Team-Based Care Reduces Risk in Patients with Diabetic Kidney Disease

Juliana C. N. Chan, MD,

Technology-assisted team-based care improved the attainment of multiple treatment targets as well as empowerment in high-risk patients with diabetic kidney disease (DKD), according to new findings.

Data show randomization to team-based care increased the likelihood of attaining multiple treatment targets by 17 to 27% (RR, 1.17 - 1.27) compared to the usual care group or empowered care group.

“In the present RCT, only the team-based empowered care group had improved control of multiple risk factors, likely because of the complex medical needs of these patients, although the favorable effect on self-management in the empowered care group was encouraging,” wrote study author Juliana C. N. Chan, MD, Department of Medicine and Therapeutics, The Chinese University of Hong Kong.

Investigators evaluated the effects of the Joint Asia Diabetes Evaluation (JADE) web portal, nurse reminders, and team-based care on multiple risk factors in patients with DKD at 13 hospital-based diabetes centers in Asia.

All eligible patients had type 2 diabetes, defined as nonketotic presentation or no insulin requirement within 1 year of diagnosis. Further, DKD was defined as an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m² or serum creatinine with a 30% or higher reference limit to facilitate recruitment.

Additionally, eligible patients at each study site were randomized in a 1:1:1 ratio to usual care, empowered care, or team-based empowered care. All randomized patients underwent a JADE portal-guided assessment at baseline and the end of the study at month 12.

Primary outcomes were the proportion of patients who attained multiple treatment targets:

• HbA1c level less than 7.0%
• Blood pressure less than 130/80 mm Hg
• Low-density lipoprotein (LDL) cholesterol level less than 1.8 mmol/L
• Triglyceride level <1.7 mmol/L
• Persistent use of renin-angiotensin-aldosterone system inhibitors

A total of 2393 patients were randomized to the usual care group (n = 795), empowered care group (n = 802), and team-based empowered care group (n = 796). The cohort had a mean age of 67.7 years and was composed of 1267 men (52.9%) and 1126 women (47.1%).

At baseline, these patients had a mean duration of diabetes of 16.4 years and 34.7% of patients (n = 830) had at least 3 targets at baseline. Investigators observed the team-based empowered care group (44.6%) had the highest proportion of patients who attained multiple treatment targets compared with those in the usual care (38.2%) or empowered care (35.7%) groups at month 12.

Data show the within-group differences were 3.9% (95% CI, 0.0% - 7.8%) in the usual care group, 1.3% (95% CI, -2.8% to 5.4%) in the empowered care group, and 9.1% (95% CI, 4.7% - 13.5%) in the team-based empowered care group.

Investigators found patients in the team-based empowered care group compared with the usual care group (RR, 1.17; 95% CI, 1.00 - 1.37) and the empowered care group (RR, 1.25; 95% CI, 1.06 - 1.48) were more likely to attain multiple treatment targets.

Then, at month 12, the team-based empowered care group showed greater reductions in mean HbA1c level (-0.39%; P = .004) and LDL-C level (-0.14 mmol/L; P = .001).

In comparison to patients who did not attain multiple treatment targets, patients who attained treatment targets had a lower incidence of cardiovascular, kidney, and cancer events (8.4% [n = 51] versus 14.5% [n = 134]; P = .004).

Within the per-protocol analysis, a greater proportion of patients in the team-based empowered care group attained multiple treatment targets at month 12 than patients in the empowered care group (41.7% versus 35.6%; P = .04).

The study, “Effect of a Web-Based Management Guide on Risk Factors in Patients With Type 2 Diabetes and Diabetic Kidney Disease,” was published in JAMA Network Open.