Delivery of Multifactorial Interventions by Nurse and Dietitian Teams in a Community Setting to Prevent Diabetic Complications: A Quality-Improvement Report

doi:10.1053/j.ajkd.2007.11.012

American Journal of Kidney Diseases

Volume 51, Issue 3, March 2008, Pages 425-434

https://doi.org/10.1053/j.ajkd.2007.11.012 Get rights and content

Background

Clinical trials showed that multifactorial interventions can prevent microvascular and macrovascular complications of diabetes, but delivery of proven therapies in clinical practice is often suboptimal.

Study Design

Quality-improvement report.

Setting & Participants

Teams composed of a nurse and a dietitian were established in 5 communities, 2 urban and 3 rural, in Northern Alberta, Canada, and provided care for 424 individuals with diabetes plus hypertension or albuminuria.

Quality-Improvement Plan

To promote the use of proven therapies and achieve tight control of risk factors through community teams providing lifestyle advice, adjusting therapy using algorithms and regular follow-up.

Outcomes

The proportion of subjects prescribed angiotensin-converting enzyme–inhibitor, statin, and antiplatelet therapy and the proportion of subjects reaching targets for blood pressure (<130/80 mm Hg), blood glucose (hemoglobin A_1c [HbA_1c] < 7%), and low-density lipoprotein cholesterol (<96 mg/dL).

Measurements

Blood pressure, HbA_1c, low-density lipoprotein cholesterol, albumin-creatinine ratio, weight, and estimated glomerular filtration rate from serum creatinine.

Results

Blood pressure, HbA_1c, and low-density lipoprotein cholesterol levels improved during follow-up (133 ± 19/74 ± 11 versus 129 ± 17/71 ± 10 mm Hg, 8.1% ± 1.9% versus 7.5% ± 1.3%, and 104 ± 35 versus 93 ± 31 mg/dL, respectively; P < 0.001 for all), whereas there was no increase in weight (95 ± 22 versus 95 ± 23 kg; P = 0.3). The proportion of patients prescribed angiotensin-converting enzyme–inhibitor, lipid-lowering, and antiplatelet therapy increased (37% versus 60.1%; P < 0.001), as did the proportion of patients reaching targets for blood pressure, low-density lipoprotein cholesterol (43.5% versus 55% and 43.4% versus 61.6%, respectively; P < 0.001), and HbA_1c levels (32.1% versus 38.8%; P < 0.05).

Limitations

Short duration of follow-up and absence of economic evaluation, validity, and generalizability require confirmation in clinical trials and other settings.

Conclusions

Delivery of multifactorial interventions by nurse/dietitian teams in a community setting appears feasible and may achieve clinically significant improvements in blood pressure, lipids, and glycemic control, which would be expected to decrease cardiovascular morbidity and mortality.

Section snippets

Setting

Alberta, a province in Western Canada, has a geographic area the same as Texas, but a population of only 3 million. Two thirds live in 2 major cities (Edmonton and Calgary; Fig 1). The remainder live in rural or semirural settings, mostly distant from major health care facilities.

Canada has a universal, publicly funded, national health care insurance program administered by provincial governments that function as the single insurer. Within Alberta, 9 health regions deliver health care services,

Results

Between March 2004 and December 2005, a total of 570 referrals were received, of which 568 (99%) satisfied entry criteria. A total of 94.5% of referrals were received from family physicians, and the remainder were from specialists. Referrals were received from 189 family physicians, and mean number of patients referred was 3.5 per family physician.

Four hundred sixty-four of these patients had been scheduled for an initial assessment during the data-collection period. Thirty-seven individuals

Discussion

We show that multifactorial interventions can be delivered effectively to patients with diabetes in a community setting using RN/RD teams following algorithms. The proportion of participants using ACE-inhibitor, antiplatelet, and lipid-lowering therapy increased, as did proportions reaching blood pressure, lipid, and glycemic targets. Furthermore, clinically significant improvements in blood pressure, glycemia, lipid levels, and albuminuria were achieved, particularly in subjects not at target

Acknowledgements

Initial funding for the Diabetic Nephropathy Prevention Program was from Alberta Health & Wellness Province Wide Services. Ongoing funding is through the Northern Alberta Renal Program. Capital Health operates the clinics in partnership with East Central Health, Aspen Health, and David Thompson Health Regions. The hard work of our clinical and clerical staff and the cooperation of local primary care physicians is gratefully acknowledged.

