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Andersen TH, Marcussen TM, Nørgaard O. Information needs for GPs on type 2 diabetes in Western countries: a systematic review. Br J Gen Pract 2024:BJGP.2023.0531. [PMID: 38429111 PMCID: PMC11388096 DOI: 10.3399/bjgp.2023.0531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/26/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Most people with type 2 diabetes receive treatment in primary care by GPs who are not specialised in diabetes. Thus, it is important to uncover the most essential information needs regarding type 2 diabetes in general practice. AIM To identify information needs related to type 2 diabetes for GPs. DESIGN AND SETTING Systematic review focused on literature relating to Western countries. METHOD MEDLINE, Embase, PsycInfo and CINAHL were searched from inception to January 2024. Two researchers conducted the selection process, and citation searches were performed to identify any relevant articles missed by the database search. Quality appraisal was conducted with the Mixed Methods Appraisal Tool. Meaning units were coded individually, grouped into categories, and then studies were summarised within the context of these categories using narrative synthesis. An evidence map was created to highlight research gaps. RESULTS Thirty-nine included studies revealed eight main categories and 36 subcategories of information needs. Categories were organised into a comprehensive hierarchical model of information needs, suggesting 'Knowledge of guidelines' and 'Reasons for referral' as general information needs alongside more specific needs on 'Medication', 'Management', 'Complications', 'Diagnosis', 'Risk factors', and 'Screening for diabetes'. The evidence map provides readers with the opportunity to explore the characteristics of the included studies in detail. CONCLUSION This systematic review provides GPs, policymakers, and researchers with a hierarchical model of information and educational needs for GPs, and an evidence map showing gaps in the current literature. Information needs about clinical guidelines and reasons for referral to specialised care overlapped with needs for more specific information.
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Affiliation(s)
- Tue Helms Andersen
- Danish Diabetes Knowledge Center, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Thomas Møller Marcussen
- Danish Diabetes Knowledge Center, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Ole Nørgaard
- Danish Diabetes Knowledge Center, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
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2
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Gatlin B, Miller J, Chang S. Optimizing Collaborative Care of Patients with Chronic Kidney Disease Associated with Type 2 Diabetes: An Example Practice Model at a Health Care Practice in Kentucky, United States. Diabetes Ther 2024; 15:1-11. [PMID: 37914833 PMCID: PMC10786800 DOI: 10.1007/s13300-023-01500-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 10/17/2023] [Indexed: 11/03/2023] Open
Abstract
Suboptimal multidisciplinary team collaboration is a barrier to effective health care provision for patients with chronic kidney disease (CKD) associated with type 2 diabetes mellitus (T2DM). We describe an example practice model of a clinical practice called Baptist Health Deaconess, based in Madisonville, Kentucky, USA, where a small multidisciplinary team consisting of an endocrinologist, nurse practitioner, and pharmacist (authors of this article) work collaboratively in an ambulatory care setting to provide health care to the patients they serve. Many of the patients who receive care at Baptist Health Deaconess are on a low income, have poor health literacy, and do not have a primary care physician. The presence of a pharmacist in the team allows for insurance/access investigations to assess drug choice and affordability; such aspects can be performed quickly with a pharmacist in the office.
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Affiliation(s)
- Benjamin Gatlin
- Baptist Health Deaconess Madisonville, Madisonville, KY, USA.
| | - Jamie Miller
- Baptist Health Deaconess Madisonville, Madisonville, KY, USA
| | - Sergio Chang
- Baptist Health Deaconess Madisonville, Madisonville, KY, USA
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3
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Levin SR, Alonso A, Salazar ED, Farber A, Chitalia VC, King EG, Cheng TW, Siracuse JJ. Recent evaluation by nephrologists is associated with decreased incidence of tunneled dialysis catheter being used at the time of first arteriovenous access creation. J Vasc Surg 2024; 79:128-135. [PMID: 37742733 DOI: 10.1016/j.jvs.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/14/2023] [Accepted: 09/17/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Late primary care provider (PCP) or nephrologist evaluation of patients with progressive kidney disease may be associated with increased morbidity and mortality. Among patients undergoing initial arteriovenous (AV) access creation, we aimed to study the relationship of recent PCP and nephrologist evaluations with perioperative morbidity and mortality. METHODS We performed a retrospective review of patients from 2014 to 2022 who underwent initial AV access creation at an urban, safety-net hospital. Univariable and multivariable analyses identified associations of PCP and nephrologist evaluations <1 year and <3 months before surgery, respectively, with hemodialysis initiation via tunneled dialysis catheters (TDCs), 90-day readmission, and 90-day mortality. RESULTS Among 558 patients receiving initial AV access, mean age was 59.7 ± 14 years, 59% were female gender, and 60.6% were Black race. Recent PCP and nephrology evaluations occurred in 386 (69%) and 362 (65%) patients, respectively. On multivariable analysis, unemployed and uninsured statuses were associated with decreased likelihood of PCP evaluation (unemployment: odds ratio [OR], 0.51; 95% confidence interval [CI], 0.34-0.77; uninsured status: OR, 0.05; 95% CI, 0.01-0.45) and nephrologist evaluation (unemployment: OR, 0.63; 95% CI, 0.43-0.91; uninsured status: OR, 0.22; 95% CI, 0.06-0.83) (all P < .05). Social support was associated with increased likelihood of PCP evaluation (OR, 1.81; 95% CI, 1.07-3.08) (all P < .05). Hemodialysis was initiated with TDCs in 304 patients (55%). Older age (OR, 0.98; 95% CI, 0.96-0.99), obesity (OR, 0.38; 95% CI, 0.25-0.58), and nephrologist evaluation (OR, 0.12; 95% CI, 0.08-0.19) were