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BACKGROUND: Early detection and appropriate management of chronic kidney disease (CKD) in primary care are essential to reduce morbidity and mortality. AIM: To assess the quality of care (QoC) of CKD in primary healthcare in relation to patient and practice characteristics in order to tailor improvement strategies. DESIGN AND SETTING: Retrospective study using data between 2008 and 2011 from 47 general practices (207 469 patients of whom 162 562 were adults). METHOD: CKD management of patients under the care of their general practitioner (GP) was qualified using indicators derived from the Dutch interdisciplinary CKD guideline for primary care and nephrology and included (1) monitoring of renal function, albuminuria, blood pressure, and glucose, (2) monitoring of metabolic parameters, and alongside the guideline: (3) recognition of CKD. The outcome indicator was (4) achieving blood pressure targets. Multilevel logistic regression analysis was applied to identify associated patient and practice characteristics. RESULTS: Kidney function or albuminuria data were available for 59 728 adult patients; 9288 patients had CKD, of whom 8794 were under GP care. Monitoring of disease progression was complete in 42% of CKD patients, monitoring of metabolic parameters in 2%, and blood pressure target was reached in 43.1%. GPs documented CKD in 31.4% of CKD patients. High QoC was strongly associated with diabetes, and to a lesser extent with hypertension and male sex. CONCLUSION: Room for improvement was found in all aspects of CKD management. As QoC was higher in patients who received structured diabetes care, future CKD care may profit from more structured primary care management, e.g. according to the chronic care model. KEY POINTS: Quality of care for chronic kidney disease patients in primary care can be improved. In comparison with guideline advice, adequate monitoring of disease progression was observed in 42%, of metabolic parameters in 2%, correct recognition of impaired renal function in 31%, and reaching blood pressure targets in 43% of chronic kidney disease patients. Quality of care was higher in patients with diabetes. Chronic kidney disease management may be improved by developing strategies similar to diabetes care.
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Manejo de la Enfermedad , Medicina General/normas , Pautas de la Práctica en Medicina/normas , Atención Primaria de Salud/normas , Calidad de la Atención de Salud , Insuficiencia Renal Crónica/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Países Bajos , Estudios Retrospectivos , Adulto JovenRESUMEN
OBJECTIVE: The determinants of insulin-associated weight gain in type 2 diabetes mellitus (T2DM) are partly unknown. Therefore, we conducted a prospective study to identify predictors of insulin-associated weight gain. RESEARCH DESIGN AND METHODS: In patients with T2DM, we assessed physical activity by accelerometry and measured diabetes-related distress by questionnaires before and 6 and 12 months after starting insulin therapy. Glycemic control (HbA1c) and insulin dose were monitored. RESULTS: After 12 months of insulin therapy, mean body weight had increased by 3.0 ± 2.5 kg (P < 0.001). The drop in HbA1c was correlated with insulin-associated weight gain. With the use of a multiple linear regression model, a cluster of variables was identified that significantly related to weight gain. Diabetes-related distress, initial insulin dose, and the increase of insulin dose during the course of the study as well as age appeared to be important predictors of weight gain after initiation of insulin therapy. Physical activity (measured as MET) decreased from 1.40 ± 0.04 at baseline to 1.32 ± 0.04 MET (P < 0.05) but was not significantly related to weight changes. CONCLUSIONS: Diabetes-related distress, initial and titration of insulin dose, and age all significantly predict insulin-associated weight gain. After the initiation of insulin therapy, physical activity decreased significantly, but this did not determine weight gain over the first 12 months. Our study findings may have clinical implications.
