Chronic Kidney Disease Management – What Can We Learn from South African and Australian Efforts?

Role of primary care in enhancing continuity of care for adolescents and young adults with chronic kidney disease undergoing transition to adult health services

The transition from pediatric to adult health care is a vulnerable period for adolescents and young adults (AYA) with chronic conditions as it involves a multitude of changes and challenges while they enter adulthood. The transition to adult care can be particularly challenging for AYA living with chronic kidney disease (CKD) due to the complex care needed for treatment. Continuity of care is crucial for a successful transition to adult health care. The aim of this educational review is to discuss the potential role of primary care providers in the transition from pediatric to adult health services for AYA with CKD and kidney failure treated with dialysis and/or transplant. We address the significance of the medical home model and how it can provide continuity of care for AYA with CKD. Primary care providers can enhance care for AYA with chronic conditions by providing continuity of care, reducing exacerbation of chronic health conditions, providing holistic care, and fostering collaboration with specialists. Despite their vital role, primary care providers face barriers in maintaining this continuity, necessitating further attention and support in this area. By addressing these barriers and encouraging primary care providers to work alongside pediatric and adult nephrologists during the transition to adult health care, there are significant opportunities to improve the care and health outcomes of AYA with CKD.

[Nephrology in Sub-saharan Africa: Past, present, future]

Nephrology was a relatively poorly known specialty in sub-Saharan Africa until the early 1980s, because of low awareness and lack of access to diagnosis and renal replacement therapies. Nephrology has seen progress on the continent despite an unfavourable economic and geopolitical environment. With a prevalence of fewer than five nephrologists per million inhabitants, the training of nephrologists, now carried out on the continent, allowed to have more than 200 specialists trained in the last decade in French-speaking sub-Saharan Africa. Clinical and basic research is developing with quality work published from the continent in major international journals. The population receiving haemodialysis remains small, between 0 and 200 per million inhabitants. Kidney transplantation, with a prevalence between 0 and 5 per million inhabitants, is only well structured in South Africa. In this context of scarce resources, a strategy based on the prevention of non-communicable diseases in general, and chronic kidney disease in particular, should be prioritised.

Cost of dialysis therapies in rural and remote Australia - a micro-costing analysis

BACKGROUND

Maintenance dialysis is a costly and resource intense activity. In Australia, inadequate health infrastructure and poor access to technically skilled staff can limit service provision in remote areas where many Aboriginal dialysis patients live. With most studies based on urban service provision, there is little evidence to guide service development. However permanent relocation to an urban area for treatment can have significant social and financial impacts that are poorly quantified. This study is part of a broader project to quantify the costs and benefits of dialysis service models in urban and remote locations in Australia's Northern Territory (NT).

METHODS

We undertook a micro-costing analysis of dialysis service delivery costs in urban, rural and remote areas in the NT from the payer perspective. Recurrent maintenance costs (salaries, consumables, facility management and transportation) as well as capital costs were included. Missing and centralised costs were standardised; results were inflated to 2017 values and reported in Australian dollars.

RESULTS

There was little difference between the average annual cost for urban and rural services with respective median costs of $85,919 versus $84,629. However remote service costs were higher ($120,172 - $124,492), driven by higher staff costs. The inclusion of capital costs did not add substantially to annual costs. Annual home haemodialysis costs ($42,927) were similar to other jurisdictions despite the significant differences in program delivery and payment of expenses not traditionally borne by governments. Annual peritoneal dialysis costs ($58,489) were both higher than home and in-centre haemodialysis by recent national dialysis cost studies.

CONCLUSION

The cost drivers for staffed services were staffing models and patient attendance rates. Staff salaries and transport costs were significantly higher in remote models of care. Opportunities to reduce expenditure exist by encouraging community supported services and employing local staff. Despite the delivery challenges of home haemodialysis including high patient attrition, the program still provides a cost benefit compared to urban staffed services. The next component of this study will examine patient health service utilisation and costs by model of care to provide a more comprehensive analysis of the overall cost of providing services in each location.

Chronic kidney disease care models in low- and middle-income countries: a systematic review

Introduction

The number of persons with chronic kidney disease (CKD) living in low- and middle-income countries (LMIC) is increasing rapidly; yet systems built to care for them have received little attention. In order to inform the development of scalable CKD care models, we conducted a systematic review to characterise existing CKD care models in LMICs.

Methods

We searched PubMed, Embase and WHO Global Health Library databases for published reports of CKD care models from LMICs between January 2000 and 31 October 2017. We used a combination of database-specific medical subject headings and keywords for care models, CKD and LMICs as defined by the World Bank.