Support: Dr Senior and Dr Jindal are supported by the

References (26)

S. Wild et al.
Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030
Diabetes Care
(2004)
M. El Nahas
The global challenge of chronic kidney disease
Kidney Int
(2005)
M. Massi-Benedetti
The cost of diabetes type II in Europe: The CODE-2 Study
Diabetologia
(2002)
CORR Report: Dialysis and Renal Transplantation, 2001
(2001)
D.E. Schaubel et al.
End-stage renal disease in Canada: Prevalence projections to 2005
CMAJ
(1999)
D.W. Ploth et al.
Prospective analysis of global costs for maintenance of patients with ESRD
Am J Kidney Dis
(2003)
Effect of intensive therapy on the development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial
Kidney Int
(1995)
Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38
BMJ
(1998)
C.E. Mogensen
Long-term antihypertensive treatment inhibiting progression of diabetic nephropathy
Br Med J
(1982)
E.J. Lewis et al.
The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathyThe Collaborative Study Group
N Engl J Med
(1993)

Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)

Lancet

(1998)

MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: A randomised placebo-controlled trial

Lancet

(2002)

R. Collins et al.

MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: A randomised placebo-controlled trial

Lancet

(2003)

Cited by (26)

Low Mediterranean Diet scores are associated with reduced kidney function and health related quality of life but not other markers of cardiovascular risk in adults with diabetes and chronic kidney disease
2021, Nutrition, Metabolism and Cardiovascular Diseases
Citation Excerpt :
While we did not explicitly ask patients about how frequently they were following up with this clinic, that fact that diet quality did not improve over time despite likely access to a dietitian, was expected as this has been previously reported [23]. That being said, the success of this program with regards to improvements in glycemic control, blood pressures and lipids through pharmalogical management has been previously documented and likely somewhat explains our cohort's stable cardiometabolic risk factors [46,47]. A strength of this study was the use of repeated 3-day food records enabling serial diet assessments.
How Mediterranean-style diets impact cardiovascular and health outcomes in patients with diabetes and chronic kidney disease (CKD) is not well known. Our aim was to investigate the association between diet quality, using Mediterranean Diet Scores (MDS) and health outcomes.
This is a post-hoc analysis of an RCT and longitudinal study investigating patients with diabetes and CKD. MDS was calculated annually. Scores were analyzed for correlation with lipids, HbA_1c, serum potassium, health-related quality of life (HRQOL) and depression. 178 diet records from 50 patients who attended two or more visits were included. Mean MDS was moderate (4.1 ± 1.6) and stable over time. Stage 1–2 vs 3–5 CKD had lower raw MDS (3.8 ± 1.5 vs 4.6 ± 1.5, p < 0.001). Having hyperkalemia was associated with a lower raw MDS scores (3.6 ± 1.6 vs 4.2 ± 1.5, p = 0.03) but not energy adjusted MDS. MDS was not associated with HbA_1c or lipids. High vs low MDS was associated with improved HRQOL (mental health 84.4 ± 14.3 vs 80.3 ± 17.1, p < 0.05; general health 62.6 ± 21.0 vs 56.3 ± 19.8, p < 0.001) and fewer depressive symptoms (9.1 ± 7.4 vs 11.7 ± 10.6, p = 0.01).
Low MDS was associated with reduced kidney function and health related quality of life, but not other markers of cardiovascular risk. Further studies are needed to understand the nature and direction of the association between diet quality and disease outcomes in this population.
Frailty, Health-Related Quality of Life, Cognition, Depression, Vitamin D and Health-Care Utilization in an Ambulatory Adult Population With Type 1 or Type 2 Diabetes Mellitus and Chronic Kidney Disease: A Cross-Sectional Analysis
2019, Canadian Journal of Diabetes
Frailty can cause increased vulnerability to adverse health outcomes, such as falls, fractures, depression and reduced health-related quality of life (HRQoL). This cross-sectional study compared the differences in body composition, HRQoL, mental health and cognitive and vitamin D (vitD) status with health-care utilization by frail and nonfrail adults with diabetes mellitus (type 1 and type 2) and with chronic kidney disease (stages 1 through 5).
We studied adults with type 1 and type 2 diabetes and chronic kidney disease stages 1 through 5 who were participating in a longitudinal follow-up study (41 to 83 years of age; n=41). Body composition (dual-energy x-ray absorptiometry); vitD status (serum 25[OH]D₃); frailty (Edmonton Frail Scale); depression (Major Depression Inventory); HRQoL (Short Form Health Survey-36); and cognitive status (Mini Mental State exam) were measured using validated tools. Participants who were on dialysis and had body weights >136 kg, and coinciding comorbidities known to influence vitD metabolism were excluded.
Frailty occurred in 17% of participants (n=7). Frail participants had lower lean body mass, lower HRQoL scores (individual and composite scores), more depression (p=<0.05) and higher numbers of health visits (total, inpatient and emergency) compared with nonfrail participants (p<0.05). No differences in health-care visit types or vitD status were noted between frail and nonfrail participants (p>0.05).
