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A prospective clinical trial of specialist renal nursing in the primary care setting to prevent progression of chronic kidney: a quality improvement report.

Walker RC, Marshall MR, Polaschek NR - BMC Fam Pract (2014)

Bottom Line: There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk.Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI.Self-management significantly improved across all relevant domains.

View Article: PubMed Central - PubMed

Affiliation: Counties Manukau District Health Board, Auckland, New Zealand. mrmarsh@woosh.co.nz.

ABSTRACT

Background: Early detection and effective management of risk factors can potentially delay progression of chronic kidney disease (CKD) to end-stage kidney disease, and decrease mortality and morbidity from cardiovascular (CV) disease. We evaluated a specialist nurse-led intervention in the primary care setting to address accepted risk factors in a study sample of adults at 'high risk of CKD progression', defined as uncontrolled type II diabetes and/or hypertension and a history of poor clinic attendance.

Methods: The study was a non-controlled quality improvement study with pre- and post- intervention comparisons to test feasibility and potential effectiveness. Patients within two primary care practices were screened and recruited to the study. Fifty-two patients were enrolled, with 36 completing 12-months follow-up. The intervention involved a series of sessions led by the nephrology Nurse Practitioner with assistance from practice nurses. These sessions included assessment, education and planned medication and lifestyle changes. The primary outcome measured was proteinuria (ACR), and the secondary outcomes estimated glomerular filtration rate (eGFR) and 5-year absolute CV risk. Several 'intermediary' secondary outcomes were also measured including: blood pressure, serum total cholesterol, glycosylated haemoglobin (HbA1c), body mass index (BMI), prevalence of active smoking, a variety of self-management domains, and medication prescription. Analysis of data was performed using linear and logistic regression as appropriate.

Results: There was a significant improvement in ACR (average decrease of -6.75 mg/mmol per month) over the course of the study. There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk. Blood pressure, serum total cholesterol, and HbA1c all decreased significantly. Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI. Self-management significantly improved across all relevant domains.

Conclusions: The results suggest that a collaborative model of care between specialist renal nurses and primary care clinicians may improve the management of risk factors for progression of CKD and CV death. Further larger, controlled studies are warranted to definitively determine the effectiveness and costs of this intervention.

Trial registration: Australian and New Zealand Clinical Trials Registry number: ACTRN12613000791730.

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Related in: MedlinePlus

Patient flow.
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Fig1: Patient flow.

Mentions: Patients were screened and recruited through the primary care practices. Inclusion criteria required that all of the following conditions were met: ‘high risk of CKD progression’ (as defined below), age >18 years, diagnosis of type two diabetes mellitus, hypertension, and albuminuria defined as an albumin to creatinine ratio (ACR) >30 mg/mmol on at least three occasions separated by at least 1 week [18]. The main exclusion criterion was CKD due to renal parenchymal disease other than diabetic nephropathy. Patients at "high risk of CKD progression" were defined as those with at least 12 months of uncontrolled diabetes and/or hypertension (glycoslyated haemoglobin (HbA1c) >8% and blood pressure (BP) >140/90 mmHg [19, 20]) and a history of poor attendance and engagement with their GP (history of unplanned non-attendance of 25% or more of scheduled appointments over the course of 12 months). Over 500 patients were identified from the initial screen within the practices and fifty-four high risk patients were identified by the primary care teams as also meeting the criteria for poor attendance. These fifty-four were given written information and invitation to participate by their GP or practice nurse. All were subsequently re-contacted by phone to answer any questions, and offered an initial assessment. Fifty two patients subsequently enrolled and participated in the study (Figure 1).Figure 1


A prospective clinical trial of specialist renal nursing in the primary care setting to prevent progression of chronic kidney: a quality improvement report.

Walker RC, Marshall MR, Polaschek NR - BMC Fam Pract (2014)

Patient flow.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4263018&req=5

Fig1: Patient flow.
Mentions: Patients were screened and recruited through the primary care practices. Inclusion criteria required that all of the following conditions were met: ‘high risk of CKD progression’ (as defined below), age >18 years, diagnosis of type two diabetes mellitus, hypertension, and albuminuria defined as an albumin to creatinine ratio (ACR) >30 mg/mmol on at least three occasions separated by at least 1 week [18]. The main exclusion criterion was CKD due to renal parenchymal disease other than diabetic nephropathy. Patients at "high risk of CKD progression" were defined as those with at least 12 months of uncontrolled diabetes and/or hypertension (glycoslyated haemoglobin (HbA1c) >8% and blood pressure (BP) >140/90 mmHg [19, 20]) and a history of poor attendance and engagement with their GP (history of unplanned non-attendance of 25% or more of scheduled appointments over the course of 12 months). Over 500 patients were identified from the initial screen within the practices and fifty-four high risk patients were identified by the primary care teams as also meeting the criteria for poor attendance. These fifty-four were given written information and invitation to participate by their GP or practice nurse. All were subsequently re-contacted by phone to answer any questions, and offered an initial assessment. Fifty two patients subsequently enrolled and participated in the study (Figure 1).Figure 1

Bottom Line: There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk.Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI.Self-management significantly improved across all relevant domains.

View Article: PubMed Central - PubMed

Affiliation: Counties Manukau District Health Board, Auckland, New Zealand. mrmarsh@woosh.co.nz.

ABSTRACT

Background: Early detection and effective management of risk factors can potentially delay progression of chronic kidney disease (CKD) to end-stage kidney disease, and decrease mortality and morbidity from cardiovascular (CV) disease. We evaluated a specialist nurse-led intervention in the primary care setting to address accepted risk factors in a study sample of adults at 'high risk of CKD progression', defined as uncontrolled type II diabetes and/or hypertension and a history of poor clinic attendance.

Methods: The study was a non-controlled quality improvement study with pre- and post- intervention comparisons to test feasibility and potential effectiveness. Patients within two primary care practices were screened and recruited to the study. Fifty-two patients were enrolled, with 36 completing 12-months follow-up. The intervention involved a series of sessions led by the nephrology Nurse Practitioner with assistance from practice nurses. These sessions included assessment, education and planned medication and lifestyle changes. The primary outcome measured was proteinuria (ACR), and the secondary outcomes estimated glomerular filtration rate (eGFR) and 5-year absolute CV risk. Several 'intermediary' secondary outcomes were also measured including: blood pressure, serum total cholesterol, glycosylated haemoglobin (HbA1c), body mass index (BMI), prevalence of active smoking, a variety of self-management domains, and medication prescription. Analysis of data was performed using linear and logistic regression as appropriate.

Results: There was a significant improvement in ACR (average decrease of -6.75 mg/mmol per month) over the course of the study. There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk. Blood pressure, serum total cholesterol, and HbA1c all decreased significantly. Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI. Self-management significantly improved across all relevant domains.

Conclusions: The results suggest that a collaborative model of care between specialist renal nurses and primary care clinicians may improve the management of risk factors for progression of CKD and CV death. Further larger, controlled studies are warranted to definitively determine the effectiveness and costs of this intervention.

Trial registration: Australian and New Zealand Clinical Trials Registry number: ACTRN12613000791730.

Show MeSH
Related in: MedlinePlus