Digital team-based approach helps patients manage diabetic kidney disease



A team-based digital approach to care could be key for treating patients with diabetic kidney disease (DKD), according to results of a new study in JAMA

Researchers found that patients enrolled in the Joint Asia Diabetes Evaluation (JADE) web portal who received a team-based empowered-care program met more of their treatment targets than the participants enrolled in standard of care or a straightforward empowered-care program, which included medical follow-ups. 

“In this multinational RCT [randomized controlled trial] involving patients with DKD, randomization to the team-based empowered-care group compared with the usual-care group or empowered-care group increased the likelihood of attaining multiple treatment targets by 17% to 27% (RR of 1.17 to 1.27),” the authors of the study wrote.

“Both the team-based empowered-care and empowered-care groups showed better self-management, although nurse support alone in the empowered-care group did not increase the likelihood of attaining multiple targets.”


Authors of the study found the team-based group had the highest level of patients who “further increased in attainment of multiple treatment targets.” In fact, 44.6% of participants in the team-based care group attained multiple treatment targets. However, 38.2% of the usual-care group and 35.7% of the empowered group met multiple treatment targets. 

Researchers found that after a year the team-based group had an overall lower HbA1C and LDL cholesterol levels compared to the other two groups.

“This RCT found that using a physician-nurse team to implement multicomponent, data-driven integrated care, with the assistance of information technology (JADE web portal in this trial), can improve communication between patients and healthcare practitioners as well as result in the reduction of multiple risk factors, attainment of multiple treatment targets, and empowerment among high-risk patients with DKD,” authors of the study wrote. 


Patients were randomized into usual-care, empowered-care and team-based empowered-care groups. Caregivers for all three groups used the JADE web portal, which gives assessment templates and guidelines for documentation of lifestyle and medical history. The portal also includes decision support for clinicians and reports for patients to self-manage their care, according to the study.

The research included a total of 2,393 patients with diabetes. Patients in the empowered care group got a personalized report and calls from nurses every three months, as well as usual care. Patients in the team-based empowered-care group also got reports and nurse calls, but also received “additional face-to-face reviews every 2 months from a physician-nurse team.”


Diabetes impacts 422 million people globally, according to the World Health Organization. Increasingly the healthcare industry is looking to digital resources to help individuals manage the condition.

Billions of dollars have been invested into the space. For example, in 2021 Virta Health scored $133 million in a Series E funding. That same year ​​Glooko closed a funding round worth $30 million. Telehealth giant Teladoc scooped up chronic disease management company Livongo in 2020 for a whopping $18.5 billion. 


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