Frailty in an ambulatory population of adults with chronic kidney disease and diabetes is associated with low lean body mass, low HRQoL, greater depression and higher numbers of health-care visits.
La fragilité peut accroître la vulnérabilité aux événements indésirables tels que les chutes, les fractures, la dépression et diminuer la qualité de vie liée à la santé (QVLS). La présente étude transversale a permis de comparer les différences de la constitution corporelle, la QVLS, la santé mentale et cognitive, et le statut en vitamine D (vit D) à l'utilisation des soins de santé par les adultes fragiles et les adultes non fragiles atteints de diabète sucré (de type 1 ou de type 2) et de néphropathie chronique (de stades 1 à 5).
Les adultes (de 41 à 83 ans; n=41) atteints de diabète de type 1 ou de type 2 et de néphropathie chronique de stades 1 à 5 qui participaient à une étude de suivi longitudinale ont fait l'objet de notre étude. Nous avons mesuré au moyen d'outils validés la constitution corporelle (absorptiométrie à rayons X à énergie double), le statut en vit D (la concentration sérique de 25[OH]D₃), la fragilité (l'échelle Edmonton Frail Scale), la dépression (le Major Depression Inventory), la QVLS (le questionnaire sur l'état de santé SF-36) et l'état cognitif (mini-examen de l'état mental). Nous avons exclu les participants qui suivaient une dialyse et avaient un poids corporel>136 kg, et qui présentaient des maladies concomitantes connues pour influencer le métabolisme de la vit D.
La fragilité était présente chez 17 % des participants (n=7). Les participants fragiles avaient des masses maigres plus faibles, des scores de QVLS plus élevés (scores individuels et composites), davantage de dépression (p=<0,05) et un nombre plus élevé de consultations (totales, en milieu hospitalier et à l'urgence) par rapport aux participants non fragiles (p<0,05). Nous n'avons noté aucune différence dans les types de consultations ou le statut de la vit D entre les participants fragiles et les participants non fragiles (p>0,05).
La fragilité chez une population d'adultes sur pied atteints de néphropathie chronique et de diabète est associée à une masse maigre faible, une faible QVLS, davantage de dépression et un nombre élevé de consultations.
Improved Access to and Impact of Registered Dietitian Nutritionist Services Associated with an Integrated Care Model in a High-Risk, Minority Population
2018, Journal of the Academy of Nutrition and Dietetics
Citation Excerpt :
The traditional PCP schedule does not allow for adequate time or frequency of visits to address these complex diet and lifestyle behavior changes and PCPs admit to not having the expertise or additional training in behavioral change or obesity management necessary to be effective.10,21 Consequently, repeat and frequent appointments are necessary to see significant changes among a high-risk population.1,4,7,12,14,22 Providing increased access to the RDN allows for increased utilization of RDN services in a more time-efficient manner by eliminating wait times for the referral process and by reducing the need to schedule and return to the clinic for separate appointments.
Integrated health care models create opportunities for registered dietitian nutritionists (RDNs) to provide nutrition-related care and engage in multidisciplinary teams to improve clinical outcomes. While benefits of integrated care (IC) have been reported, little is known about the impact of the RDN within an IC model.
Our primary objective was to identify whether IC vs traditional care (TC) increases the number of RDN patient visits. Our secondary objective was to evaluate clinical outcomes of patients seeing an RDN vs not, regardless of care model.
This was a retrospective cohort study.
Patients were aged 3 to 94 years and from a patient-centered medical home in Boston, MA.
We measured 3-month total and average number of patients seen by the RDN in TC vs IC. Changes in adult hemoglobin A1c, weight, and pediatric body mass index (measured as kg/m²) among high-risk patients seen by an RDN compared to patients not seen by an RDN.
Data were obtained from electronic medical records and analyzed utilizing Mann-Whitney U test, analysis of covariance, and paired sample t tests.
The RDN saw 145 patients (137 adult, 8 pediatric) in the TC model compared to 185 patients (135 adult, 50 pediatric) in the IC model. Mean number of patients seen per session was 3.20 in the TC model vs 4.63 in the IC model (P=0.004). Adult hemoglobin A1c within-group differences decreased by 0.42%±1.49% (P=0.007) for patients seen by an RDN and decreased 0.15%±1.47% (P=0.012) for patients not seen by an RDN. Adult weight within-group differences decreased 1.0±7.2 kg (P=0.15) for patients seen by a RDN and increased 0.1±5.6 kg (P=0.70) for patients not seen by a RDN. Pediatric BMI showed no change between or within groups.
The IC model increased 3-month total number of patients seen by an RDN. High-risk patients who saw an RDN had a significant decrease in hemoglobin A1c.
Vitamin D<inf>3</inf> supplementation, bone health and quality of life in adults with diabetes and chronic kidney disease: Results of an open label randomized clinical trial
2017, Clinical Nutrition
