Early diagnosis of chronic kidney disease in patients with diabetes in France: multidisciplinary expert opinion, prevention value and practical recommendations.

Diabetes is the leading cause of end-stage kidney disease (ESKD), accounting for approximately 50% of patients starting dialysis. However, the management of these patients at the stage of chronic kidney disease (CKD) remains poor, with fragmented care pathways among healthcare professionals (HCPs). Diagnosis of CKD and most of its complications is based on laboratory evidence. This article provides an overview of critical laboratory evidence of CKD and their limitations, such as estimated glomerular filtration rate (eGFR), urine albumin-to-creatinine ratio (UACR), Kidney Failure Risk Equation (KFRE), and serum potassium. eGFR is estimated using the CKD-EPI 2009 formula, more relevant in Europe, from the calibrated dosage of plasma creatinine. The estimation formula and the diagnostic thresholds have been the subject of recent controversies. Recent guidelines emphasized the combined equation using both creatinine and cystatin for improved estimation of GFR. UACR on a spot urine sample is a simple method that replaces the collection of 24-hour urine. Albuminuria is the preferred test because of increased sensitivity but proteinuria may be appropriate in some settings as an alternative or in addition to albuminuria testing. KFRE is a new tool to estimate the risk of progression to ESKD. This score is now well validated and may improve the nephrology referral strategy. Plasma or serum potassium is an important parameter to monitor in patients with CKD, especially those on renin-angiotensin-aldosterone system (RAAS) inhibitors or diuretics. Pre-analytical conditions are essential to exclude factitious hyperkalemia. The current concept is to correct hyperkalemia using pharmacological approaches, resins or diuretics to be able to maintain RAAS blockers at the recommended dose and discontinue them at last resort. This paper also suggests expert recommendations to optimize the healthcare pathway and the roles and interactions of the HCPs involved in managing CKD in patients with diabetes.

[Creation of a consumer representatives committee in a multidisciplinary primary health care center. Findings, limitations and prospects]. / Mise en place d'un comité de représentants des usagers dans une maison de santé pluridisciplinaire. Constats, limites et perspectives.

INTRODUCTION: The St Claude multidisciplinary health centre in Besançon encouraged the creation of a consumer representatives committee to promote health democracy in primary health care. This project was developed with the help of a local consumers association. This study evaluated the perception and expectations of these fifteen health users/citizens. METHODS: A qualitative study based on individual semistructured interviews was carried out before initiation of the project. RESULTS: The results highlight the motivation and sense of initiative of the participants in this innovative project, who wish to discuss a wide range of topics. These topics were compared to the health centre's health project. Four common themes emerged: maintenance at home for the elderly, management of urgent consultations in the health centfre, prevention and information. These themes were used to guide the formation of this consumer group. The limitations defined by the consumers were also taken into account to ensure durability of the project. This study identified several markers: the original modality of identification of representatives, the themes shared with professionals, the proposed method of structuring activities. DISCUSSION: These preliminary observations and orientations could be used by other organizations to facilitate the creation of a group of consumer representatives.

[A regional federation of multidisciplinary health houses: some views on the case of Franche-Comté]. / Une Fédération Régionale des Maisons de Santé : regards sur l'expérience franc-comtoise.

Social innovation is firmly rooted in the history of Franche-Comté, and the creation of the first regional federation of health houses is an integral part of this process. The challenge of this initiative is to ensure an appropriate fit between the "needs of the population" and the "demands of health professionals". Multi-professional groupings appear to be particularly effective in this context, although health houses are not the only solution. The federation of health houses of Franche-Comté (Femasac) has an important role to play in supporting healthcare projects and their effective implementation. The health professionals currently operating in these centers can provide invaluable support to their peers in what is?sometimes a rather complex initiative. Many doctors and paramedical workers are unaccustomed to the mechanisms and customs of shared medical practice. The issue is to enable the emergence of the concept without imposing "one's own" solution. This approach requires good listening skills, an ability for synthetic thought and a modicum of patience. The transition from solitary medical practice to group work needs to be carried out in several stages and requires time, a "temporality of development" on the part of elected representatives and institutional partners. This is, in fact, a sine qua non condition of success. The role of Femasac is precisely to act as the link between elected representatives and enabling institutional partners on the one hand and the health professionals keen to participate in the creation of health house or health center projects on the other.

[Aid to quality approach in French multidisciplinary health houses through a patients satisfaction assessment.]. / Aide à la démarche qualité dans les maisons de santé : apport d'une enquête de satisfaction auprès des patients.

French multidisciplinary health houses gather professionals of primary and ambulatory healthcare together, who practise with a shared care project. In a quality approach standpoint, two French primary healthcare houses in Franche-Comté, one which is located in rural areas and the other one in urban areas, were volunteer for taking part in an assessment of the patients satisfaction. So, 360 patients have been given a questionnaire during office consultation or home visit, in accordance with a distribution that was proportional to the activity of each group of professionals of health. Satisfaction rates were particularly high about reception conditions and available services. The differences of the way of running between those two structures are mainly due to their geographic location. Some improvable points have been identified, such as informations delivered in the waiting room, screening and prevention activities, and closer relations with social services. This study, that permitted to define patients expectations and overall to improve the way of running of the concerned structures, is the beginning of a true quality approach for multidisciplinary teams practising in health houses.