independently associated with decreased hemodialysis initiation with TDCs in patients receiving an initial AV access (all P < .05). Ninety-day readmission occurred in 270 cases (48%). Cirrhosis (OR, 2.5; 95% CI, 1.03-6.03; P = .04), coronary artery disease (OR, 2.31; 95% CI, 1.5-3.57), prosthetic AV access (OR, 1.84; 95% CI, 1.04-3.26), and impaired ambulation (OR, 1.75; 95% CI, 1.15-2.66) were independently associated with increased readmission (all P < .05). Older age (OR, 0.98; 95% CI, 0.97-0.99), prior TDC (OR, 0.65; 95% CI, 0.45-0.94), and unemployment (OR, 0.58; 95% CI, 0.39-0.86) were associated with decreased readmission (all P < .05). Ninety-day mortality occurred in 1.6% of patients. Neither PCP nor nephrologist evaluation was associated with readmission or mortality. CONCLUSIONS Recent nephrology evaluation was associated with reduced hemodialysis initiation with TDCs among patients undergoing initial AV access creation. Unemployed and uninsured statuses posed barriers to accessing nephrology care.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Andrea Alonso
- Division of Vascular and Endovascular Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Eduardo D Salazar
- Division of Vascular and Endovascular Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Vipul C Chitalia
- Renal Section, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA; Veterans Affairs Boston Healthcare System, Boston, MA; Institute of Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
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4
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Raffray M, Vigneau C, Couchoud C, Laude L, Campéon A, Schweyer FX, Bayat S. The dynamics of the general practitioner-nephrologist collaboration for the management of patients with chronic kidney disease before and after dialysis initiation: a mixed-methods study. Ther Adv Chronic Dis 2022; 13:20406223221108397. [PMID: 36199764 PMCID: PMC9527990 DOI: 10.1177/20406223221108397] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/01/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Effective collaboration between general practitioners (GP) and nephrologists is crucial in CKD care. We aimed to analyse GPs’ and nephrologists’ presence and involvement in CKD care and assess how they intertwine to shape patients’ trajectories. Methods: We conducted a mixed-methods study that included all patients with CKD who started dialysis in France in 2015 (the REIN registry) and a sample of nephrologists and GPs. We quantified professionals’ presence through patients’ reimbursed healthcare from the French National Health Data System, 2 years before and 1 year after dialysis start. Involvement in CKD care was derived from the nephrologists’ and GPs’ interviews. Results: Among 8856 patients included, nephrologists’ presence progressively increased from 29% to 67% of patients with a contact during the 2 years before dialysis start. However, this was partly dependent on the GPs’ referral practices. Interviews revealed that GPs initially controlled the therapeutic strategy on their own. Although unease grew with CKD’s management complexity, reducing their involvement in favour of nephrologists, GPs’ presence remained frequent throughout the pre-dialysis period. Upon dialysis start, nephrologists’ presence and involvement became total, while GPs’ greatly decreased (48% of patients with a contact at month 12 after dialysis start). Collaboration was smooth when GPs maintained contact with patients and could contribute to their care through aspects of their specialty they valued. Conclusions: This mixed-methods study shows presences and forms of involvement of GPs and nephrologists in CKD care adjusting along the course of CKD and unveils the mechanisms at play in their collaboration.
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Affiliation(s)
- Maxime Raffray
- Univ Rennes, EHESP, CNRS, Inserm, Arènes – UMR 6051, RSMS (Recherche sur les Services et Management en Santé) – U 1309, F-35000 Rennes, France
| | - Cécile Vigneau
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) – UMR_S 1085, Rennes, France
| | - Cécile Couchoud
- Renal Epidemiology and Information Network (REIN) Registry, Biomedecine Agency, Saint-Denis, France
| | - Laetitia Laude
- Univ Rennes, EHESP, CNRS, Inserm, Arènes – UMR 6051, RSMS (Recherche sur les Services et Management en Santé) – U 1309, Rennes, France
| | | | | | - Sahar Bayat
- Univ Rennes, EHESP, CNRS, Inserm, Arènes – UMR 6051, RSMS (Recherche sur les Services et Management en Santé) – U 1309, Rennes, France
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5
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Manski-Nankervis JA, Alexander K, Biezen R, Jones J, Hunter B, Emery J, Lumsden N, Boyle D, Gunn J, McMorrow R, Prictor M, Taylor M, Hallinan C, Chondros P, Janus E, McIntosh J, Nelson C. Towards optimising chronic kidney disease detection and management in primary care: Underlying theory and protocol for technology development using an Integrated Knowledge Translation approach. Health Informatics J 2021; 27:14604582211008227. [PMID: 33853414 DOI: 10.1177/14604582211008227] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Worldwide, Chronic Kidney Disease (CKD), directly or indirectly, causes more than 2.4 million deaths annually with symptoms generally presenting late in the disease course. Clinical guidelines support the early identification and treatment of CKD to delay progression and improve clinical outcomes. This paper reports the protocol for the codesign, implementation and evaluation of a technological platform called Future Health Today (FHT), a software program that aims to optimise early detection and management of CKD in general practice. FHT aims to optimise clinical decision making and reduce practice variation by translating evidence into practice in real time and as a part of quality improvement activities. This protocol describes the co-design and plans for implementation and evaluation of FHT in two general practices invited to test the prototype over 12 months. Service design thinking has informed the design phase and mixed methods will evaluate outcomes following implementation of FHT. Through systematic application of co-design with service users, clinicians and digital technologists, FHT attempts to avoid the pitfalls of past studies that have failed to accommodate the complex requirements and dynamics that can arise between researchers and service users and improve chronic disease management through use of health information technology.
