A community-based model of care improves blood pressure control and delays progression of proteinuria, left ventricular hypertrophy and diastolic dysfunction in Maori and Pacific patients with type 2 diabetes and chronic kidney disease: a randomized controlled trial

Abstract

Correspondence and offprint requests to: Geoffrey Douglas Braatvedt; E-mail: g.braatvedt@auckland.ac.nz Abstract Background. In this study, our main goal was to determine whether an integrated, community-based model of care using culturally appropriate health-care assistants to manage hypertension in Māori and Pacific patients with diabetes and chronic kidney disease (CKD) is more effective than conventional care in achieving blood pressure (BP) targets and delaying progression of cardiac and renal end-organ damage. Methods. Sixty-five Māori and Pacific patients (aged 47-75 years) with type 2 diabetes, moderate CKD (>0.5 g proteinuria/day, serum creatinine 130-300 μmol/l) and hypertension were randomized to usual care (n = 32) or community/intervention care (n = 33) for 12 months. Community care patients were visited monthly by a nurse-led health-care assistant for BP measurement. Antihypertensives were adjusted using a stepwise protocol, aiming for a BP <130/80 mmHg. Office BP and renal and echocardiographic parameters were measured at baseline and 12 months.Results. Baseline characteristics including office BP, renal and echocardiographic parameters, and number of antihypertensives were well matched in both groups. By 12 months, the community care patients had achieved a significantly greater reduction in office systolic BP (−21 ± 26 mmHg vs −12 ± 20 mmHg, P = 0.04) and in 24-h urine protein (−1.4 ± 2.6 g vs +0.1 ± 2.8 g, P = 0.04). The number of prescribed antihypertensives was greater in these patients at 12 months (3.4 ± 1.1 vs 2.3 ± 1.0, P < 0.01). Left ventricular (LV) mass and left atrial (LA) volume progressed in the usual care group, but not in the intervention group (P < 0.05).Conclusion. This novel model of care is more effective than conventional care in lowering systolic BP and reducing cardiac and renal end-organ damage in these highrisk patients.

Progression of Kidney Disease in Indigenous Australians: The eGFR Follow-up Study

“…Management of diabetes and hypertension remains a crucial part of CKD management programs. Other community-based approaches have been successful, such as the integrated model of care using community health workers for Maori and Pacific Islander participants with CKD and hypertension that resulted in improved BP control and albuminuria; these are key to developing targeted management approaches (30). In addition, incorporation of the rate of eGFR decline into the CKD definition may help identify high-risk patients (31).…”

‘Healthy’ individuals’ perceptions of type 1 and type 2 diabetes cause and management

“…It is also more prevalent among some ethnic groups (e.g. in Asian, Māori or Polynesian individuals; Hotu et al, 2010).…”

Impact of prior CKD management in a renal care network on early outcomes in incident dialysis patients: a prospective observational study

“…This could explain the favourable impact of network care on CKD progression. A recent study by Hotu et al showed that in diabetic and hypertensive CKD patients, a community based model of care leads to a higher decrease in proteinuria and BP than in patients receiving usual care [18]. To our knowledge, this issue was addressed by only one observational study [11].…”

“…In patients with diabetes mellitus, studies have found positive effects of this type of care delivery on patient’s outcomes [12,13]. In CKD patients, several studies have also found some positive effects of MDRC comparatively to standard care on renal outcomes [14-18]. Presently, the best way to organize those multidisciplinary renal clinics is, however, not standardized.…”