Models of care for co-morbid diabetes and chronic kidney disease.

Diabetes and chronic kidney disease (CKD) are two of the most prevalent co-morbid chronic diseases in Australia. The increasing complexity of multi-morbidity, and current gaps in health-care delivery for people with co-morbid diabetes and CKD, emphasize the need for better models of care for this population. Previously, proposed published models of care for co-morbid diabetes and CKD have not been co-designed with stake-holders or formally evaluated. Particular components of health-care shown to be effective in this population are interventions that: are structured, intensive and multifaceted (treating diabetes and multiple cardiovascular risk factors); involve multiple medical disciplines; improve self-management by the patient; and upskill primary health-care. Here we present an integrated patient-centred model of health-care delivery incorporating these components and co-designed with key stake-holders including specialist health professionals, general practitioners and Diabetes and Kidney Health Australia. The development of the model of care was informed by focus groups of patients and health-professionals; and semi-structured interviews of care-givers and health professionals. Other distinctives of this model of care are routine screening for psychological morbidity; patient-support through a phone advice line; and focused primary health-care support in the management of diabetes and CKD. Additionally, the model of care integrates with the patient-centred health-care home currently being rolled out by the Australian Department of Health. This model of care will be evaluated after implementation across two tertiary health services and their primary care catchment areas.

The Perspectives of Patients on Health-Care for Co-Morbid Diabetes and Chronic Kidney Disease: A Qualitative Study.

BACKGROUND: Multi-morbidity due to diabetes and chronic kidney disease (CKD) remains challenging for current health-systems, which focus on single diseases. As a first step toward health-care improvement, we explored the perspectives of patients and their carers on factors influencing the health-care of those with co-morbid diabetes and CKD. METHODS: In this qualitative study participants with co-morbid diabetes and CKD were purposively recruited using maximal variation sampling from 4 major tertiary health-services from 2 of Australia's largest cities. Separate focus groups were conducted for patients with CKD stages 3, 4 and 5. Findings were triangulated with semi-structured interviews of carers of patients. Discussions were transcribed verbatim and thematically analysed. RESULTS: Twelve focus groups with 58 participants and 8 semi-structured interviews of carers were conducted. Factors influencing health-care of co-morbid diabetes and CKD grouped into patient and health service level factors. Key patient level factors identified were patient self-management, socio-economic situation, and adverse experiences related to co-morbid diabetes and CKD and its treatment. Key health service level factors were prevention and awareness of co-morbid diabetes and CKD, poor continuity and coordination of care, patient and carer empowerment, access and poor recognition of psychological co-morbidity. Health-service level factors varied according to CKD stage with poor continuity and coordination of care and patient and carer empowerment emphasized by participants with CKD stage 4 and 5, and access and poor recognition of psychological co-morbidity emphasised by participants with CKD stage 5 and carers. CONCLUSIONS: According to patients and their carers the health-care of co-morbid diabetes and CKD may be improved via a preventive, patient-centred health-care model which promotes self-management and that has good access, continuity and coordination of care and identifies and manages psychological morbidity.

Estimating the total incidence of kidney failure in Australia including individuals who are not treated by dialysis or transplantation.

BACKGROUND: To date, incidence data for kidney failure in Australia have been available for only those who start renal replacement therapy (RRT). Information about the total incidence of kidney failure, including non-RRT-treated cases, is important to help understand the burden of kidney failure in the community and the characteristics of patients who die without receiving treatment. STUDY DESIGN: Data linkage study of national observational data sets. SETTING & PARTICIPANTS: All incident treated cases recorded in the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) probabilistically linked to incident untreated kidney failure cases derived from national death registration data for 2003-2007. PREDICTOR: Age, sex, and year. OUTCOMES: Kidney failure, a combination of incident RRT or death attributed to kidney failure (without RRT). MEASUREMENTS: Total incidence of kidney failure (treated and untreated) and treatment rates. RESULTS: There were 21,370 incident cases of kidney failure in 2003-2007. The incidence rate was 20.9/100,000 population (95% CI, 18.3-24.0) and was significantly higher among older people and males (26.1/100,000 population; 95% CI, 22.5-30.0) compared with females (17.0/100,000 population; 95% CI, 14.9-19.2). There were similars number of treated (10,949) and untreated (10,421) cases, but treatment rates were influenced highly by age. More than 90% of cases in all age groups between 5 and 60 years were treated, but this percentage decreased sharply for older people; only 4% of cases in persons 85 years or older were treated (ORs for no treatment of 115 [95% CI, 118-204] for men ≥80 years and 400 [95% CI, 301-531] for women ≥80 years compared with women who were <50 years). LIMITATIONS: Cross-sectional design, reliance on accurate coding of kidney failure in death registration data. CONCLUSIONS: Almost all Australians who develop kidney failure at younger than 60 years receive RRT, but treatment rates decrease substantially above that age.