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Affiliation(s)
| | | | | | - Julia Jones
- Department of Nephrology, Western Health, Australia.,Western Health Chronic Disease Alliance, Australia.,University of Melbourne, Australia
| | | | | | - Natalie Lumsden
- Department of Nephrology, Western Health, Australia.,Western Health Chronic Disease Alliance, Australia
| | | | | | | | | | | | | | | | - Edward Janus
- Western Health Chronic Disease Alliance, Australia.,University of Melbourne, Australia.,General Internal Medicine Unit, Western Health, Australia
| | | | - Craig Nelson
- Department of Nephrology, Western Health, Australia.,Western Health Chronic Disease Alliance, Australia.,University of Melbourne, Australia
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6
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Zimbudzi E, Lo C, Ranasinha S, Earnest A, Teede H, Usherwood T, Polkinghorne KR, Fulcher G, Gallagher M, Jan S, Cass A, Walker R, Russell G, Johnson G, Kerr PG, Zoungas S. A co-designed integrated kidney and diabetes model of care improves mortality, glycaemic control and self-care. Nephrol Dial Transplant 2021; 37:1472-1481. [PMID: 34314493 DOI: 10.1093/ndt/gfab230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Current health-care models are ill-equipped for managing people with diabetes and chronic kidney disease (CKD). We evaluated the impact of a new diabetes and kidney disease service (DKS) on hospitalisation, mortality, clinical and patient relevant outcomes. METHODS Longitudinal analyses of adult patients with diabetes and CKD (stages 3a to 5) were performed using outpatient and hospitalisation data from January 2015 to October 2018. Data was handled according to whether patients received the DKS intervention (n = 196) or standard care (n = 7511). The DKS provided patient-centered, coordinated multi-disciplinary assessment and management of patients. Primary analyses examined hospitalisation and mortality rates between the two groups. Secondary analyses evaluated the impact of the DKS on clinical target attainment, changes in eGFR, HbA1c, self-care and patient activation at 12 months. RESULTS Patients who received the intervention had a higher hospitalisation rate (incidence rate ratio (IRR), 1.20; 95% CI, 1.13 to 1.30; P < 0.0001), shorter median length of stay (2 days [interquartile range (IQR), 6-1] versus 4 days [IQR 9-1]; P < 0.0001) and lower all-cause mortality rate (IRR 0.4; 95% CI, 0.29 to 0.64; P < 0.0001) than those who received standard care. Improvements in overall self-care (MD 2.26, 95% CI 0.83, 3.69; P < 0.001) and in statin use, foot and eye examination were observed. Mean eGFR did not significantly change after 12 months (MD 1.30, 95% CI -4.17, 1.67; P = 0.40) mls/min per 1.73 m2. HbA1c levels significantly decreased by 0.40, 0.35, 0.34 and 0.23% at 3, 6, 9 and 12 months follow-up respectively. CONCLUSIONS A co-designed, person-centred integrated model of care improved all-cause mortality, kidney function, glycaemic control and self-care for patients with diabetes and CKD.
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Affiliation(s)
- Edward Zimbudzi
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia.,Department of Nephrology, Monash Health, VIC, Australia
| | - Clement Lo
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia.,Diabetes and Vascular Medicine Unit, Monash Health, VIC, Australia
| | - Sanjeeva Ranasinha
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia
| | - Arul Earnest
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia
| | - Helena Teede
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia.,Diabetes and Vascular Medicine Unit, Monash Health, VIC, Australia
| | - Tim Usherwood
- The George Institute for Global Health, University of NSW, NSW, Australia.,Department of General Practice, Sydney Medical School, University of Sydney, Australia
| | - Kevan R Polkinghorne
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia.,Department of Nephrology, Monash Health, VIC, Australia.,School of Clinical Sciences, Monash University, VIC, Australia
| | - Gregory Fulcher
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, University of Sydney, NSW, Australia.,Northern Clinical School, University of Sydney, Sydney, Australia
| | - Martin Gallagher
- The George Institute for Global Health, University of NSW, NSW, Australia.,Concord Clinical School, University of Sydney, NSW, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of NSW, NSW, Australia.,Sydney Medical School, University of Sydney, NSW, Australia
| | - Alan Cass
- The George Institute for Global Health, University of NSW, NSW, Australia.,Menzies School of Health Research, NT, Australia
| | - Rowan Walker
- Department of Renal Medicine, Alfred Health, VIC, Australia
| | - Grant Russell
- School of Primary Health Care, Monash University, VIC, Australia
| | | | - Peter G Kerr
- Department of Nephrology, Monash Health, VIC, Australia.,School of Clinical Sciences, Monash University, VIC, Australia
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia.,Diabetes and Vascular Medicine Unit, Monash Health, VIC, Australia.,The George Institute for Global Health, University of NSW, NSW, Australia
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7
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Voigt P, Kairys P, Voigt A, Frese T. [Non-dialysis chronic kidney disease in primary care - a questionnaire study among general practitioners]. Dtsch Med Wochenschr 2021; 146:e39-e46. [PMID: 33477172 PMCID: PMC7972822 DOI: 10.1055/a-1334-2513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The majority of patients with non-dialysis chronic kidney disease are cared for by general practitioners. Especially for Germany, the evidence of this topic is still very low. The aim of the survey was to estimate the perceived frequency of non-dialysis chronic kidney disease in general practice, the use of diagnostics and therapy, used tools considering the professional background and experience of the responding general practitioners. METHODS A questionnaire was self-designed in the cooperation of several disciplines. 1130 general practitioners from Saxony and Saxony-Anhalt were randomly selected and the questionnaire was sent by post. Data were collected from June 2019 to July 2019. RESULTS Of the 1,130 questionnaires sent, 372 returned analysable (response rate: 32.9 %). The prevalence of non-dialysis chronic kidney disease was estimated to be 6-15 %. 97 % of the general practitioners rated the adjustment of high blood pressure and diabetes mellitus as a high to very high priority. Concerning the diagnosis of proteinuria, the use of a urine dipstick test was stated by 60.8 % of the respondents and the requirement for an albumin/creatinine-ratio was stated by 22.6 %. Only a few differences could be revealed in the response behavior of the participating groups of doctors. Working experience is an important factor in choosing tools, especially guidelines. CONCLUSIONS The results showed that the doctors interviewed followed international recommendations for the care of patients with non-dialysis chronic kidney disease. However, improvements in progression diagnostics are necessary and important. General practitioners and internal medicines working as general practitioners have a comparable level of competence in the primary medical care of the non-dialysis chronic kidney disease. Significant differences were created by the professional experience of the doctors. KEY POINTS · General practitioners estimate the prevalence of non-dialysis chronic kidney disease in their practice at 6-15 %.. · Using the albumin/creatinine-ratio for proteinuria diagnostics is requested too rarely compared to the urine dipstick test.. · General practitioners, specialists in general medicine and internists working in general medicine have a comparable level of competence to treat patients with non-dialysis chronic kidney disease.. · Working experience is an important factor in choosing tools, especially guidelines..
