Delivery of public-sector primary care in Hong Kong occurs through government-funded General Out-Patient Clinics (GOPC) managed by the Hospital Authority (HA). There are currently 74 clinics divided into seven geographical districts and referred to as HA clusters servicing the population of Hong Kong requiring government-subsidized health care. These primary care clinics provided 4,979,754 general outpatient attendances in 2010–2011 [1
] and the number of attendances was estimated to increase further in the coming years. The majority of patients are elderly, of lower socio-economic status or have chronic diseases which require regular monitoring or medication such as hypertension and diabetes mellitus.
Type 2 diabetes mellitus (DM) is a major cause of morbidity and was the ninth commonest cause of death in Hong Kong in 2008 [2
]. There are approximately 190,000 patients receiving care for DM in the GOPC according to data from HA. Until recently however, there have not been any formal standardized guidelines or protocols regarding the delivery of care for diabetic patients within the public primary care setting. In August 2009, the HA introduced a multi-disciplinary Risk Assessment and Management Programme (RAMP) to improve the quality of care for patients receiving diabetic care in the GOPCs. The RAMP utilizes a standardized protocol consisting of a workflow of checking of relevant clinical parameters including HbA1c, blood pressure (BP), low density lipoprotein-cholesterol (LDL-C), and an agreed risk assessment criteria for risk level stratification, with different management options assigned to patients of different risk levels and with different needs. Patients with DM who are independent in their activities of daily living and being followed up at regularly at the GOPCs are eligible to enter the RAMP. All enrolled patients undergo a comprehensive risk assessment and screening for diabetes-related complications, and are then assigned to receive appropriate interventions and education provided by a team of multi-disciplinary healthcare professionals according to their stratified risk level. Low risk patients continue with the usual GOPC follow up, medium risk patients are given additional intervention by an advanced practice nurse (APN), and high risk/very high risk patients are given additional intervention by an APN and an associate consultant, who is a specialist family physician. The RAMP is repeated once at least every one to two years for all patients who are enrolled.
A review of the international literature on risk stratification of diabetic patients supports the benefit of identifying high-risk patients through the clinical information system [3
]. Risk factors can be identified based on the level of glycaemic control and/or presence of complications where improvement in HbA1c, BP, and LDL-C can be achieved through more intensive interventions [3
]. Moreover, health service utilization such as Accidents and Emergency (A&E) department attendance, consultations, and hospital admissions can also be reduced [5
]. A number of non-Asian countries have already successfully adopted such stratified models for chronic diabetic care including the United Kingdom, Australia, New Zealand and Canada [7
In Asia, the Joint Asia Diabetes Evaluation (JADE) Program, incorporating a comprehensive risk engine, care protocol, clinical decision and self-management support has recently been developed to improve ambulatory diabetes care [12
]. Although the JADE was developed based on data from patients receiving secondary or tertiary care, it forms the base for the stratification of local diabetic patients into very high risk, high risk, medium risk and low risk in the RAMP at primary care level. Apart from stratifying diabetic patients into different risk levels, equations integrating different patient’s clinical parameters have been formulated to predict the diabetic patient’s 5-year risk of coronary heart disease, stroke, end-stage renal disease, and all-cause mortality [12
The goal of care for patients with DM is to prevent DM-related complications such as cardiovascular diseases and renal failure. Cardiovascular risk prediction rules have been developed, mostly based on the Framingham Study [16
], but these may not be applicable to the Asian or Chinese population [17
]. Studies have shown that the original Framingham functions might over-estimate the risk of coronary heart disease (CHD) in Chinese adults [18
]. The Joint Asia Diabetes Evaluation (JADE) equations have been formulated and tested on local data from the Hong Kong Diabetes Registry showing good validity and discriminating power.
With the threat of aging population and the foreseeable increase in demand of public primary healthcare service on providing care to patients with chronic diseases, programmes that can be proved to be effective and provide a good quality of care are one of the solutions to deal with the complexity and demand of the health needs. Since DM is a common chronic condition with diverse complications in our locality as well as worldwide, we would like to evaluate the QOC and the effectiveness of the RAMP to prove if such kind of approach of chronic disease management works.
The evaluation of QOC and effectiveness is an essential step in assessing a chronic disease management programme on whether the intended care is provided and the expected health benefit is achieved. The information will influence future policy and service planning related to healthcare.
Aims and objectives
The aim of this study is to evaluate the quality of care (QOC) and effectiveness of a multi-disciplinary risk assessment and management programme (RAMP) for type 2 diabetic patients attending government-funded primary care clinics in Hong Kong. The evaluation will be conducted using a structured and comprehensive evidence-based evaluation framework.
The objectives of the study are:
1) To review and identify the structure, process and outcome indicators of quality of care;
2) To identify the criterion and set the target standard for each indicator;
3) To compare the observed standards against the target standards;
4) To identify any on-site problems related to implantation of the RAMP;
5) To provide feedback on quality of care of RAMP;
6) To identify possible areas for improvement;
7) To give recommendations for enhancement of service delivery
The following hypotheses will be tested:
1) The structure and process criteria of care of different aspects should be achieved up to standards in all participating clinics;
2) A higher proportion of patients should have achieved the outcome targets for HbA1c, blood pressure, and LDL-C after the RAMP;
3) Patients participated in the RAMP should have better clinical outcomes than non-participants (control) managed by usual care;
4) Patients participated in the RAMP should not have higher health service utilization rates than non-participants (control) managed by usual care;
5) In longer terms, RAMP will lower the complication rate and cardiovascular risk level of diabetic patients.