Long-term effectiveness of a community-based model of care in Māori and Pacific patients with type 2 diabetes and chronic kidney disease: a 4-year follow up of the DElay Future End Stage Nephropathy due to Diabetes (DEFEND) study

Adverse Clinical Outcomes Attributable to Socioeconomic and Ethnic Disparities Among People with Type 2 Diabetes in New Zealand Between 1994-2018: A Multiple Linked Cohort Study

Purpose

The study aimed to examine the separate population-level contributions of the ethnic and socioeconomic disparities among people with type 2 diabetes mellitus (T2DM) and residence in New Zealand (NZ).

Patients and Methods

A prospective cohort enrolled T2DM patients from 01/01/1994 into the Diabetes Care Support Service, a primary care audit program in Auckland, NZ. The cohort was linked to national registry databases (socioeconomic status, pharmaceutical claim, hospitalization, and death registration). Each cohort member was followed up till death or the study end time (31/12/2019), whichever came first. Incident clinical events (stroke, myocardial infarction (MI), heart failure (HF), end-stage renal disease (ESRD), and premature mortality (PM)) were used as outcomes. The attributable fractions (AFs) were estimated for the whole population and for specific population with NZ Europeans (NZE) and/or least deprived population as reference, both unadjusted and with adjustment for covariables by Cox Regression models.

Results

Among 36,267 patients, adjusted population AFs indicated 6.6(-30.8-33.3)% of PM, 17.1(5.8-27.0)% of MI, 35.3(22.6-46.0)% of stroke, 14.3(3.2-24.2)% of HF, and 15.9(6.7-24.2)% of ESRD could be attributed to deprivation; while 14.3(3.3-25.4)% of PM, -3.3(-8.3-1.5)% of MI, -0.5(-6.7-5.3)% of stroke, 4.7(0.3-8.8)% of HF, 13.3(9.9-16.6)% of ESRD could be attributed to ethnicity. Deprivation contributed a significant AF to stroke, while ethnicity was important for ESRD. Gradient of AF for deprivation indicated NZE and Asians were most affected by deprivation across outcomes. Conversely, Māori, with the highest AFs for ethnicity of PM and ESRD, were unaffected by deprivation. At same deprivations, the AFs of MI and stroke were greatest among NZE compared with other ethnic groups; the AF of ESRD was greatest among Māori and Pasifika.

Conclusion

Both socioeconomic deprivation and ethnicity are strongly associated with outcomes in patients with T2DM in NZ, although the extent of the deprivation gradient is greatest among NZE and Asians, and least among Māori.

Ethnic differences in 25-year risk of incident chronic kidney disease among people with type 2 diabetes in New Zealand

INTRODUCTION

Insights into ethnic differences in the natural history of chronic kidney disease (CKD) among people with type 2 diabetes mellitus (T2DM) might inform clinical strategies to address disparities in hospitalization and mortality. Risks of CKD II-V stages over a 25-year period between New Zealand Europeans (NZEs), Māori and Pasifika, and with T2DM in Auckland, New Zealand (NZ) were compared.

RESEARCH DESIGN AND METHODS

As a primary care audit program in Auckland, the Diabetes Care Support Service was linked with national registration databases. People with existing CKD II-V were ruled out. To balance potential confounders, we applied a tapered matching method . 'Quasi-trial'-matched cohorts were set up separately between Māori and NZE and between Pasifika and NZE. Ethnic population differences in risk of any and each stage of CKD over 1994-2018 were examined by weighted Cox regression model.

RESULTS

The HRs for developing any CKD, CKD stages II-V for Māori (n=2215) versus NZE (n=2028) were 1.18 (95% CI 0.99 to 1.41), 1.10 (95% CI 0.91 to 1.32), 1.70 (95% CI 1.19 to 2.43), 3.93 (95% CI 2.16 to 7.14), and 3.74 (95% CI 1.74 to 8.05), respectively. Compared with NZE (n=2474), the HRs for developing any CKD, CKD stages II-V for Pasifika (n=3101) were 1.31 (95% CI 1.09 to 1.57), 1.26 (95% CI 1.05 to 1.52), 1.71 (95% CI 1.14 to 2.57), 3.75 (95% CI 1.40 to 10.05), and 4.96 (95% CI 1.56 to 15.75), respectively.

CONCLUSIONS

Among people with T2DM in NZ, significant ethnic differences exist in the risk of progressing to each stage of CKD (stage V in particular). Mechanism studies underlying these differences, as well as the need for identification of biomarkers to predict the early onset renal lesion, are warranted.

Ethnic differences in metabolic achievement between Māori, Pacific, and European New Zealanders with type 2 diabetes

AIMS

To compare variations in metabolic target achievement by ethnicity (Europeans, Māori and Pasifika) among patients with type 2 diabetes (T2DM) in Auckland, New Zealand (NZ) between 1994 and 2013.

METHODS

32,237 patients were enrolled. Adjusted marginal difference (European as reference) of systolic blood pressure (SBP), body mass index (BMI), HbA1c and total cholesterol, alongside the proportion achieving metabolic targets were estimated using multivariable mixed effect models at baseline, 1-, 2-, 3-, 4-, and 5-years, adjusted for covariates.

