title: Effects of structured care by a pharmacist-diabetes specialist team in patients with type 2 diabetic nephropathy.
abstract: OBJECTIVE
  We developed a disease management program for patients with Type 2 diabetic nephropathy and evaluated its effects on the time to onset of end-stage renal disease or all-cause death compared with usual care.
  
  
  METHODS
  In a 2-year, prospective cohort study, we compared the clinical outcomes of patients managed by a structured care protocol (n = 80) to a group receiving usual care (n=80) in the same hospital. Patients aged < or =80 years with type 2 diabetes, serum creatinine 150-400 micromol/L, and micro- or macroalbuminuria were recruited. The structured care protocol was implemented by a pharmacist-diabetes specialist team with particular emphasis on periodic laboratory assessments, patient adherence, risk factors control, and use of renin-angiotensin system inhibitor. The primary endpoint was the composite of end-stage renal disease or all-cause death. Other endpoints were the rate of renal decline, processes-of-care measures, and control of risk factors.
  
  
  RESULTS
  During 22.8+/-7.9 months of follow-up, the primary endpoint developed in 24 and 40 patients in the structured care and usual care groups, respectively (adjusted risk reduction, 60%, P< .001). Structured care (hazard ratio [95% confidence interval (CI)], 0.40 [0.23-0.68]), age (0.95 [0.93-0.98]), baseline systolic blood pressure (BP) (1.014 [1.003-1.026]), logarithm (base 10) of baseline serum creatinine (34 441 [2290-517915]), and macroalbuminuria (8.95 [1.22-65.38]) were independent predictors for the primary endpoint. Structured care slowed the rate of renal decline (P=.032). More intensive laboratory measurements, increased use of renin-angiotensin system inhibitor, and greater reductions in BP and low-density lipoprotein (LDL) cholesterol were reported by patients receiving structured care.
  
  
  CONCLUSIONS
  Structured care delivered by a pharmacist-diabetes specialist team reduced the incidence of end-stage renal disease or death compared with usual care in patients with type 2 diabetic nephropathy.
authors.affiliation: Department of Medicine and Therapeutics, The Chinese University of Hong Kong, The Prince of Wales Hospital, Shatin, Hong Kong. wilson_lg@hotmail.com
authors.forename: Wilson Y S
authors.initials: WY
authors.lastname: Leung
authors.forename: Wing-Yee
authors.initials: WY
authors.lastname: So
authors.forename: Peter C Y
authors.initials: PC
authors.lastname: Tong
authors.forename: Norman N
authors.initials: NN
authors.lastname: Chan
authors.forename: Juliana C N
authors.initials: JC
authors.lastname: Chan
mesh_terms: D000328:Adult; D000368:Aged; D002423:Cause of Death; D003924:Diabetes Mellitus, Type 2 / Q000150:complications*; D003928:Diabetic Nephropathies / Q000628:therapy*; D019468:Disease Management; D023381:Endpoint Determination; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000209:etiology / Q000401:mortality* / Q000517:prevention & control*; D008297:Male; D008511:Medicine; D008875:Middle Aged; D010348:Patient Care Team; D010595:Pharmacists; D011446:Prospective Studies; D012307:Risk Factors; D013038:Specialization