2009;26:693-699. ArticlePubMed
  • 7. Jiao FF, Fung CS, Wong CK, Wan YF, Dai D, Kwok R, Lam CL. Effects of the Multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) on biomedical outcomes, observed cardiovascular events and cardiovascular risks in primary care: a longitudinal comparative study. Cardiovasc Diabetol 2014;13:127ArticlePubMedPMCPDF
  • 8. Jiao F, Fung CS, Wan YF, McGhee SM, Wong CK, Dai D, Kwok R, Lam CL. Long-term effects of the multidisciplinary risk assessment and management program for patients with diabetes mellitus (RAMP-DM): a population-based cohort study. Cardiovasc Diabetol 2015;14:105ArticlePubMedPMC
  • 9. Jiao F, Fung CS, Wan YF, McGhee SM, Wong CK, Dai D, Kwok R, Lam CL. Effectiveness of the multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) for diabetic microvascular complications: a population-based cohort study. Diabetes Metab 2016;42:424-432. ArticlePubMed
  • 10. Steinsbekk A, Rygg LO, Lisulo M, Rise MB, Fretheim A. Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis. BMC Health Serv Res 2012;12:213ArticlePubMedPMCPDF
  • 11. Duke SA, Colagiuri S, Colagiuri R. Individual patient education for people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2009;(1):CD005268ArticlePubMedPMC
  • 12. Jarvis J, Skinner TC, Carey ME, Davies MJ. How can structured self-management patient education improve outcomes in people with type 2 diabetes? Diabetes Obes Metab 2010;12:12-19. ArticlePubMed
  • 13. Wong CK, Wong WC, Lam CL, Wan YF, Wong WH, Chung KL, Dai D, Tsui EL, Fong DY. Effects of Patient Empowerment Programme (PEP) on clinical outcomes and health service utilization in type 2 diabetes mellitus in primary care: an observational matched cohort study. PLoS One 2014;9:e95328ArticlePubMedPMC
  • 14. Wong CK, Wong WC, Wan YF, Chan AK, Chung KL, Chan FW, Lam CL. Patient Empowerment Programme in primary care reduced all-cause mortality and cardiovascular diseases in patients with type 2 diabetes mellitus: a population-based propensity-matched cohort study. Diabetes Obes Metab 2015;17:128-135. ArticlePubMed
  • 15. Wong CK, Wong WC, Wan YF, Chan AK, Chan FW, Lam CL. Patient Empowerment Programme (PEP) and risk of microvascular diseases among patients with type 2 diabetes in primary care: a population-based propensity-matched cohort study. Diabetes Care 2015;38:e116-e117. ArticlePubMedPDF
  • 16. Wong CK, Wong WC, Wan YF, Chan AK, Chan FW, Lam CL. Effect of a structured diabetes education programme in primary care on hospitalizations and emergency department visits among people with type 2 diabetes mellitus: results from the Patient Empowerment Programme. Diabet Med 2016;33:1427-1436. ArticlePubMed
  • 17. Kong X, Yang Y, Gao J, Guan J, Liu Y, Wang R, Xing B, Li Y, Ma W. Overview of the health care system in Hong Kong and its referential significance to mainland China. J Chin Med Assoc 2015;78:569-573. ArticlePubMed
Fig. 1

Total number of diabetic patients under the care of the Hong Kong Hospital Authority.

dmj-41-81-g001.jpg
Fig. 2

Number of diabetic patients new to the Hospital Authority.

dmj-41-81-g002.jpg
Fig. 3

Hospital Authority's service framework for the provision of diabetes care.

dmj-41-81-g003.jpg
Fig. 4

Algorithm for blood glucose lowering therapy. DPP-4, dipeptidyl peptidase-4; CI, confidence interval; HbA1c, glycosylated hemoglobin.

dmj-41-81-g004.jpg
Fig. 5

Percentage of diabetic patients under the care of Hospital Authority achieving glycosylated hemoglobin <7%.

dmj-41-81-g005.jpg
Table 1

The dual-track health care system of Hong Kong

dmj-41-81-i001.jpg
Public sector Private sector
Funding source Highly subsidized by government Payment-out-pocket by patients
Private medical insurance
Expenditure as % of GDP 2.6% 2.8%
Access Open to all citizens Individual choice depending on affordability
Providers Hospital Authority 11 Private hospitals
41 Hospitals Around 100 private clinics
47 Specialist Outpatient Clinics >2,000 Private doctors in solo or group practice
73 General Outpatient Clinics
Market share
 Inpatient 90% 10%
 Outpatient 29% 71%

GDP, gross domestic product.