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Affiliation(s)
- Paul Voigt
- Institute of General Practice and Family Medicine, Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| | - Paul Kairys
- Institute of General Practice and Family Medicine, Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| | - Anne Voigt
- Institute of General Practice and Family Medicine, Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| | - Thomas Frese
- Institute of General Practice and Family Medicine, Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
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8
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Clemens KK, Ouédraogo AM, Liu SL, Bleah P, Mikalachki A, Spaic T. Providing diabetes education to patients with chronic kidney disease: A survey of diabetes educators in Ontario, Canada. JOURNAL OF MULTIMORBIDITY AND COMORBIDITY 2021; 11:26335565211062758. [PMID: 34926313 PMCID: PMC8671669 DOI: 10.1177/26335565211062758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients with diabetes and chronic kidney disease (CKD) have complex diabetes care needs. Diabetes educators can play an important role in their clinical care. AIM To understand diabetes educators' experience providing diabetes support to patients with CKD and elicit their view on the additional care needs of this population. METHODS We conducted a quantitative online survey of diabetes educators between May 2019 and May 2020. We surveyed English-speaking educators actively practicing in Ontario, Canada for at least 1 year. We recruited them through provincial Diabetes Education Programs and Diabetes Education Section Chairs of Diabetes Canada. RESULTS We made email contact with 219/233 (94%) Diabetes Education Programs and 11/12 (92%) provincial Diabetes Canada Section Chairs. 122 unique diabetes educators submitted complete surveys (survey participation rate ∼79%). Most worked in community education programs (91%). Almost half were registered nurses (48%), and 39% had practiced for more than 15 years. Respondents noted difficulty helping patients balance complex medical conditions (19%), faced socioeconomic barriers (17%), and struggled to provide dietary advice (16%). One-third were uncertain of how to support those receiving dialysis. Eighty-five percent felt they needed more training and education to care for this high-risk group. When asked about the care needs of patients with CKD, almost all (90%) felt that patients needed more diabetes support in general. Improvement in care coordination was most commonly suggested (38%). CONCLUSIONS In this study of the diabetes educators' experience treating patients with diabetes and CKD, respondents noted numerous challenges. There may be opportunities to better support both diabetes care professionals, and patients who live with multiple medical comorbidities.
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Affiliation(s)
- Kristin K Clemens
- Department of Medicine, Division of Endocrinology and Metabolism, Western University, London, ON, Canada
- Centre for Diabetes, Endocrinology and Metabolism, St. Joseph’s Health Care London, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
- ICES Western, London, ON, Canada
| | | | - Selina L Liu
- Department of Medicine, Division of Endocrinology and Metabolism, Western University, London, ON, Canada
- Centre for Diabetes, Endocrinology and Metabolism, St. Joseph’s Health Care London, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Paulina Bleah
- University Health Network, Division of Nephrology, Toronto General Hospital, Toronto, ON, Canada
| | | | - Tamara Spaic
- Department of Medicine, Division of Endocrinology and Metabolism, Western University, London, ON, Canada
- Centre for Diabetes, Endocrinology and Metabolism, St. Joseph’s Health Care London, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
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9
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Gor D, Gerber BS, Walton SM, Lee TA, Nutescu EA, Touchette DR. Antidiabetic drug use trends in patients with type 2 diabetes mellitus and chronic kidney disease: A cross-sectional analysis of the National Health and Nutrition Examination Survey. J Diabetes 2020; 12:385-395. [PMID: 31652390 DOI: 10.1111/1753-0407.13003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/25/2019] [Accepted: 10/13/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There is little information on medication use, trends across time, and the impact of guidelines on appropriate use of antidiabetic drugs in participants with type 2 diabetes mellitus (T2DM) with chronic kidney disease (CKD). METHODS A cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) from 2005-2016 was carried out for participants with T2DM with and without CKD. Multivariate survey-weighted regression models were used to evaluate trends in antidiabetic drug use across the time periods and CKD severity. Guideline-discordant use of metformin and glyburide were assessed among those with glomerular filtration rate and serum creatinine-based contraindications. RESULTS Out of 3237 study participants with T2DM, 35.9% had CKD. Comparing 2013-2016 with 2005-2008, use of metformin (non-CKD: 69% vs 83.8%, CKD: 58.6% vs 68.2%) increased, whereas the use of sulfonylureas (non-CKD: 46.3% vs 27.2%, CKD: 54.7% vs 36.6%) and thiazolidinediones (non-CKD: 29.3% vs 3.9%, CKD: 24.6% vs 5.5%) decreased. In combined NHANES cycles and across stages of CKD severity, metformin use decreased (non-CKD, stage 1/2, stage 3, stage 4/5: 78.4%, 69.5%, 54.6%, 4.9%, respectively; P < .01), and insulin use increased (18.5%, 26.8%, 25%, 52.8%, respectively; P < .01) from non-CKD to progressed CKD. Guideline-discordant use of metformin and glyburide was observed in 8.3% and 2.8% of the participants, respectively, in 2013-2016. CONCLUSIONS Use of particular antidiabetic medications in patients with CKD changed noticeably over the years, most in accordance with guidelines and regulatory decisions. Gaps in quality of care still exist, which warrants increasing awareness and implementing programs to mitigate inappropriate use.
