ENHIDE telehealth primary care support of adults with diabetes and chronic kidney disease: a pilot study – rationale and study design

Peter H Winocour, Karen Moore-Haines, Andrew Solomon, Anne Currie, Dawn Hardy

Abstract


Introduction: Diabetes is considered the main identified cause of end stage renal disease and this combination is becoming more prevalent as populations age and become more obese. Individuals with diabetes and chronic kidney disease (CKD) have additional multi-morbidity and may represent 25–40% of those on diabetes registers in primary care, where the majority receive medical care. The East and North Herts Clinical Commissioning Group (CCG) commissioned the East and North Herts Institute of Diabetes and Endocrinology (ENHIDE) to pilot an innovative approach to the identification and care of this complex cohort in primary care. This paper reports the project design and objectives.

Aims: There were five core objectives of the pilot: (1) to examine the feasibility of extraction of comprehensive datasets from primary care diabetes registers; (2) to examine the feasibility of the individualised data utilisation for patient care; (3) to evaluate the practicality and acceptability of primary care of telehealth virtual case-based reviews; (4) to evaluate the extent of unmet clinical need; and (5) to create new sources of information to improve self-management. In addition, three key performance indicators were set for those with CKD: (1) change in any aspect of management in 20%; (2) reduction of admissions and ambulance call outs for hypoglycaemia in 20%; and (3) reductions in admissions with active foot disease by 20%.

Study outline: All patients with estimated glomerular filtration rates (eGFR) <60 mL/min and/or urine albumin creatinine ratio (ACR) >10 mg/mmol were to be identified from practice diabetes registers enabling a holistic review of ‘15 pillars of care’. In addition to blood glucose management and review of renal function, this included recording of cardiovascular disease (CVD) and CVD risk factor status, risk of hypoglycaemia, assessment of anaemia, metabolic bone disease, foot and retinal health and hospitalisation.

Progress: The project was initiated in December 2016 and data are currently being updated for full analysis. 20 of the 55 general practices in the catchment area of the acute trust agreed to participate in the project, enabling case review of 2,874 cases. This initial phase of the pilot has established that the core principles of the project can be delivered in larger numbers, subject to developing new models of data capture and creation of clinically underpinned care algorithms.


Keywords


diabetes, chronic kidney disease, Telehealth, care planning, clinical information systems, albuminuria, cardiovascular disease, hypertension, lipids, glycaemia, retinopathy, foot heath, metabolic bone health

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References


Steenkamp R, Caskey F. UK Renal Registry 18th Annual Report: Chapter 6. Comorbidities and current smoking status amongst patients starting renal replacement therapy in England, Wales and Northern Ireland from 2013 to 2014. Nephron 2016;132(Suppl 1):145–54. https://doi.org/10.1159/000444820

Kidney Disease Outcomes Quality Initiative (KDOQI). Clinical practice guideline for diabetes and CKD: 2012 update. Am J Kidney Dis 2012;60:850–86. https://doi.org/10.1053/j.ajkd.2012.07.005

Holman N, Forouhi NG, Goyder E, Wild SH. The Association of Public Health Observatories (APHO) Diabetes Prevalence Model: estimates of total diabetes prevalence for England, 2010-2030. Diabet Med 2011; 28:575–82. https://doi.org/10.1111/j.1464-5491.2010.03216.x

Ellam T, Twohig H, Khwaja A. Chronic kidney disease in elderly people: disease or disease label. BMJ 2016;352:h6559. https://doi.org/10.1136/bmj.h6559

Winocour PH. Diabetes and chronic kidney disease: an increasingly common multi-morbid disease in need of a paradigm shift in care. Diabet Med 2018;35:300–5. https://doi.org/10.1111/dme.13564

Hill CJ, Cardwell CR , Maxwell AP, et al. Obesity and kidney disease in type 1 and type 2 diabetes: an analysis of the National Diabetes Audit. Q J Med 2013;106:933–42. https://doi.org/10.1093/qjmed/hct123

Mark, PB, Winocour P, Day C. Management of lipids in adults with diabetes mellitus and nephropathy and/or chronic kidney disease: summary of joint guidance from the Association of British Clinical Diabetologists (ABCD) and the Renal Association (RA). Br J Diabetes 2017;17:64–72. http://dx.doi.org/10.15277/bjd.2017.125

Dasgupta I, Banerjee D, Chowdhury TA, et al. Association of British Clinical Diabetologists (ABCD) and Renal Association clinical guidelines: hypertension management and renin-angiotensin-aldosterone system blockade in patients with diabetes, nephropathy and/or chronic kidney disease. Summary of recommendations. Br J Diabetes 2017;17:160–4. https://doi.org/10.15277/bjd.2017.152

Winocour PH, Bain SC, Chowdhury T, et al. Managing hyperglycaemia in patients with diabetes and diabetic nephropathy–chronic kidney disease. Summary of recommendations 2018. Br J Diabetes 2018;18:78–89. https://doi.org/10.15277/bjd.2018.172

