Authors: (including presenting author): :
Yan KS, Hui PSG, Cheng HC, Wong YSF, Wong SC, Ko WYD, Ko YTP, Chan YYR
Affiliation: :
Diabetic Centre, Department of Medicine & Rehabilitation, Tung Wah Eastern Hospital
Keyword 1: :
diabetes mellitus
Keyword 2: :
HbA1c reduction
Keyword 3: :
metabolic outcome improvement
Keyword 4: :
team-based approach
Keyword 5: :
Comprehensive Diabetes Team Interventions
Keyword 6: :
Diabetes Team Interventions
Introduction: :
Uncontrolled diabetes mellitus (DM) can lead to severe microvascular and macrovascular complications. A coordinated diabetes team approach can help patients manage their condition, reduce complications, and improve quality of life.
Objectives: :
To evaluate the effectiveness of Comprehensive Diabetes Team Interventions (CDTI) on metabolic outcomes in patients with suboptimal diabetes control.
Methodology: :
The study was piloted from April 2025. Patients with suboptimal HbA1c (7-8%), aged 18-75 years, and not under the care of diabetic specialists were recruited. (1) Diabetologists provided management advice. (2) Diabetes nurses prescribed electronic pamphlets via HA Go and made follow-up phone calls to ensure compliance. (3) Selected patients were followed up by diabetic nurses and dietitians or were referred to join community programmes. Changes in metabolic outcomes from baseline to follow-up were analysed using paired t-tests. Statistical significance was set at p < 0.05. Analyses were performed using Microsoft Excel.
Result & Outcome: :
By the end of November 2025, of over 400 patients screened, 212 had complete data for analysis. 62.2% of the patients were male. The mean age was 62 years (range 36-75), with a mean disease duration of 16 years. 21.2% were insulin users. The results indicated a significant reduction in HbA1c levels, which decreased from 7.5 ± 0.30% to 7.12 ± 0.61% (p < 0.001); 39.6% of patients achieved HbA1c of less than 7%. Additionally, there was a modest yet statistically significant reduction in body mass index (BMI) (25.21 ± 4.33 to 25.04 ± 4.27 kg/m², p = 0.0011). Low-density lipoprotein (LDL) levels and systolic blood pressure (SBP) showed non-significant reductions (2.06 ± 0.59 to 2.05 ± 0.56 mmol/L, p = 0.70, and 131.3 ± 18.5 to 130.9 ± 17.0 mmHg, p = 0.72, respectively). This study demonstrates that CDTI can significantly improve glycaemic control in patients with suboptimally controlled diabetes, with a notable proportion (39.6%) achieving target HbA1c. It also resulted in a modest yet statistically significant BMI reduction. This feasible, team-based approach shows promise for broader implementation to improve metabolic outcomes.