Table 2

Treatment target values for adult patients with type 2 diabetes

dmj-41-81-i002.jpg
Variable Ideal control Unsatisfactory control
Fasting plasma glucose, mmol/L 4–6 ≥8
Glycosylated hemoglobin <7a ≥8
Body mass index, kg/m2 <23 ≥27
Waist circumference for male, cm <90 (<36 inches) ≥90 (≥36 inches)
Waist circumference for female, cm <80 (<32 inches) ≥80 (≥32 inches)
Systolic blood pressure, mm Hg <130b ≥160
Diastolic blood pressure, mm Hg <80b ≥95
Total cholesterol, mmol/L <4.5 ≥6.2
HDL-C for male, mmol/L >1.0 <0.9
HDL-C for female, mmol/L >1.3 <0.9
LDL-C, mmol/L <2.6c ≥4.2
Triglyceride, mmol/L <1.7 ≥2.8

HDL-C, high density lipoprotein cholesterol; LDL-C, low density lipoprotein cholesterol.

aGoals should be individualized, bFor those with ≥1 g/day of proteinuria, the blood pressure target might be <125/75 mm Hg, cIn people with overt cardiovascular disease, a lower LDL-C goal of <1.8 mmol/L is an option.

Figure & Data

References

    Citations

    Citations to this article as recorded by  
    • Risk of Dementia Among Patients With Diabetes in a Multidisciplinary, Primary Care Management Program
      Kailu Wang, Shi Zhao, Eric Kam-Pui Lee, Susan Zi-May Yau, Yushan Wu, Chi-Tim Hung, Eng-Kiong Yeoh
      JAMA Network Open.2024; 7(2): e2355733.     CrossRef
    • Evaluating different low‐density lipoprotein cholesterol thresholds to initiate statin for prevention of cardiovascular diseases in patients with type 2 diabetes mellitus: A target trial emulation study
      Eric Yuk Fai Wan, Wanchun Xu, Anna Hoi Ying Mok, Weng Yee Chin, Esther Yee Tak Yu, Celine Sze Ling Chui, Esther Wai Yin Chan, Ian Chi Kei Wong, Cindy Lo Kuen Lam, Goodarz Danaei
      Diabetes, Obesity and Metabolism.2024; 26(5): 1877.     CrossRef
    • Prevalence and factors associated with diabetes-related distress in type 2 diabetes patients: a study in Hong Kong primary care setting
      Man Ho Wong, Sin Man Kwan, Man Chi Dao, Sau Nga Fu, Wan Luk
      Scientific Reports.2024;[Epub]     CrossRef
    • SGLT2i reduces risk of developing HCC in patients with co-existing type 2 diabetes and hepatitis B infection: A territory-wide cohort study in Hong Kong
      Chi-Ho Lee, Lung-Yi Mak, Eric Ho-Man Tang, David Tak-Wai Lui, Jimmy Ho-Cheung Mak, Lanlan Li, Tingting Wu, Wing Lok Chan, Man-Fung Yuen, Karen Siu-Ling Lam, Carlos King Ho Wong
      Hepatology.2023; 78(5): 1569.     CrossRef
    • Team-Based Diabetes Care in Ontario and Hong Kong: a Comparative Review
      Calvin Ke, Emaad Mohammad, Juliana C. N. Chan, Alice P. S. Kong, Fok-Han Leung, Baiju R. Shah, Douglas Lee, Andrea O. Luk, Ronald C. W. Ma, Elaine Chow, Xiaolin Wei
      Current Diabetes Reports.2023; 23(7): 135.     CrossRef
    • Association of eGFR slope with all-cause mortality, macrovascular and microvascular outcomes in people with type 2 diabetes and early-stage chronic kidney disease
      Qiao Jin, Cindy Lo Kuen Lam, Eric Yuk Fai Wan
      Diabetes Research and Clinical Practice.2023; 205: 110924.     CrossRef
    • Association Between SGLT2 Inhibitors vs DPP-4 Inhibitors and Risk of Pneumonia Among Patients With Type 2 Diabetes
      Philip C M Au, Kathryn C B Tan, Bernard M Y Cheung, Ian C K Wong, Ying Wong, Ching-Lung Cheung
      The Journal of Clinical Endocrinology & Metabolism.2022; 107(4): e1719.     CrossRef
    • Effectiveness of Integrative Chinese–Western Medicine for Chronic Kidney Disease and Diabetes: A Retrospective Cohort Study
      Kam Wa Chan, Tak Yee Chow, Kam Yan Yu, Yibin Feng, Lixing Lao, Zhaoxiang Bian, Vivian Taam Wong, Sydney Chi-Wai Tang