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Affiliation(s)
- Deval Gor
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Ben S Gerber
- Division of Academic Internal Medicine and Geriatrics, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Surrey M Walton
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
| | - Edith A Nutescu
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
| | - Daniel R Touchette
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
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10
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Neale EP, Middleton J, Lambert K. Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review. BMC Nephrol 2020; 21:83. [PMID: 32160886 PMCID: PMC7066820 DOI: 10.1186/s12882-020-01731-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 02/19/2020] [Indexed: 02/07/2023] Open
Abstract
Background Chronic kidney disease (CKD) is growing population health concern worldwide, and with early identification and effective management, kidney disease progression can be slowed or prevented. Most patients with risk factors for chronic kidney disease are treated within primary healthcare. Therefore, it is important to understand how best to support primary care providers (PC-P) to detect and manage chronic kidney disease. The aim of this systematic review was to evaluate barriers and enablers to the diagnosis and management of CKD in primary care. Methods A systematic review of qualitative research on the barriers and/or enablers to detection and/or management of CKD in adults within primary healthcare was conducted. The databases Medline (EBSCO), PubMed, Cochrane CENTRAL, CINAHL (EBSCO) and Joanna Briggs Institute Evidence Based Practice (Ovid) were searched until 27th August 2019. Barriers and/or enablers reported in each study were identified, classified into themes, and categorised according to the Theoretical Domains Framework. Results A total of 20 studies were included in this review. The most commonly reported barriers related to detection and management of CKD in primary care were categorised into the ‘Environmental context and resources’ domain (n = 16 studies). Overall, the most common barrier identified was a lack of time (n = 13 studies), followed by a fear of delivering a diagnosis of CKD, and dissatisfaction with CKD guidelines (both n = 10 studies). Overall, the most common enabler identified was the presence of supportive technology to identify and manage CKD (n = 7 studies), followed by the presence of a collaborative relationship between members of the healthcare team (n = 5 studies). Conclusion This systematic review identified a number of barriers and enablers which PC-P face when identifying and managing CKD. The findings of this review suggest a need for time-efficient strategies that promote collaboration between members of the healthcare team, and practice guidelines which consider the frequently co-morbid nature of CKD. Enhanced collaboration between PC-P and nephrology services may also support PC-Ps when diagnosing CKD in primary care, and facilitate improved patient self-management.
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Affiliation(s)
- Elizabeth P Neale
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, 2522, Australia. .,Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, 2522, Australia. .,Health Impacts Research Cluster, University of Wollongong, Wollongong, NSW, 2522, Australia.
| | - Justin Middleton
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Kelly Lambert
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, 2522, Australia.,Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, 2522, Australia.,Health Impacts Research Cluster, University of Wollongong, Wollongong, NSW, 2522, Australia.,Department of Clinical Nutrition, Wollongong Hospital, Level 5, Block C, Crown St, Wollongong, NSW, 2500, Australia
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11
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Sperati CJ, Soman S, Agrawal V, Liu Y, Abdel-Kader K, Diamantidis CJ, Estrella MM, Cavanaugh K, Plantinga L, Schell J, Simon J, Vassalotti JA, Choi MJ, Jaar BG, Greer RC. Primary care physicians' perceptions of barriers and facilitators to management of chronic kidney disease: A mixed methods study. PLoS One 2019; 14:e0221325. [PMID: 31437198 PMCID: PMC6705804 DOI: 10.1371/journal.pone.0221325] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 08/06/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Given the high prevalence of chronic kidney disease (CKD), primary care physicians (PCPs) frequently manage early stage CKD. Nonetheless, there are challenges in providing optimal CKD care in the primary care setting. This study sought to understand PCPs' perceptions of barriers and facilitators to the optimal management of CKD. STUDY DESIGN Mixed methods study. SETTINGS AND PARTICIPANTS Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC and San Francisco, CA. METHODOLOGY We used a self-administered questionnaire and conducted 4 focus groups of PCPs (n = 8 PCPs/focus group) in each city to identify key barriers and facilitators to management of patients with CKD in primary care. ANALYTIC APPROACH We conducted descriptive analyses of the survey data. Major themes were identified from audio-recorded interviews that were transcribed and coded by the research team. RESULTS Of 32 participating PCPs, 31 (97%) had been in practice for >10 years, and 29 (91%) practiced in a non-academic setting. PCPs identified multiple barriers to managing CKD in primary care including at the level of the patient (e.g., low awareness of CKD, poor adherence to treatment recommendations), the provider (e.g., staying current with CKD guidelines), and the health care system (e.g., inflexible electronic medical record, limited time and resources). PCPs desired electronic prompts and lab decision support, concise guidelines, and healthcare financing reform to improve CKD care. CONCLUSIONS PCPs face substantial but modifiable barriers in providing care to patients with CKD. Interventions that address these barriers and promote facilitative tools may improve PCPs' effectiveness and capacity to care for patients with CKD.
