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

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.