      The American Journal of Chinese Medicine.2022; 50(02): 371.     CrossRef
    • Association Between SGLT2 Inhibitors vs DPP4 Inhibitors and Renal Outcomes Among Patients With Type 2 Diabetes
      Philip C M Au, Kathryn C B Tan, Bernard M Y Cheung, Ian C K Wong, Hang-Long Li, Ching-Lung Cheung
      The Journal of Clinical Endocrinology & Metabolism.2022; 107(7): e2962.     CrossRef
    • Association Between Team-Based Continuity of Care and Risk of Cardiovascular Diseases Among Patients With Diabetes: A Retrospective Cohort Study
      Kam Suen Chan, Eric Yuk Fai Wan, Weng Yee Chin, Esther Yee Tak Yu, Ivy Lynn Mak, Will Ho Gi Cheng, Margaret Kay Ho, Cindy Lo Kuen Lam
      Diabetes Care.2022; 45(5): 1162.     CrossRef
    • mRNA (BNT162b2) and Inactivated (CoronaVac) COVID-19 Vaccination and Risk of Adverse Events and Acute Diabetic Complications in Patients with Type 2 Diabetes Mellitus: A Population-Based Study
      Eric Yuk Fai Wan, Celine Sze Ling Chui, Anna Hoi Ying Mok, Wanchun Xu, Vincent Ka Chun Yan, Francisco Tsz Tsun Lai, Xue Li, Carlos King Ho Wong, Esther Wai Yin Chan, David Tak Wai Lui, Kathryn Choon Beng Tan, Ivan Fan Ngai Hung, Cindy Lo Kuen Lam, Gabriel
      Drug Safety.2022; 45(12): 1477.     CrossRef
    • Evaluation of Fracture Risk Among Patients With Type 2 Diabetes and Nonvalvular Atrial Fibrillation Receiving Different Oral Anticoagulants
      David Tak Wai Lui, Eric Ho Man Tang, Ivan Chi Ho Au, Tingting Wu, Chi Ho Lee, Chun Ka Wong, Chloe Yu Yan Cheung, Carol Ho Yi Fong, Wing Sun Chow, Yu Cho Woo, Kathryn Choon Beng Tan, Karen Siu Ling Lam, Carlos King Ho Wong
      Diabetes Care.2022; 45(11): 2620.     CrossRef
    • Ten-Year Effectiveness of the Multidisciplinary Risk Assessment and Management Programme–Diabetes Mellitus (RAMP-DM) on Macrovascular and Microvascular Complications and All-Cause Mortality: A Population-Based Cohort Study
      Eric Ho Man Tang, Ivy Lynn Mak, Emily Tsui Yee Tse, Eric Yuk Fai Wan, Esther Yee Tak Yu, Julie Yun Chen, Weng Yee Chin, David Vai Kiong Chao, Wendy Wing Sze Tsui, Tony King Hang Ha, Carlos King Ho Wong, Cindy Lo Kuen Lam
      Diabetes Care.2022; 45(12): 2871.     CrossRef
    • An Intervention to Change Illness Representations and Self-Care of Individuals With Type 2 Diabetes: A Randomized Controlled Trial
      Virginia W.Y. Chan, Alice P.S. Kong, Joseph T.F. Lau, Winnie W.S. Mak, Linda D. Cameron, Phoenix K.H. Mo
      Psychosomatic Medicine.2021; 83(1): 71.     CrossRef
    • Risk of mortality and complications in patients with schizophrenia and diabetes mellitus: population-based cohort study
      Joe Kwun Nam Chan, Corine Sau Man Wong, Philip Chi Fai Or, Eric Yu Hai Chen, Wing Chung Chang
      The British Journal of Psychiatry.2021; 219(1): 375.     CrossRef
    • Screening for diabetic retinopathy with different levels of financial incentive in a randomized controlled trial
      Jin Xiao Lian, Sarah Morag McGhee, Ching So, Alfred Siu Kei Kwong, Rita Sum, Wendy Wing Sze Tsui, David Vai Kiong Chao, Jonathan Cheuk Hung Chan
      Journal of Diabetes Investigation.2021; 12(9): 1632.     CrossRef
    • Greater variability in lipid measurements associated with kidney diseases in patients with type 2 diabetes mellitus in a 10-year diabetes cohort study
      Eric Yuk Fai Wan, Esther Yee Tak Yu, Weng Yee Chin, Christie Sze Ting Lau, Anna Hoi Ying Mok, Yuan Wang, Ian Chi Kei Wong, Esther Wai Yin Chan, Cindy Lo Kuen Lam
      Scientific Reports.2021;[Epub]     CrossRef
