OBJECTIVES: An integrated diabetes care (IDC) program was implemented in a Chinese county to address the challenges of diabetes management faced by countries worldwide. This study aims to assess whether the IDC model can improve patient outcomes in primary care settings.

METHODS: A cohort study were conducted to evaluate the clinical effectiveness of the IDC program compared to usual care for patients with type 2 diabetes. The study spanned a one-year follow-up period and utilized real-world data. Propensity score matching (PSM) and difference-in-differences (DID) approaches were applied. Clinical indicators included fasting blood glucose (FBG), systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index (BMI). Subgroup analyses were conducted to determine the effects on patients with FBG over 8 mmol/L at baseline. To identify the functional mechanism of the IDC program, key informant interviews were conducted with medical staff, patients, and administrators involved in either the usual care or the IDC program.

RESULTS: A total of 525 patients from the intervention group and 9785 patients from the control group were included in the analyses. Our PSM-DID analysis showed that the decline rates for FBG, SBP, and DBP were significantly faster and larger in the intervention group than in the control group. The changes in BMI did not differ significantly between the two groups. Subgroup analyses presented similar results. The results of key informant interviews indicated that the eHealth system plays a pivotal role in the IDC program and ensures the effectiveness of all other interventions.

CONCLUSIONS: The IDC program improved patient outcomes in primary healthcare settings compared to usual care, with eHealth playing a key role in supporting multidisciplinary services, clinical decisions, and self-management. Therefore, IDC model can be integrated into primary healthcare settings to improve outcomes in China and countries with similar needs.