Citation Excerpt :
A total of 1390 potential participants from two clinics (Diabetes Nephropathy Prevention Clinic [DNPC] and Renal Insufficiency Clinics [RIC]) in the Northern Alberta Renal Program at Alberta Health Services were screened. The DNPC is a regional program offering specialized interdisciplinary healthcare to patients with DM and CKD; with a focus on co-morbidity risk prevention [21]. The RIC is a regional program offering specialized interdisciplinary healthcare focused on the overall management of patients with CKD (including DM) with the goal of preventing dialysis.
Adults with diabetes (DM) and chronic kidney disease (CKD) are at risk for vitamin D (vitD) insufficiency, suboptimal bone health and reduced quality of life (QoL) due to limited sunlight exposure, poor vitD intake and CKD.
This open-labeled, randomized clinical trial, compared the impact of daily (2000 IU/D) verses monthly (40,000 IU/month) vitD₃ supplementation over six months on markers of vitD status, bone health and QoL in adults with DM and CKD (stages: 1–4).
Participants (18–80 years) were randomized to daily (n = 60) or monthly (n = 60) vitD₃ for six months. Primary outcomes included: vitD status (25-hydroxyvitD [25(OH)D], 1, 25-dihydroxyvitD [1,25(OH)₂D], bone health (bone mineral density [BMD] and serum concentrations of bone-specific alkaline phosphatase [BSAP], osteocalcin [OC], N-telopeptide-type 1-collagen [NTx]) and Fibroblast Growth Factor-23 (FGF-23). Secondary outcomes included QoL (Short Form-36 questionnaire).
Adherence by dose allocation over six months was 95.0 ± 5.7% (daily) and 94.1 ± 4.1% (monthly), respectively (p = 0.44); resulting in an overall median [95% CI] increase in serum 25(OH)D of 19 (12–26) nmol/L (p < 0.001). Serum 25(OH)D increased at three (p < 0.001) and six months (p < 0.001) in the daily and monthly groups, respectively. No significant differences over six months between groups were observed in serum concentrations of 1,25(OH)₂D, FGF-23, OC and NTx, BMD and QoL measures (p > 0.05). Serum 25(OH)D ≥ 75 nmol/L was associated with significant reductions in BSAP (p = 0.01) and improved physical functioning vs those with concentrations < 75 nmol/L (62.5 ± 26.8 vs 52.7 ± 26.3; p = 0.03) in the monthly and daily groups, respectively.
Daily (2000 IU/D) and monthly (40,000 IU/month) vitD₃ supplementation for six months in adults with DM and CKD was safe, and resulted in equivalent adherence and improvements in overall vitD status, but only modest changes in markers of bone health and QoL.
The roads less traveled? Diverging research and clinical priorities for dialysis patients and those with less severe CKD
2014, American Journal of Kidney Diseases
Over the last 4 decades, there has been tremendous growth in the number of long-term hemodialysis patients and kidney transplantation has been identified as the renal replacement modality of choice. These developments have been accompanied by substantial increases in the age and comorbid conditions of the typical dialysis patient, a general failure to identify treatments that prevent hard clinical outcomes in dialysis populations, and the recognition that patients and their physicians often have very different perspectives about which outcomes matter most. In parallel with this, the global epidemic of noncommunicable chronic diseases has led to unprecedented numbers of people worldwide who have or are at risk for CKD, many of whom do not have access to renal replacement therapies. These observations suggest that future clinical and research priorities should differ substantially for dialysis patients compared with those for individuals with less severe CKD. For dialysis populations, clinical and research efforts should be refocused to better align with the preferences and priorities of patients. In those with less severe CKD, new methods of health service delivery are needed to address the tremendous burden of illness at a population level, especially in lower income settings. This article describes how this divergence of priorities could be approached.
Kidney failure: Aims for the next 10 years and barriers to success
2013, The Lancet
Citation Excerpt :
Similar considerations apply to the delivery of care to patients with acute kidney injury or with multiple organ failure syndromes (eg, combined hepatic and renal insufficiency; cardiorenal syndrome). Care models that incorporate nurse practitioners are being increasingly used for the management of chronic diseases.51 In view of the success in other fields, the large population at risk for chronic kidney disease, and the low availability of trained nephrologists for the number of patients, it is important to test care models in which physicians partner with nurse practitioners to deliver care.
Although in some parts of the world acute and chronic kidney diseases are preventable or treatable disorders, in many other regions these diseases are left without any care. The nephrology community needs to commit itself to reduction of this divide between high-income and low-income regions. Moreover, new and exciting developments in fields such as pharmacology, genetic, or bioengineering, can give a boost, in the next decade, to a new era of diagnosis and treatment of kidney diseases, which should be made available to more patients.

