Quality Standards for Diabetes Care Toolkit

Management

Within the New Zealand Primary Care Handbook 2012 (p 54), specific recommendations for microalbuminuria: monitoring and management in the context of diagnosed diabetes are stated as:

microalbuminuria is the earliest sign of diabetic kidney disease and should be treated promptly if identified

younger people with type 2 diabetes have a higher lifetime risk of renal complications

annual screening for microalbuminuria using albumin:creatinine ratio (ACR) measurement is recommended. More frequent monitoring of renal status is indicated for Māori, Pacific Island and South Asian peoples

those at moderate to high risk of diabetes-related complications (see Figure 3) should have their ACR measured six-monthly

patients with confirmed microalbuminuria should be treated with an angiotensin-converting-enzyme (ACE) inhibitor or angiotensin 2 receptor blocker (ARB) whether or not hypertension is present

combination ACE inhibitor and ARB therapy should not be used without recommendation of a diabetes or renal specialist

use of loop diuretics instead of or in combination with thiazide diuretics is considered appropriate for patients with significant renal impairment (eGFR <45 ml/min/1.73m2).

The New Zealand Primary Care Handbook 2012 (Table 4, p 55) details the appropriate management of raised blood pressure and microalbuminuria in type 2 diabetes.
In the ‘Management of chronic kidney diseases in primary care: A national consensus statement’ (not yet publicly released), two strategies to effectively manage CKD in primary care are identified: ‘Recent pilot projects have demonstrated the effectiveness of two complementary strategies to improve management of CKD in primary care through the actions listed above. The first strategy, an electronic desktop tool, facilitates the detection and management of CKD management in a patient population in a primary care setting. The second, nurse-led clinics, involves intensive management of a group of identified high-risk CKD patients in a primary care setting’.
This strategy involves a nurse managing a group of high-risk CKD patients through regular clinics:

identified in the primary care practice

using an individualised programme with each patient

supported by specialist secondary care nursing and medical expertise

aiming to improve identified risk factors for the patients.
During the clinics the nurse oversees management of the high-risk CKD patients by:

producing an individualised care plan based on a comprehensive assessment

focusing on education of patients about their condition and management

monitoring and follow-up to ensure management optimisation of key patient parameters such as BP, blood sugars, cholesterol

regular review of progress toward clinical goals with the patient

maintenance of patient database to enable audit of practice.

To be successfully used the nurse-led clinic needs to fit into current general practice work patterns through:

systems able to readily identify suitable high-risk CKD patients and provide appropriate recall appointments

access to resources for patient education and protocols for patient management

integration with medical management of CKD in primary care

availability of specialist nurses to work in primary care settings

support from secondary renal and diabetes services.

Given the current configuration of primary and secondary care, challenges to implementation include:

availability of specialist nurses and effective clinical support from secondary care renal and diabetes services to initiate clinics and upskill primary care nurses and GPs

development of processes for mentoring practice nurses to upskill them to undertake clinics

funding of practice nurse time for free clinics for patients

adequate protocols to integrate with medical management in primary and secondary care.