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Envejecimiento/fisiología , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/psicología , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Aumento de Peso/fisiología , Adulto , Anciano , Peso Corporal/fisiología , Diabetes Mellitus Tipo 2/fisiopatología , Relación Dosis-Respuesta a Droga , Femenino , Estudios de Seguimiento , Hemoglobina Glucada/análisis , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Actividad Motora/fisiología , Valor Predictivo de las Pruebas , Estudios Prospectivos , Encuestas y CuestionariosRESUMEN
AIMS/HYPOTHESIS: The best treatment strategy for a patient with type 2 diabetes who shows pronounced weight gain after the introduction of insulin treatment is unclear. We determined whether addition of a glucagon-like peptide-1 (GLP-1) analogue could reverse pronounced insulin-associated weight gain while maintaining glycaemic control, and compared this with the most practised strategy, continuation and intensification of standard insulin therapy. METHODS: In a 26-week, randomised controlled trial (ELEGANT), conducted in the outpatient departments of one academic and one large non-academic teaching hospital in the Netherlands, adult patients with type 2 diabetes with ≥ 4% weight gain during short-term (≤ 16 months) insulin therapy received either open-label addition of liraglutide 1.8 mg/day (n = 26) or continued standard therapy (n = 24). A computer-generated random number list was used to allocate treatments. Participants were evaluated every 4-6 weeks for weight, glycaemic control and adverse events. The primary endpoint was between-group weight difference after 26 weeks of treatment (intention to treat). RESULTS: Of 50 randomised patients (mean age 58 years, BMI 33 kg/m(2), HbA1c 7.4% [57 mmol/mol]), 47 (94%) completed the study; all patients were analysed. Body weight decreased by 4.5 kg with liraglutide and increased by 0.9 kg with standard therapy (mean difference -5.2 kg [95% CI -6.7, -3.6 kg]; p < 0.001). The respective changes in HbA1c were -0.77% (-8.4 mmol/mol) and +0.01% (+0.1 mmol/mol) (difference -0.74% [-8.1 mmol/mol]) ([95% CI -1.08%, -0.41%] [-11.8, -4.5 mmol/mol]; p < 0.001); respective changes in insulin dose were -29 U/day and +5 U/day (difference -33 U/day [95% CI -41, -25 U/day]; p < 0.001). In five patients (19%), insulin could be completely discontinued. Liraglutide was well tolerated; no severe adverse events or severe hypoglycaemia occurred. CONCLUSIONS/INTERPRETATION: In patients with pronounced insulin-associated weight gain, addition of liraglutide to their treatment regimen reverses weight, decreases insulin dose and improves glycaemic control, and hence seems a valuable therapeutic option compared with continuation of standard insulin treatment. Trial registration ClinicalTrials.gov NCT01392898. Funding The study was funded by Novo Nordisk.
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Glucemia/efectos de los fármacos , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Péptido 1 Similar al Glucagón/análogos & derivados , Hipoglucemiantes/uso terapéutico , Insulina/administración & dosificación , Insulina/uso terapéutico , Aumento de Peso/efectos de los fármacos , Anciano , Femenino , Péptido 1 Similar al Glucagón/uso terapéutico , Humanos , Liraglutida , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Chronic kidney disease (CKD) is highly prevalent in patients with diabetes or hypertension in primary care. A shared care model could improve quality of care in these patients AIM: To assess the effect of a shared care model in managing patients with CKD who also have diabetes or hypertension. Design and setting A cluster randomised controlled trial in nine general practices in The Netherlands. METHOD: Five practices were allocated to the shared care model and four practices to usual care for 1 year. Primary outcome was the achievement of blood pressure targets (130/80 mmHg) and lowering of blood pressure in patients with diabetes mellitus or hypertension and an estimated glomerular filtration rate (eGFR)<60 ml/min/1.73 m(2). RESULTS: Data of 90 intervention and 74 control patients could be analysed. Blood pressure in the intervention group decreased with 8.1 (95% CI = 4.8 to 11.3)/1.1 (95% CI = -1.0 to 3.2) compared to -0.2 (95% CI = -3.8 to 3.3)/-0.5 (95% CI = -2.9 to 1.8) in the control group. Use of lipid-lowering drugs, angiotensin-system inhibitors and vitamin D was higher in the intervention group than in the control group (73% versus 51%, 81% versus 64%, and 15% versus 1%, respectively, [P = 0.004, P = 0.01, and P = 0.002]). CONCLUSION: A shared care model between GP, nurse practitioner and nephrologist is beneficial in reducing systolic blood pressure in patients with CKD in primary care.
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Diabetes Mellitus Tipo 2/enfermería , Nefropatías Diabéticas/enfermería , Hipertensión/enfermería , Insuficiencia Renal Crónica/enfermería , Anciano , Antagonistas de Receptores de Angiotensina/uso terapéutico , Presión Sanguínea/fisiología , Análisis por Conglomerados , Diabetes Mellitus Tipo 2/complicaciones , Nefropatías Diabéticas/complicaciones , Femenino , Medicina General/métodos , Tasa de Filtración Glomerular/fisiología , Humanos , Hipertensión/complicaciones , Hipertensión/fisiopatología , Hipolipemiantes/uso terapéutico , Masculino , Nefrología , Enfermería en Nefrología/métodos , Enfermeras Practicantes/organización & administración , Grupo de Atención al Paciente/organización & administración , Calidad de la Atención de Salud , Insuficiencia Renal Crónica/complicaciones , Resultado del Tratamiento , Vitamina D/uso terapéutico , Vitaminas/uso terapéuticoRESUMEN
PURPOSE: A Web-based consultation system (telenephrology) enables family physicians to consult a nephrologist about a patient with chronic kidney disease. Relevant data are exported from the patient's electronic file to a protected digital environment from which advice can be formulated by the nephrologist. The primary purpose of this study was to assess the potential of telenephrology to reduce in-person referrals. METHODS: In an observational, prospective study, we analyzed telenephrology consultations by 28 family practices and 5 nephrology departments in the Netherlands between May 2009 and August 2011. The primary outcome was the potential reduction of in-person referrals, measured as the difference between the number of intended referrals as stated by the family physician and the number of referrals requested by the nephrologist. The secondary outcome was the usability of the system, expressed as time invested, the implementation in daily work hours, and the response time. Furthermore, we evaluated the questions asked. RESULTS: One hundred twenty-two new consultations were included in the study. In the absence of telenephrology, 43 patients (35.3%) would have been referred by their family physicians, whereas the nephrologist considered referral necessary in only 17 patients (13.9%) (P <.001). The family physician would have treated 79 patients in primary care. The nephrologist deemed referral necessary for 10 of these patients. Time investment per consultation amounted to less than 10 minutes. Consultations were mainly performed during office hours. Response time was 1.6 days (95% CI, 1.2-1.9 days). Most questions concerned estimated glomerular filtration rate, proteinuria, and blood pressure. CONCLUSION: A Web-based consultation system might reduce the number of referrals and is usable. Telenephrology may contribute to an effective use of health facilities by allowing patients to be treated in primary care with remote support by a nephrologist.