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Original InvestigationPathogenesis and Treatment of Kidney DiseaseDelivery of Multifactorial Interventions by Nurse and Dietitian Teams in a Community Setting to Prevent Diabetic Complications: A Quality-Improvement Report

Background

Study Design

Setting & Participants

Quality-Improvement Plan

Outcomes

Measurements

Results

Limitations

Conclusions

Section snippets

Setting

Results

Discussion

Acknowledgements

Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030

Diabetes Care

The global challenge of chronic kidney disease

Kidney Int

The cost of diabetes type II in Europe: The CODE-2 Study

Diabetologia

CORR Report: Dialysis and Renal Transplantation, 2001

End-stage renal disease in Canada: Prevalence projections to 2005

CMAJ

Prospective analysis of global costs for maintenance of patients with ESRD

Am J Kidney Dis

Effect of intensive therapy on the development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial

Kidney Int

Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38

BMJ

Long-term antihypertensive treatment inhibiting progression of diabetic nephropathy

Br Med J

The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathyThe Collaborative Study Group

N Engl J Med

Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)

Lancet

MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: A randomised placebo-controlled trial

Lancet

MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: A randomised placebo-controlled trial

Lancet

Original Investigation
Pathogenesis and Treatment of Kidney Disease
Delivery of Multifactorial Interventions by Nurse and Dietitian Teams in a Community Setting to Prevent Diabetic Complications: A Quality-Improvement Report