Quality Standards for Diabetes Care Toolkit

Early intervention

Continued early proactive intervention on blood pressure, microalbuminuria, lipid and glycaemic control in primary care settings (Health Workforce New Zealand 2011).

Establishment of specialist nurse clinics and outreach nephrology clinics with emphasis on diabetic renal disease (Health Workforce New Zealand 2011).

Targeted screening for young individuals and ethnic groups most affected by CKD (Health Workforce New Zealand 2011).

Continued development of an appropriately enabled and multidisciplinary primary care workforce to deal with CKD in its earlier stages (National Renal Advisory Board 2006).

Continued development of support/guidance from secondary care (National Renal Advisory Board 2006).

Continued development of innovative approaches to primary/secondary consultation, such as greater ability of GPs to discuss issues with consultants. Other options in this area include enhanced capacity of nurse specialists and general practitioners working across the interface with secondary care; guidelines for managing people in this pre-RRT stage through primary care; and enhanced support services.

Continued innovations connecting GPs with secondary care.

Build a strong interface between the sectors.

Continued workforce development/recruitment of GPs and practice nurses to meet the required need in primary care.

There is consensus that CKD should be classified by stage 1 to 5 and as stable or progressive as management of CKD depends on stage, level of CVD risk and other indications for referral. Recommended ongoing investigations depend on CKD stage. Minimum frequency for tests is shown below (Best Practice Advocacy Centre 2009):

Stages 1 and 2 – annually

Stage 3 to 5 – three-monthly then six-monthly if stable.

An information system that can provide:

access to complete data records by all health care providers involved in an individual’s care

accurate reporting of CKD incidence/stage on database.