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Nefrología/métodos , Atención Primaria de Salud/métodos , Consulta Remota/métodos , Insuficiencia Renal Crónica/terapia , Adulto , Anciano , Anciano de 80 o más Años , Registros Electrónicos de Salud , Femenino , Humanos , Difusión de la Información/métodos , Comunicación Interdisciplinaria , Internet , Masculino , Persona de Mediana Edad , Países Bajos , Estudios Prospectivos , Insuficiencia Renal Crónica/fisiopatologíaRESUMEN
BACKGROUND: Patients with diabetes or cardiovascular disease are at risk of reduced renal function and frequently use drugs that interact with renal function. GPs monitor renal function in these patients. Computerised prescription systems produce alerts in patients labelled as having chronic kidney disease, but alerts are often ignored. If pharmacists use a pharmacy medication alert system (PMAS) based on renal function, they can provide the GP with therapeutic advice to optimise the medication. The extent of this advice and the feasibility in the clinical context are unknown. AIM: To assess the therapeutic advice formulated by pharmacists with help of a PMAS based on the renal function of patients aged ≥70 years with diabetes or cardiovascular disease. DESIGN AND SETTING: Observational study in primary health care in the Netherlands. METHOD: GPs provided pharmacists with the renal function of older patients with diabetes or cardiovascular disease who were using target drugs, that is, drugs requiring therapeutic advice in patients with reduced renal function. With the help of a PMAS, pharmacists assessed the actual medication. The GP weighed the advice in relation to the clinical context of the individual patient. RESULTS: Six hundred and fifty patients were prescribed 1333 target drugs. Pharmacists formulated 143 therapeutic recommendations (11% of target drugs) concerning 89 patients (13.7% of study population). In 71 recommendations in 52 patients (8.0% of study population), the GP agreed immediately. CONCLUSION: The use of a PMAS resulted in therapeutic advice in 11% of the target drugs. After weighing the clinical context, the GP agreed with half of the advice.
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Bloqueadores del Receptor Tipo 1 de Angiotensina II/uso terapéutico , Medicina General , Sistemas de Entrada de Órdenes Médicas/estadística & datos numéricos , Farmacia , Medicamentos bajo Prescripción/uso terapéutico , Insuficiencia Renal Crónica/complicaciones , Antagonistas Adrenérgicos beta/uso terapéutico , Anciano , Anciano de 80 o más Años , Consejo , Angiopatías Diabéticas/tratamiento farmacológico , Angiopatías Diabéticas/fisiopatología , Diuréticos/uso terapéutico , Femenino , Tasa de Filtración Glomerular/fisiología , Humanos , Hipoglucemiantes/uso terapéutico , Relaciones Interprofesionales , Masculino , Países Bajos , Insuficiencia Renal Crónica/fisiopatologíaRESUMEN
Two men (61 and 81 years old) with mild impaired kidney function developed acute renal failure due to dehydration combined with the use of inhibitors of the renin-angiotensin-aldosterone system (RAAS). After rehydration, correction of hyperkalaemia and stopping RAAS-inhibition and diuretics, they recovered completely. Many patients using RAAS-inhibitors have impaired renal function. In the case of dehydration due to gastroenteritis or prolonged fever they risk developing acute renal failure. The high risk groups are elderly patients, patients with atherosclerosis or heart failure and those with co-medication of diuretics or NSAIDs. The underlying mechanism is that the normal pathways to protect kidney perfusion in case of hypovolaemia are blocked by the use of RAAS-inhibitors or NSAIDs. In the case of dehydration in patients with chronic kidney disease using RAAS-inhibitors, serum creatinine and potassium levels should be monitored. Temporary discontinuation of RAAS-inhibitors or diuretics is often necessary.