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Innovations to Improve the Primary and Secondary Care Collaboration in the
Management of Diabetic Related Kidney Disease
Julie Lewis DSN.
Renal and Diabetes Centre
Glan Clwyd Hospital
Denbighshire
North Wales.
AIMS
• Review incidence / prevalence of Diabetes and Diabetic Nephropathy
• Share experience in the development of our Diabetic Nephropathy Service to date
DIABETIC NEPHROPATHY
• Gradually progressive condition associated with increased risk of cardiovascular disease, significantly impacting mortality if left to progress without detection or treatment.
• Incidence: Increasing.
• Prevalence : 10 – 40%• Leading cause of ESRD.
• Diabetic nephropathy is now the single most common cause of CKD in the US and Europe.
What is Diabetic Renal Disease? • Dipstick – ve: Microalbuminuria 1) Albumin - >20mg/l 2) Albumin Excretion Rate (AER) : 20- 200µg/min 3) Albumin Creatinine Ratio(ACR) - >2.4
Males >3.5 mg/mmol cr Females • Dipstick –ve: renal impairment without
proteinuria : MacIsaac RJ et al Nonalbuminuria Renal Insufficiency in Type 2 Diabetes Diabetes Care 27:195-200
• Dipstick +ve: Macroalbuminuria(+/- Renal Impairment)
AER >200µg/min or ACR >30 or 24 urinary protein >0.3g/day ( diabetic nephropathy)
Innovation 1.2001 - 2002
• 6 Primary Care doctors (GPs) + Practice Nurses and Receptionists
• Renal/Diabetes Research Nurse Specialist• Nephrologists• Diabetologists• Radiologist• Chemical Pathologist• Audit Administrator
Objectives
• Primary Care audit to establish no.T2DM screening for microalbuminuria
• Prevalence of MA in T2DM in our region• Establish the best testing method (accuracy
and compliance)• Establish whether effective screening and
management for MA in T2DM can happen in Primary Care
Main Findings• Patients were not being screened for MA • Using AER had low patient compliance
(30%)• What was our prevalence of MA? – 22%• Lab acquired equipment for ACR(patient
compliance improved to 83%)• Produced local screening and treatment
guidelines for diabetic renal disease
Screening for Diabetic Renal Disease
Early Morning Urine for Albumin / Creatinine Ratio
ACR (mg/mmol cr)
< 2.5 Men
< 3.5 Women
> 2.5 Men
> 3.5 Women
Repeat ACR
Annually
Repeat ACR within 1 Month
REPEAT ACR
< 2.5 Men
<3.5 Women
>2.5 Men
>3.5 Women
< 2.5 Men
< 3.5 Women
> 2.5 Men
> 3.5 Women
Start:1 ACEi or A11RA
2 Aspirin •Ace-I: Angiotensin Converting Enzyme Inhibitor
•A11RA:Angiotensin 2 Receptor Antagonist
Treatment Guidelines for Diabetic Renal Disease
The following ACE inhibitors (ACEi) and Angiotensin II Receptor Antagonist (AII RA) are
licensed for treatment of diabetic renal disease – accepted by D&T and LHB Drug Start Dose (mg) Target Dose (mg)
Lisinopril 2.5 >10
Ramipril 2.5 10
Irbesartan 150 300
Losartan 50 100
Titrate start dose at 2 weekly intervals, to target dose. Check BP at each dose increment and reduce dose if symptomatic hypotension develops.Repeat ACR or 24hr urinary protein every 3-6 monthly.
Check U&Es before, 1 week after initiating and after dose increase of ACEi or AIIRA. STOP ACEi or AIIRA if serum creatinine rises c GFR drops >20% above baseline or if hyperkalaemia (potassium >6.0mml/l) develops.
Aim for the following targets and advise patient to stop smoking: BP < 130/70
HbA1C < 7.0 Cholesterol < 5.0mmol/l
Refer to diabetic nephropathy clinic if a) creatinine >150µmol/l or rises >20% above baseline b) micro or macroalbuminuria continues to rise , despite target doses of ACEi or AIIRA c) nephrotic syndrome develops. Arrange renal ultrasound scan.
Do not use ACEi or AIIRA in pregnancy or patients planning pregnancy, bilateral renovascular disease, aortic stenosis .