    • Development and validation of the CHIME simulation model to assess lifetime health outcomes of prediabetes and type 2 diabetes in Chinese populations: A modeling study
      Jianchao Quan, Carmen S. Ng, Harley H. Y. Kwok, Ada Zhang, Yuet H. Yuen, Cheung-Hei Choi, Shing-Chung Siu, Simon Y. Tang, Nelson M. Wat, Jean Woo, Karen Eggleston, Gabriel M. Leung, Weiping Jia
      PLOS Medicine.2021; 18(6): e1003692.     CrossRef
    • Age‐Specific Associations of Usual Blood Pressure Variability With Cardiovascular Disease and Mortality: 10‐Year Diabetes Mellitus Cohort Study
      Eric Yuk Fai Wan, Esther Yee Tak Yu, Weng Yee Chin, Jessica K. Barrett, Ian Chi Kei Wong, Esther Wai Yin Chan, Celine Sze Ling Chui, Shiqi Chen, Cindy Lo Kuen Lam
      Journal of the American Heart Association.2021;[Epub]     CrossRef
    • Diabetes complication burden and patterns and risk of mortality in people with schizophrenia and diabetes: A population-based cohort study with 16-year follow-up
      Joe Kwun Nam Chan, Corine Sau Man Wong, Philip Chi Fai Or, Eric Yu Hai Chen, Wing Chung Chang
      European Neuropsychopharmacology.2021; 53: 79.     CrossRef
    • Age‐specific associations of glycated haemoglobin variability with cardiovascular disease and mortality in patients with type 2 diabetes mellitus: A 10‐ year cohort study
      Eric Yuk Fai Wan, Esther Yee Tak Yu, Weng Yee Chin, Florence Ting Yan Ng, Shu Ming Cheryl Chia, Ian Chi Kei Wong, Esther Wai Yin Chan, Cindy Lo Kuen Lam
      Diabetes, Obesity and Metabolism.2020; 22(8): 1316.     CrossRef
    • The Impact of Cardiovascular Disease and Chronic Kidney Disease on Life Expectancy and Direct Medical Cost in a 10-Year Diabetes Cohort Study
      Eric Yuk Fai Wan, Weng Yee Chin, Esther Yee Tak Yu, Ian Chi Kei Wong, Esther Wai Yin Chan, Shirley Xue Li, Nico Kwan Lok Cheung, Yuan Wang, Cindy Lo Kuen Lam
      Diabetes Care.2020; 43(8): 1750.     CrossRef
    • Greater variability in lipid measurements associated with cardiovascular disease and mortality: A 10‐year diabetes cohort study
      Eric Y. F. Wan, Esther Y. T. Yu, Weng Y. Chin, Jessica K. Barrett, Anna H. Y. Mok, Christie S. T. Lau, Yuan Wang, Ian C. K. Wong, Esther W. Y. Chan, Cindy L. K. Lam
      Diabetes, Obesity and Metabolism.2020; 22(10): 1777.     CrossRef
    • Age at diagnosis, glycemic trajectories, and responses to oral glucose-lowering drugs in type 2 diabetes in Hong Kong: A population-based observational study
      Calvin Ke, Thérèse A. Stukel, Baiju R. Shah, Eric Lau, Ronald C. Ma, Wing-Yee So, Alice P. Kong, Elaine Chow, Juliana C. N. Chan, Andrea Luk, Sanjay Basu
      PLOS Medicine.2020; 17(9): e1003316.     CrossRef
    • Age‐Specific Associations Between Systolic Blood Pressure and Cardiovascular Disease: A 10‐Year Diabetes Mellitus Cohort Study
      Eric Yuk Fai Wan, Esther Yee Tak Yu, Weng Yee Chin, Ian Chi Kei Wong, Esther Wai Yin Chan, Shiqi Chen, Cindy Lo Kuen Lam
      Journal of the American Heart Association.2020;[Epub]     CrossRef
    • Associations between usual glycated haemoglobin and cardiovascular disease in patients with type 2 diabetes mellitus: A 10‐year diabetes cohort study
      Eric YF Wan, Esther YT Yu, Julie Y Chen, Ian CK Wong, Esther WY Chan, Cindy LK Lam
      Diabetes, Obesity and Metabolism.2020; 22(12): 2325.     CrossRef
    • Cultural adaptation and psychometric properties of the Chinese Burden of Treatment Questionnaire (C-TBQ) in primary care patients with multi-morbidity