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Affiliation(s)
- C. John Sperati
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Sandeep Soman
- Division of Nephrology, Henry Ford Hospital, Detroit, Michigan, United States of America
| | - Varun Agrawal
- Division of Nephrology and Hypertension, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Yang Liu
- Johns Hopkins Medicine International, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States of America
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center; Vanderbilt Center for Kidney Disease, Nashville, Tennessee, United States of America
| | - Clarissa J. Diamantidis
- Divisions of General Internal Medicine and Nephrology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Michelle M. Estrella
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco and San Francisco VA Health Care System, San Francisco, California, United States of America
| | - Kerri Cavanaugh
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center; Vanderbilt Center for Kidney Disease, Nashville, Tennessee, United States of America
| | - Laura Plantinga
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Jane Schell
- Section of Palliative Care and Medical Ethics, Division of Renal-Electrolyte, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - James Simon
- Department of Nephrology and Hypertension, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Joseph A. Vassalotti
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
- National Kidney Foundation, New York, New York, United States of America
| | - Michael J. Choi
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Bernard G. Jaar
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Nephrology Center of Maryland, Baltimore, Maryland, United States of America
- The Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland, United States of America
| | - Raquel C. Greer
- The Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland, United States of America
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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12
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Lo C, Zimbudzi E, Teede H, Cass A, Fulcher G, Gallagher M, Kerr PG, Jan S, Johnson G, Mathew T, Polkinghorne K, Russell G, Usherwood T, Walker R, Zoungas S. Models of care for co-morbid diabetes and chronic kidney disease. Nephrology (Carlton) 2019; 23:711-717. [PMID: 29405503 DOI: 10.1111/nep.13232] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2018] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Clement Lo
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Victoria, Australia
| | - Edward Zimbudzi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Nephrology, Monash Health, Melbourne, Victoria, Australia
| | - Helena Teede
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Victoria, Australia
| | - Alan Cass
- Menzies School of Health Research, Darwin, Northern Territory, Australia.,The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia
| | - Greg Fulcher
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Martin Gallagher
- The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Nephrology, Concord Hospital, Concord, New South Wales, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Health, Melbourne, Victoria, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia
| | | | - Tim Mathew
- Kidney Health Australia, South Melbourne, Victoria, Australia
| | | | - Grant Russell
- School of Primary Health Care, Monash University, Melbourne, Victoria, Australia
| | - Tim Usherwood
- The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia.,Department of General Practice, Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Rowan Walker
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Victoria, Australia.,The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia
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13
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Zimbudzi E, Lo C, Robinson T, Ranasinha S, Teede HJ, Usherwood T, Polkinghorne KR, Kerr PG, Fulcher G, Gallagher M, Jan S, Cass A, Walker R, Russell G, Johnson G, Zoungas S. The impact of an integrated diabetes and kidney service on patients, primary and specialist health professionals in Australia: A qualitative study. PLoS One 2019; 14:e0219685. [PMID: 31306453 PMCID: PMC6629146 DOI: 10.1371/journal.pone.0219685] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/30/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND To address guideline-practice gaps and improve management of patients with both diabetes and chronic kidney disease (CKD), we involved patients, health professionals and patient advocacy groups in the co-design and implementation of an integrated diabetes-kidney service. OBJECTIVE In this study, we explored the experiences of patients and health-care providers, within this integrated diabetes and kidney service. METHODS 5 focus groups and 2 semi-structured interviews were conducted amongst attending patients, referring primary health professionals, and attending specialist health professionals. Maximal variation sampling was used for both patients and referring primary health professionals to ensure an equal representation of males and females, and patients of different CKD stages. All discussions were audiotaped and transcribed verbatim, before being thematically analysed independently by 2 researchers. RESULTS The mean age (SD) for specialist health professionals, primary care professionals and patients who participated was 45 (11), 44 (15) and 68 (5) years with men being 50%, 80% and 76% of the participants respectively. Key strengths of the diabetes and kidney service were noted to be better integration of care and a perception of improved health and management of health. Whilst some aspects of access such as time between referral and initial appointment and having fewer appointments improved, other aspects such as in-clinic waiting times and parking remained problematic. Specialist health professionals noted that health professional education could be improved. Patient self-management was also noted by to be an issue with some patients requesting more information and some health professionals expressing difficulty in empowering some patients. CONCLUSIONS Health professionals and patients reported that a co-designed integrated diabetes kidney service improved integration of care and improved health and management of health. However, some aspects of the process of care, health professional education and patient self-management remained challenging.