Impact
• Results of this study with screening and treatment guidelines communicated to all GP’s and P/N’s
• No. of screening tests for Microalbuminuria using the ACR increased
Innovation 2
• Satellite clinics for T2DM patients identified with microalbuminuria
• Opportunity to develop skills and knowledge in Primary care
• Reinforced screening and treatment guidelines for diabetic kidney disease
SATELLITE CLINIC INTERVENTIONS
N=62
88% Needed life-modifying advice
59% Medication changes made
30% Had renal impairment and
transferred to Hospital clinic:• US Kidneys - all patients
• Renal MRA - 9 patients (no RAS)
• Renal Biopsy - 4 patients
Findings
• Simple innovative measures improved the primary secondary care interface and enhanced the screening and management of diabetic renal disease and its associated risk factors in our region
• Specialist support to implement these measures requires continuity to be fully effective, but has the potential to enable the majority of people with Diabetic Renal Disease to be effectively managed with evidence based guidelines in primary care.
Impact
• Raised awareness
• Improved communication
• Coinciding with GMS contract
• Increase ACR screening further
NEPHROPATHY SCREENING
0
100
200
300
400
500
600
700
800
Jan-
96
May
-96
Sep-9
6
Jan-
97
May
-97
Sep-9
7
Jan-
98
May
-98
Sep-9
8
Jan-
99
May
-99
Sep-9
9
Jan-
00
May
-00
Sep-0
0
Jan-
01
May
-01
Sep-0
1
Jan-
02
May
-02
Sep-0
2
Jan-
03
May
-03
Sep-0
3
Jan-
04
MONTH
NU
MB
ER
OF
SA
MP
LE
S B
Y M
ON
TH
MALB
ACR
ALL
MA Testing – on the Increase!
Impact
• Clear referral guidelines congested Secondary care diabetic nephropathy clinic
• Unacceptable waiting list for this high risk group
Innovation 3
• Increased referrals to secondary care.
• Review current service.
• Essential to re-structure service provision for diabetic nephropathy.
Clinic Pathway
Referral
Primary CareSecondary care diabetes clinic
Specialist Physician -New patient assessment
•Investigation•Diagnosis
Treatment Plan
Nurse-led Review Physician review
Low ClearanceClinic
Supported dischargeTo P.C
Continued secondary care review
Developing a Nurse-led Diabetic Nephropathy Review Service
• Professional development • Education – skills and knowledge
– Competence – Patient protection
• Treatment plan – Evidence based• Optimise Modifiable Risks – reduce
progression of Diabetic Nephropathy• Structured patient education – strategies for
self-management
Nurse-led Review• Implement action plan
• Inclusive – sharing knowledge
• Follow up visits to evaluate effectiveness of clinical interventions
• Pre testing• Inclusive – discussing results and treatment plan –
increasing understanding
• Telephone clinics – glycaemic control• Continuity – supporting compliance and optimising control
• Promote partnership approach to behaviour / lifestyle changes
• Realistic goal setting• Motivation• Responsibility
Effective strategies for Self-Management
• Realistic• Collaborative• Patient centred• Identify barriers for self-management
• Knowledge• Helplessness / frustration• Grieving for loss of health – denial / indifference
• Continued Support / encouragement
Nurse-led Review - Collaboration
• Promote knowledge and understanding
• Offer advice
• Coaching and encouragement
• Empowerment – informed decision making
• Weigh up options• Make choices
Nurse led Clinic - Benefits
• Cost effective
• Increased diabetic nephropathy review slots by 250 per year
• No DNA’s
• Audit of clinical effectiveness and patient satisfaction - Summer 2006
• Encourage Practice Nurses to attend clinic
Nurse-led Clinic Limitations
• One session per week – clinic• One session per month – telephone
clinic• Collaboration between Primary and
Secondary care hindered by poor IT provision
• Numbers still increasing - ? Group education
Link with Policy
• Diabetes NSF / Renal NSF / NICE / Chronic Disease Management strategies– Early detection– Delay progression– Structured education / patient
empowerment
• Effective CDM = Shared care
Shared Care?• Increasing numbers • Economic drivers• CDM policy• Accessibility• Evidence based intervention strategies to be
addressed largely in Primary care• Primary care need to be assured that specialist
secondary care services can be accessed for their CD patients who– Fail to respond to treatment guidelines– Deteriorate despite recommended target treatment
CKD: A Typical GP Practice of 10000CKD: A Typical GP Practice of 10000
Stage 1
Stage 5
Stage 4
Stage 3
Stage 2
460
60
6
380
90
60
15
30
eGFReGFR
Conclusion• Series of innovations since 2001 to
manage diabetic nephropathy in our region – ongoing process
• Enhanced the collaboration between Primary and Secondary care to manage this condition
• Developing approaches to promote self-management in line with CDM strategy
• ACR testing – likelihood of unnecessary duplication
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