RESULTS

Compared with Europeans, Māori and Pasifika had continuously, significantly higher HbA1c (by 0.3% (+3.5 mmol/mol) and 0.6% (+6.8 mmol/mol) respectively and BMI (+1.5 and +0.3 kg/m² respectively) but lower SBP (-1.8 and -3.4 mmHg respectively) and TG (-0.03 and -0.34 mmol/L respectively), and insignificantly TC (+0.004 and +0.01 respectively), by 5-years of follow-up. While 49% Europeans were within target HbA1c, this was achieved by only 30% Māori and 27% Pasifika. Conversely, 41% Europeans, 46% Māori and 59% Pasifika achieved the SBP target (all P < 0.0001).

CONCLUSIONS

Managing hyperglycemia appears to be more challenging than treating hypertension and dyslipidemia among Māori and Pasifika. New anti-hyperglycemia treatments, addressing health literacy, socioeconomic and any cultural barriers to management and self-management are urgently needed to reduce these disparities.

Ngātiwai Whakapakari Tinana: strengthening bodies through a Kaupapa Māori fitness and exercise programme

INTRODUCTION Activity based weight loss programmes may result in modest reductions in weight. Despite the small successes demonstrated by these interventions, there are few examples that specifically address the disparity of obesity for Māori compared to non-Māori. AIM This research highlights the results of a Kaupapa Māori fitness and exercise programme that aimed to assist mainly Māori adults, to lose weight. The programme was designed to support participants by using Māori cultural values. METHODS A Muay Thai kickboxing exercise programme was developed with community involvement. Kaupapa Māori principles underpinned the programme, such as whanaungatanga and tino rangatiratanga. Ninety-three participants were followed for at least 3 months. Participants' blood pressure, weight, body mass index, mental wellbeing scores, and waist and hip circumferences were collected at regular intervals. Multiple linear models were used to calculate estimated changes per 100 days of the programme. RESULTS The mean duration of participation was 214 days. The estimated weight loss per participant per 100 days was 5.2 kg. Statistically significant improvements were noted in blood pressure, waist and hip circumference, systolic blood pressure and mental wellbeing. DISCUSSION The improvements in physical and mental wellbeing are thought to have stemmed, in part, from the use of Kaupapa Māori principles. The success of this programme strengthens the argument that programmes aiming to address the precursors of chronic disease need to be designed for Māori by Māori in order to reduce health inequities.

Nonconventional diabetes-related care strategies for patients with chronic kidney disease: A scoping review of the literature

Background

Patients with diabetes and chronic kidney disease (CKD) are at high risk of diabetes-related complications. Diabetes care can support these individuals, but outpatient clinic appointments can be difficult to attend, given their already high burden of multimorbidity.

Methods

We systematically searched the medical and grey literature for studies that evaluated the effect of nonconventional diabetes care strategies on diabetes-related outcomes in adults with stages 2-5 CKD or using dialysis (end of search December 30, 2017). We included both randomized-controlled trials and observational studies. Study selection and data extraction were completed by two independent reviewers. Diabetes-related outcomes included glycemic, blood pressure, and lipid control, along with microvascular complications, macrovascular complications, and death.

Results

After screening 2177 relevant citations, we identified 34 studies which met inclusion. The majority were observational studies. Studies were frequently small, single-centered, and excluded patients with more advanced CKD. Nonconventional diabetes care strategies included community-based care, unique self-management and education programs, nurse-led care clinics, dialysis-based diabetes programs, telemedicine, and interdisciplinary care clinics. Programs were most often developed by study investigators. Although there were limitations to several of the included studies, programs were described to have modest effects on physiologic outcomes, and in some cases, diabetes-related complications and death.

Conclusions

Nonconventional diabetes-related care might be helpful to patients with CKD. Prior to developing and implementing programs, however, it will be important to study them more rigorously, understand their acceptability to patients, and evaluate their costs and feasibility in a real-world setting.

Decline of kidney function during the pre-dialysis period in chronic kidney disease patients: a systematic review and meta-analysis

Purpose

Substantial heterogeneity exists in reported kidney function decline in pre-dialysis chronic kidney disease (CKD). By design, kidney function decline can be studied in CKD 3–5 cohorts or dialysis-based studies. In the latter, patients are selected based on the fact that they initiated dialysis, possibly leading to an overestimation of the true underlying kidney function decline in the pre-dialysis period. We performed a systematic review and meta-analysis to compare the kidney function decline during pre-dialysis in CKD stage 3–5 patients, in these two different study types.

Patients and methods

We searched PubMed, EMBASE, Web of Science and Cochrane to identify eligible studies reporting an estimated glomerular filtration rate (eGFR) decline (mL/min/1.73 m²) in adult pre-dialysis CKD patients. Random-effects meta-analysis was performed to obtain weighted mean annual eGFR decline.

Results

We included 60 studies (43 CKD 3–5 cohorts and 17 dialysis-based studies). The meta-analysis yielded a weighted annual mean (95% CI) eGFR decline during pre-dialysis of 2.4 (95% CI: 2.2, 2.6) mL/min/1.73 m² in CKD 3–5 cohorts compared to 8.5 (95% CI: 6.8, 10.1) in dialysis-based studies (difference 6.0 [95% CI: 4.8, 7.2]).

Conclusion

To conclude, dialysis-based studies report faster mean annual eGFR decline during pre-dialysis than CKD 3–5 cohorts. Thus, eGFR decline data from CKD 3–5 cohorts should be used to guide clinical decision making in CKD patients and for power calculations in randomized controlled trials with CKD progression during pre-dialysis as the outcome.