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Affiliation(s)
- Edward Zimbudzi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Nephrology, Monash Health, Melbourne, Australia
| | - Clement Lo
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Australia
| | - Tracy Robinson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sanjeeva Ranasinha
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Helena J. Teede
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Australia
| | - Tim Usherwood
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of General Practice, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kevan R. Polkinghorne
- Department of Nephrology, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Peter G. Kerr
- Department of Nephrology, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Gregory Fulcher
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, University of Sydney, Sydney, Australia
- Northern Clinical School, University of Sydney, Sydney, Australia
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Alan Cass
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Menzies School of Health Research, Darwin, Australia
| | - Rowan Walker
- Department of Renal Medicine, Alfred Health, Melbourne, Australia
| | - Grant Russell
- School of Primary Health Care, Monash University, Melbourne, Australia
| | | | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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14
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Primary Care Physicians' Perceived Barriers to Nephrology Referral and Co-management of Patients with CKD: a Qualitative Study. J Gen Intern Med 2019; 34:1228-1235. [PMID: 30993634 PMCID: PMC6614220 DOI: 10.1007/s11606-019-04975-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 12/11/2018] [Accepted: 02/20/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Effective co-management of patients with chronic kidney disease (CKD) between primary care physicians (PCPs) and nephrologists is increasingly recognized as a key strategy to ensure the delivery of efficient and high-quality CKD care. However, the co-management of patients with CKD remains suboptimal. OBJECTIVE We aimed to identify PCPs' perceptions of key barriers and facilitators to effective co-management of patients with CKD at the PCP-nephrology interface. STUDY DESIGN Qualitative study SETTING AND PARTICIPANTS: Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC; and San Francisco, CA APPROACH: We conducted four focus groups of PCPs. Two members of the research team coded transcribed audio-recorded interviews and identified major themes. KEY RESULTS Most of the 32 PCPs (59% internists and 41% family physicians) had been in practice for > 10 years (97%), spent ≥ 80% of their time in clinical care (94%), and practiced in private (69%) or multispecialty group practice (16%) settings. PCPs most commonly identified barriers to effective co-management of patients with CKD focused on difficulty developing working partnerships with nephrologists, including (1) lack of timely adequate information exchange (e.g., consult note not received or CKD care plan unclear); (2) unclear roles and responsibilities between PCPs and nephrologists; and (3) limited access to nephrologists (e.g., unable to obtain timely consultations or easily contact nephrologists with concerns). PCPs expressed a desire for "better communication tools" (e.g., shared electronic medical record) and clear CKD care plans to facilitate improved PCP-nephrology collaboration. CONCLUSIONS Interventions facilitating timely adequate information exchange, clear delineation of roles and responsibilities between PCPs and nephrologists, and greater access to specialist advice may improve the co-management of patients with CKD.
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15
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Lo C, Zimbudzi E, Teede HJ, Kerr PG, Ranasinha S, Cass A, Fulcher G, Gallagher M, Polkinghorne KR, Russell G, Usherwood T, Walker R, Zoungas S. Patient-reported barriers and outcomes associated with poor glycaemic and blood pressure control in co-morbid diabetes and chronic kidney disease. J Diabetes Complications 2019; 33:63-68. [PMID: 30621853 DOI: 10.1016/j.jdiacomp.2018.09.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 06/18/2018] [Accepted: 09/26/2018] [Indexed: 12/21/2022]
Abstract
AIMS In patients with comorbid diabetes and chronic kidney disease, the extent to which patient-reported barriers to health-care and patient reported outcomes influence the quality of health care is not well established. This study explored the association between patient-reported barriers to health-care, patient activation, quality of life and diabetes self-care, with attainment of glycaemic and blood pressure (BP) targets. METHODS This cross-sectional study recruited adults with diabetes and CKD (eGFR 20 to <60 ml/min/1.73m2) across four hospitals. We combined clinical data with results from a questionnaire comprising measures of patient-identified barriers to care, the Patient Activation Measure (PAM), 12-Item Short Form Survey (SF-12), and the Summary of Diabetes Self-Care Activity (SDSCA). RESULTS 199 patients, mean age 68.7 (SD 9.6), 70.4% male and 90.0% with type 2 diabetes were studied. Poor glycaemic control was associated with increased odds of patient reported "poor family support" (OR 4.90; 95% CI 1.80 to 13.32, p < 0.002). Poor BP control was associated with increased odds of patient reported, "not having a good primary care physician" (OR 6.01; 2.42 to 14.95, p < 0.001). The number of barriers was not associated with increased odds of poor control (all p > 0.05). CONCLUSIONS Specific patient-reported barriers, lack of patient perceived family and primary care physician support, are associated with increased odds of poor glycaemic and blood pressure control respectively. Interventions addressing these barriers may improve treatment target attainment.
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Affiliation(s)
- Clement Lo
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia; Diabetes and Vascular Medicine Unit, Monash Health, VIC, Australia
| | - Edward Zimbudzi
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia; Department of Nephrology, Monash Health, VIC, Australia
| | - Helena J Teede
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia; Diabetes and Vascular Medicine Unit, Monash Health, VIC, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Health, VIC, Australia
| | - Sanjeeva Ranasinha
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia
| | - Alan Cass
- Menzies School of Health Research, Casuarina, NT, Australia; The George Institute for Global Health, NSW, Australia
| | - Gregory Fulcher
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, NSW, Australia
| | - Martin Gallagher
- The George Institute for Global Health, NSW, Australia; Department of Nephrology, Concord Hospital, NSW, Australia
| | - Kevan R Polkinghorne
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia; Department of Nephrology, Monash Health, VIC, Australia
| | - Grant Russell
- Department of General Practice, School of Primary and Allied Health Care, Monash University, VIC, Australia
| | - Tim Usherwood
- The George Institute for Global Health, NSW, Australia; Department of General Practice, Sydney Medical School Westmead, NSW, Australia
| | - Rowan Walker
- Department of Renal Medicine, Alfred Health, VIC, Australia
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, VIC, Australia; Diabetes and Vascular Medicine Unit, Monash Health, VIC, Australia; The George Institute for Global Health, NSW, Australia.