      Weng Yee Chin, Carlos King Ho Wong, Cherry Cheuk Wai Ng, Edmond Pui Hang Choi, Cindy Lo Kuen Lam
      Family Practice.2019; 36(5): 657.     CrossRef
    • Association of Blood Pressure and Risk of Cardiovascular and Chronic Kidney Disease in Hong Kong Hypertensive Patients
      Eric Yuk Fai Wan, Esther Yee Tak Yu, Weng Yee Chin, Daniel Yee Tak Fong, Edmond Pui Hang Choi, Cindy Lo Kuen Lam
      Hypertension.2019; 74(2): 331.     CrossRef
    • Burden of CKD and Cardiovascular Disease on Life Expectancy and Health Service Utilization: a Cohort Study of Hong Kong Chinese Hypertensive Patients
      Eric Yuk Fai Wan, Esther Yee Tak Yu, Weng Yee Chin, Daniel Yee Tak Fong, Edmond Pui Hang Choi, Eric Ho Man Tang, Cindy Lo Kuen Lam
      Journal of the American Society of Nephrology.2019; 30(10): 1991.     CrossRef
    • Effect of Achieved Systolic Blood Pressure on Cardiovascular Outcomes in Patients With Type 2 Diabetes: A Population-Based Retrospective Cohort Study
      Eric Yuk Fai Wan, Esther Yee Tak Yu, Weng Yee Chin, Colman Siu Cheung Fung, Daniel Yee Tak Fong, Edmond Pui Hang Choi, Anca Ka Chun Chan, Cindy Lo Kuen Lam
      Diabetes Care.2018; 41(6): 1134.     CrossRef
    • Evolution of Diabetes Care in Hong Kong: From the Hong Kong Diabetes Register to JADE-PEARL Program to RAMP and PEP Program
      Ivy H.Y. Ng, Kitty K.T. Cheung, Tiffany T.L. Yau, Elaine Chow, Risa Ozaki, Juliana C.N. Chan
      Endocrinology and Metabolism.2018; 33(1): 17.     CrossRef
    • Relation between HbA1c and incident cardiovascular disease over a period of 6 years in the Hong Kong population
      E.Y.F. Wan, E.Y.T. Yu, C.S.C. Fung, W.Y. Chin, D.Y.T. Fong, A.K.C. Chan, C.L.K. Lam
      Diabetes & Metabolism.2018; 44(5): 415.     CrossRef
    • Five-Year Effectiveness of the Multidisciplinary Risk Assessment and Management Programme–Diabetes Mellitus (RAMP-DM) on Diabetes-Related Complications and Health Service Uses—A Population-Based and Propensity-Matched Cohort Study
      Eric Yuk Fai Wan, Colman Siu Cheung Fung, Fang Fang Jiao, Esther Yee Tak Yu, Weng Yee Chin, Daniel Yee Tak Fong, Carlos King Ho Wong, Anca Ka Chun Chan, Karina Hiu Yen Chan, Ruby Lai Ping Kwok, Cindy Lo Kuen Lam
      Diabetes Care.2018; 41(1): 49.     CrossRef
    • Do We Need a Patient-Centered Target for Systolic Blood Pressure in Hypertensive Patients With Type 2 Diabetes Mellitus?
      Eric Yuk Fai Wan, Esther Yee Tak Yu, Colman Siu Cheung Fung, Weng Yee Chin, Daniel Yee Tak Fong, Anca Ka Chun Chan, Cindy Lo Kuen Lam
      Hypertension.2017; 70(6): 1273.     CrossRef

    • PubReader PubReader
    • Cite this Article
      Cite this Article
      export Copy Download
      Close
      Download Citation
      Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

      Format:
      • RIS — For EndNote, ProCite, RefWorks, and most other reference management software
      • BibTeX — For JabRef, BibDesk, and other BibTeX-specific software
      Include:
      • Citation for the content below
      A Clinical Practice Guideline to Guide a System Approach to Diabetes Care in Hong Kong
      Diabetes Metab J. 2017;41(2):81-88.   Published online April 14, 2017
      Close
    • XML DownloadXML Download
    Figure
    Related articles
    Lau IT. A Clinical Practice Guideline to Guide a System Approach to Diabetes Care in Hong Kong. Diabetes Metab J. 2017;41(2):81-88.
    Received: Nov 30, 2016; Accepted: Jan 02, 2017
    DOI: https://doi.org/10.4093/dmj.2017.41.2.81.

    Diabetes Metab J : Diabetes & Metabolism Journal