Results

Of 3367 retrieved articles, we reviewed the full text of 104 and identified 17 articles describing 16 programmes from 10 countries for inclusion. National efforts (n=4) focused on the prevention of end-stage renal disease through enhanced screening, public awareness campaigns and education for primary care providers. Of the 12 clinical care models, nine focused on persons with CKD and the remaining on persons at risk for CKD; a majority in the first category implemented a multidisciplinary clinic with allied health professionals or primary care providers (rather than nephrologists) in lead roles. Four clinical care models used a randomised control design allowing for assessment of programme effectiveness, but only one was assessed as having low risk for bias; all four showed significant attenuation of kidney function decline in the intervention arms.

Conclusions

Overall, very few rigorous CKD care models have been reported from LMICs. While preliminary data indicate that national efforts or clinical CKD care models bolstering primary care are successful in slowing kidney function decline, limited data on regional causes of CKD to inform national campaigns, and on effectiveness and affordability of local programmes represent important challenges to scalability.

Evidence for improved patient management through electronic patient records at a Central Australian Aboriginal Health Service

AIM

To examine chronic disease (CD)-related clinical activity and outcomes associated with introduction of a more systematic approach to chronic disease care in a remote Aboriginal community, using data from Communicare patient record management system.

METHODS

We examined CD process measures, outcomes and clinical profiles in adults age 15+ years from Communicare data and compared results for two intervals. Process measures were clinic visits and proportions of eligible patients with recorded CD-related procedures or diagnostic tests. Outcome measures were results of CD care items and CD morbidities. Data in the interval 2007-2009 were compared with data from 2009 to 2011, in which an intensified CD program was conducted in the clinic by its own staff.

RESULTS

About one-third of adult visits were related to CD care; CD-cycle of care encounters increased significantly in the second interval, from 3.2% to 9.1%, and proportions of adults having CD-related procedures or tests were also higher. For already commonly performed items, like blood pressure, weight and lipids, proportions of adults tested were 30-50% higher in the second interval, while proportions tested for more recently emphasised items, like waist, HbA1C, urine ACR, rose by more than 200%. Levels of SBP, DBP, HbA1c and HDL-C significantly improved in the second interval. Proportions of adults with clinical values outside normal ranges decreased for at least half of observations.

CONCLUSIONS

Parameters of CD care activities and outcomes have increased significantly over the last four years in this setting, accompanied by stabilisation of or improvement in outcomes.

Adoption, implementation and prioritization of specialist outreach policy in Australia: a national perspective

The World Health Organization has endorsed the use of outreach to promote: efficient redeployment of the health-care workforce; continuity of care at the local level; and professional support for local, rural, health-care workers. Australia is the only country that has had, since 2000, a sustained national policy on outreach for subsidizing medical specialist outreach to rural areas. This paper describes the adoption, implementation and prioritization of a national specialist outreach policy in Australia. Adoption of the national policy followed a long history of successful outreach, largely driven by the professional interest and personal commitment of the workforce. Initially the policy supported only new outreach services but concerns about the sustainability of existing services resulted in eligibility for funding being extended to all specialist services. The costs of travel, travel time, accommodation, professional support, staff relief at specialists' primary practices and equipment hire were subsidized. Over time, a national political commitment to the equitable treatment of indigenous people resulted in more targeted support for outreach in remote areas. Current priorities are: (i) establishing team-based outreach services; (ii) improving local staff's skills; (iii) achieving local coordination; and (iv) conducting a nationally consistent needs assessment. The absence of subsidies for specialists' clinical work can discourage private specialists from providing services in remote areas where clinical throughput is low. To be successful, outreach policy must harmonize with the interests of the workforce and support professional autonomy. Internationally, the development of outreach policy must take account of the local pay and practice conditions of health workers.

Kidney failure: aims for the next 10 years and barriers to success

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.

Successful chronic disease care for Aboriginal Australians requires cultural competence

OBJECTIVE

To review the literature to determine the attributes of culturally appropriate healthcare to inform the design of chronic disease management (CDM) models for Aboriginal patients in urban general practice.

METHODS

A comprehensive conceptual framework, drawing on the Access to Care, Pathway to Care, Chronic Care, Level of Connectedness, and Cultural Security, Cultural Competency and Cultural Respect models, was developed to define the search strategy, inclusion criteria and appraisal methods for the literature review. Selected papers were reviewed in detail if they examined a chronic disease intervention for an Aboriginal population and reported on its evaluation, impacts or outcomes.