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16
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General practitioners' perspectives on management of early-stage chronic kidney disease: a focus group study. BMC FAMILY PRACTICE 2018; 19:81. [PMID: 29875016 PMCID: PMC5991428 DOI: 10.1186/s12875-018-0736-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 04/18/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Guideline adherence in chronic kidney disease management is low, despite guideline implementation initiatives. Knowing general practitioners' (GPs') perspectives of management of early-stage chronic kidney disease (CKD) and the applicability of the national interdisciplinary guideline could support strategies to improve quality of care. METHOD Qualitative focus group study with 27 GPs in the Netherlands. Three analysts open-coded and comparatively analysed the data. Mind-mapping sessions were performed after data-saturation. RESULTS Five themes emerged: defining CKD, knowledge and awareness, patient-physician interaction, organisation of CKD care and value of the guideline. A key finding was the abstractness of the CKD concept. The GPs expressed various perspectives about defining CKD and interpreting estimated glomerular filtration rates. Views about clinical relevance influenced the decision-making, although factual knowledge seems lacking. Striving to inform well enough without creating anxiety and to explain suitably for the intellectual ability of the patient caused tension in the patient-physician interaction. Integration with cardiovascular disease-management programmes was mentioned as a way of implementing CKD care in the future. The guideline was perceived as a rough guide rather than a leading document. CONCLUSION CKD is perceived as an abstract rather than a clinical concept. Abstractness plays a role in all formulated themes. Management of CKD patients in primary care is complex and is influenced by physician-bound considerations related to individual knowledge and perception of the importance of CKD. Strategies are needed to improve GPs' understanding of the concept of CKD by education, a holistic approach to guidelines, and integration of CKD care into cardiovascular programmes. TRIAL REGISTRATION Not applicable.
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17
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Improving access to allied health professionals through the Champlain BASE ™ eConsult service: a cross-sectional study in Canada. Br J Gen Pract 2017; 67:e757-e763. [PMID: 28993307 DOI: 10.3399/bjgp17x693125] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 07/10/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Allied health services are an important part of providing effective team-based care. The Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service facilitates quick and secure communication between primary care providers (PCPs) and allied health professionals (AHPs). AIM To assess the eConsult service's ability to improve access to advice from AHPs. DESIGN AND SETTING A cross-sectional study was carried out on all cases submitted to AHPs through the eConsult service between April 2011 and May 2016. The service covers Ottawa, Canada, and its surrounding rural communities. METHOD A descriptive overview of all cases submitted to allied health services was conducted. Utilisation and survey metrics for AHP eConsults were compared with those sent to medical specialties, in order to understand the potential differences and generalisability of eConsult access beyond the traditional medical specialty referral. RESULTS PCPs submitted 127 cases to nine allied health specialties during the study period. The most popular specialty was clinical pharmacist, which received an average of 1.5 cases per month. The median specialist response time was 2.1 days (interquartile range [IQR] 0.7-5.3 days, range 0.01-14.2 days) versus 0.9 days (IQR 0.2-3.4 days, range 0-49.5 days) for medical specialties. PCPs received advice for a new or additional course of action in 70% (versus 58% for medical specialties) of cases. They rated the service as being of high or very high value for their patients in 88% of cases (versus 93% for medical specialties), and for themselves in 89% (94% for medical specialties) of cases. CONCLUSION The eConsult service has demonstrated the ability to support prompt communication between PCPs and AHPs, improving patients' access to AHP care. Given the importance of AHPs in providing primary care, allied health services should be offered in the menu of specialties available through electronic consultation services.
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18
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van Gelder VA, Scherpbier-de Haan ND, van Berkel S, Akkermans RP, de Grauw IS, Adang EM, Assendelft PJ, de Grauw WJC, Biermans MCJ, Wetzels JFM. Web-based consultation between general practitioners and nephrologists: a cluster randomized controlled trial. Fam Pract 2017; 34:430-436. [PMID: 28158576 DOI: 10.1093/fampra/cmw131] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Consultation of a nephrologist is important in aligning care for patients with chronic kidney disease (CKD) at the primary-secondary care interface. However, current consultation methods come with practical difficulties that can lead to postponed consultation or patient referral instead. OBJECTIVE This study aimed to investigate whether a web-based consultation platform, telenephrology, led to a lower referral rate of indicated patients. Furthermore, we assessed consultation rate, quality of care, costs and general practitioner (GPs') experiences with telenephrology. METHODS Cluster randomized controlled trial with 47 general practices in the Netherlands was randomized to access to telenephrology or to enhanced usual care. A total of 3004 CKD patients aged 18 years or older who were under primary care were included (intervention group n = 1277, control group n = 1727) and 2693 completed the trial. All practices participated in a CKD management course and were given an overview of their CKD patients. RESULTS The referral rates amounted to 2.3% (n = 29) in the intervention group and 3.0% (n = 52) in the control group, which was a non-significant difference, OR 0.61; 95% CI 0.31 to 1.23. The intervention group's consultation rate was 6.3% (n = 81) against 5.0% (n = 87) (OR 2.00; 95% CI 0.75-5.33). We found no difference in quality of care or costs. The majority of GPs had a positive opinion about telenephrology. CONCLUSION The data in our study do not allow for conclusions on the effect of telenephrology on the rate of patient referrals and provider-to-provider consultations, compared to conventional methods. It was positively evaluated by GPs and was non-inferior in terms of quality of care and costs.
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Affiliation(s)
- Vincent A van Gelder
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Saskia van Berkel
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Reinier P Akkermans
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge S de Grauw
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eddy M Adang
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pim J Assendelft
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim J C de Grauw
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marion C J Biermans
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
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