The burden of chronic kidney disease in Australian patients with type 2 diabetes (the NEFRON study).

OBJECTIVE: To estimate the frequency of chronic kidney disease (CKD) in a clinic-based sample of patients with type 2 diabetes in the setting of Australian primary care. DESIGN, SETTING AND PARTICIPANTS: Expressions of interest were invited from all registered general practitioners in Australia: 500 GP investigators were randomly selected from each stratum (state and urban versus rural location), proportional to the census population, and asked to recruit and provide data for 10-15 consecutively presenting adults with type 2 diabetes between April and September 2005. MAIN OUTCOME MEASURES: Estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m(2) and evidence of kidney damage on urinalysis (eg, microalbuminuria). RESULTS: 348 GP investigators submitted data for 3893 individuals with type 2 diabetes (52% men; median age, 66 years). Almost one in every four patients consulting their GPs had an eGFR < 60 mL/min/1.73 m(2) (23.1%; 95% CI, 21.8%-24.5%). More than one in three had an elevated urinary albumin-creatinine ratio (ACR) (34.6%; 95% CI, 33.3%-35.9%). There was an overlap of 10.4% of patients with both an eGFR < 60 mL/min/1.73 m(2) and an elevated urinary ACR, meaning that almost one in two patients with type 2 diabetes consulting their GPs (47.1%; 95% CI, 45.8%-48.4%) had CKD. CKD was significantly more common in women, in older people, and in individuals with established macrovascular disease. CONCLUSION: CKD is a common complication of type 2 diabetes, found in about half of all patients with type 2 diabetes consulting their GPs. Efforts to increase the recognition of CKD will lead to improved care, and possibly survival, of patients with type 2 diabetes.

Chronic kidney disease and automatic reporting of estimated glomerular filtration rate: a position statement.

The systematic staging of chronic kidney disease (CKD) by glomerular filtration measurement and proteinuria has allowed the development of rational and appropriate management plans. One of the barriers to early detection of CKD is the lack of a precise, reliable and consistent measure of kidney function. The most common measure of kidney function is currently serum creatinine concentration. It varies with age, sex, muscle mass and diet, and interlaboratory variation between measurements is as high as 20%. The reference interval for serum creatinine concentration includes up to 25% of people (particularly thin, elderly women) who have an estimated glomerular filtration rate (eGFR) that is significantly reduced (< 60 mL/min/1.73 m). The recent publication of a validated formula (MDRD) to estimate GFR from age, sex, race and serum creatinine concentration, without any requirement for measures of body mass, allows pathology laboratories to "automatically" generate eGFR from data already acquired. Automatic laboratory reporting of eGFR calculated from serum creatinine measurements would help to identify asymptomatic kidney dysfunction at an earlier stage. eGFR correlates well with complications of CKD and an increased risk of adverse outcomes such as cardiovascular morbidity and mortality. We recommend that pathology laboratories automatically report eGFR each time a serum creatinine test is ordered in adults. As the accuracy of eGFR is suboptimal in patients with normal or near-normal renal function, we recommend that calculated eGFRs above 60 mL/min/1.73 m be reported by laboratories as "> 60 mL/min/1.73 m", rather than as a precise figure.