National Institute for Health and Care Excellence (NICE). Type 2 diabetes in adults: management. [NG 28]. December 2015. www.nice.org.uk/guidance/ng28

National Institute for Health and Care Excellence (NICE). Chronic kidney disease in adults: assessment and management. [CG182]. 2014. www.nice.org.uk/guidance/cg182

Bilo H, Coentrao L, Couchoud C, et al. Clinical practice guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min). Nephrol Dial Transplant 2015;30(Suppl 2):ii1–ii142. https://doi.org/10.1093/ndt/gfv100

Tonelli M, Muntner P, Lloyd A, et al for the Alberta Kidney Disease Network. Risk of coronary events in people with chronic kidney disease compared with those with diabetes: a population-level cohort study. Lancet 2012;380:807–14. https://doi.org/10.1016/S0140-6736(12)60572-8

Otte J, van Netten JJ, Woittiez A-JJ. The association of chronic kidney disease and dialysis treatment with foot ulceration and major amputation. J Vasc Surg 2015;62:406–11. https://doi.org/10.1016/j.jvs.2015.02.051

McDonald HI, Thomas SL, Millett ERC, Nitsch D. CKD and the risk of acute community acquired infections among older people with diabetes mellitus: a retrospective cohort study using electronic health records. Am J Kidney Dis 2015;66:60–8. https://doi.org/10.1053/j.ajkd.2014.11.027

Davis TME, Brown SGA, Jacobs IG, Bulsara M, Bruce DG, Davis WA. Determinants of severe hypoglycaemia complicating type 2 diabetes: the Fremantle Diabetes study. J Clin Endocrinol Metab 2010;95:2240–7. https://doi.org/10.1210/jc.2009-2828

Lapi F, Azoulay L, Yin H, Nessim SJ, Suissa S. Concurrent use of diuretics,angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study. BMJ 2013;346:e8528. https://doi.org/10.1136/bmj.e8525

Hill CJ, Cardwell CR, Patterson CC, et al. Chronic kidney disease and diabetes in the National Health Service: a cross-sectional survey of the UK National Diabetes Audit. Diabet Med 2014;31:448–54. https://doi.org/10.1111/dme.12312

Luk AO , Li X, Zhang Y, et al, for the JADE Study Group. Quality of care in patients with diabetic kidney disease in Asia: the Joint Asia Diabetes Evaluation (JADE) Registry. Diabetic Med 2016;33:1230–9. https://doi.org/10.1111/dme.12312

De Cosmo S, Viazzi F, Pacilli A, et al, and the AMD-Annals Study Group. Achievement of therapeutic targets in patients with diabetes and chronic kidney disease: insights from the Associazione Medici Diabetologi Annals initiative. Nephrol Dial Transplant 2015;30:1526–33. https://doi.org/10.1093/ndt/gfv101

Milne N. Improving the quality of diabetes care: an audit tool for chronic kidney disease. Diabetes and Primary Care 2014;16:78–83.

Harnett P, Jones M, Almond M, Ballasubramanian G, Kunnath V. A virtual clinic to improve long term outcomes in chronic kidney disease. Clin Med 2018;18:356–63. https://doi.org/10.7861/clinmedicine.18-5-356

Ennis J, Gillen D, Rubenstein A, et al. Clinical decision support improves physician guideline adherence for laboratory monitoring of chronic kidney disease: a matched cohort study. BMC Nephrol 2015;16:1–11. https://doi.org/10.1186/s12882-015-0159-5

Rayner HC, Hollingworth L, Higgins R, Dodds S. Systematic kidney disease management in a population with diabetes mellitus: turning the tide of kidney failure. BMJ Qual Saf 2011;20:903–10. https://doi.org/10.1136/bmjqs-2011-000061

Jones RK, Hampton D, O’Sullivan DJ, Phillips AO. Diabetes and renal disease: who does what? Clin Med 2013;13:460–4. https://doi.org/10.7861/clinmedicine.13-5-460

Camargo EG, Soares AA, Detanico AB, et al. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is less accurate in individuals with type 2 diabetes when compared with healthy individuals. Diabet Med 2011;28:90–5. https://doi.org/10.1111/j.1464-5491.2010.03161.x

Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart 2014;10(Suppl 2):ii46–ii51. https://doi.org/10.1136/heartjnl-2014-305693

Abbott CA, Carrington AL, Ashe H, et al. The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med 2002;19:377–84.

Steddon S, Sharples E. Renal Association clinical practice guideline in mineral and bone disorders in CKD. Nephron Clin Pract 2011;118(Suppl 1):c145–c152. https://doi.org/10.1159/000328066

Aspray TJ, Bowring C, Fraser W, et al. National Osteoporosis Society vitamin D guideline summary. Age Ageing 2014;43:592–5. https://doi.org/10.1093/ageing/afu093

Padhi S, Glen J, Pordes ABAJ, Thomas ME, on behalf of the Guideline Development Group. Management of anaemia in chronic kidney disease: summary of updated NICE guidance. BMJ 2015;350:32–6. https://doi.org/10.1136/bmj.h2258




DOI: https://doi.org/10.15277/bjd.2019.215

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