RESULTS

In the 173 papers examined, only 11 programs met the inclusion criteria. All were programs conducted in rural and remote Aboriginal community-controlled health services. Successful chronic disease care and interventions require adequate Aboriginal community engagement, utilising local knowledge, strong leadership, shared responsibilities, sustainable resources and integrated data and systems. These success factors fitted within the conceptual framework developed.

CONCLUSIONS

Research and development of culturally appropriate CDM models concurrently in both urban and rural settings will enable more rigorous evaluation, leading to stronger evidence for best practice. A partnership of mainstream and Aboriginal-controlled health services is essential to successfully 'close the gap'.

IMPLICATIONS

Findings will inform and guide the development, implementation and evaluation of culturally appropriate CDM in mainstream general practice and primary care.

Surveillance of chronic kidney disease around the world: tracking and reining in a global problem

In recent years, there has been a general recognition of the importance of tackling noncommunicable chronic diseases throughout the world and not just in developed nations. Chronic kidney disease (CKD) is increasingly recognized as a public health threat, based on its high prevalence, rising incidence, associated complications, and cost. It is imperative that nations develop screening and surveillance programs related to CKD. This article provides a global perspective on existing and emerging CKD surveillance efforts. A variety of programs are described, ranging from cross-sectional screening studies to determine CKD prevalence; targeted screening of high-risk populations presenting for voluntary testing; to more systematic surveillance within the scope of integrated health care systems in many developed nations. The choice of surveillance programs for many countries will depend on available resources and competing health care priorities. Integration with surveillance programs for other major chronic diseases such as diabetes, hypertension, and obesity is highly desirable and could be a key to the prevention of CKD. Finally, we propose the model of integrated health systems as one that is perhaps best suited to systematic, longitudinal surveillance of many chronic diseases, a model based on a national electronic health care record with linkage across primary care and hospital-based programs. Robust health education efforts and timely dissemination strategies will remain the key to the success of disease surveillance. It is gratifying to note that more and more countries are developing and adopting CKD surveillance programs as part of national disease prevention strategies.

Quantifying the excess risk for proteinuria, hypertension and diabetes in Australian Aborigines: comparison of profiles in three remote communities in the Northern Territory with those in the AusDiab study

OBJECTIVE

To estimate the magnitude of excess risk for proteinuria, high blood pressure and diabetes in Australian Aboriginal adults in three remote communities by comparing them with nationwide Australian data.

METHODS

Adult volunteers from three remote communities in the Northern Territory were screened for proteinuria, high blood pressure, and diabetes between 2000 and mid 2003. Rates for people age 25 to 74 years were compared with those from the AusDiab study conducted in 1999 and 2000.

RESULTS

Compared with AusDiab, rates of these conditions were elevated in all Aboriginal communities, but differed among them. With adjustment for age and sex, rates of proteinuria were elevated 2.5- to 5.3-fold, rates of high blood pressure were elevated 3.1- to 8.1-fold and rates of diabetes were elevated 5.4- to 10-fold (p < 0.001 for all). The risk of having any condition ranged from 3.0- to 8.7-fold and the risk of having two or more conditions ranged from 5.8- to 14.2-fold.

DISCUSSION

The data are compatible with the excess morbidity and mortality from cardiovascular disease, diabetes and renal disease in these Aboriginal groups. They reflect the multitude of risk factors operating in these environments. They dictate urgent and systematic intervention to modify outcomes of established disease and to prevent their development. However, the resources required for effective secondary intervention will differ among communities according to the disease burden.

Indigenous health: update on the impact of diabetes and chronic kidney disease

PURPOSE OF REVIEW

With respect to chronic diseases such as diabetes and its complications, indigenous populations are known to suffer from poor health outcomes in comparison with whites. The purpose of this review is to highlight recent epidemiologic and intervention studies that have occurred in the areas of diabetes and renal disease among indigenous populations.

RECENT FINDINGS

The burden of diabetes is increasing among younger indigenous groups with epidemic levels of end-stage kidney disease. As dialysis therapy has contributed to prolong life among indigenous patients, cardiovascular disease has now become the leading cause of mortality in these populations. Clear preventive intervention strategies to improve rates of progression to end-stage kidney disease are not prevalent nor are they emerging over time. Access to kidney transplantation is also reduced among indigenous populations in Australia, New Zealand, the USA and Canada. Reasons for this disparity are unclear but likely multifactorial.

SUMMARY

Diabetes and its complications have produced a health crisis among indigenous populations. The impact on healthcare systems in countries where these indigenous populations reside will be substantial unless significant efforts are made to improve diabetic renal disease outcomes in the near future.