Improving care of patients with diabetes and CKD: a pilot study for a cluster-randomized trial.
BACKGROUND
Family physicians may have the main role in managing patients with type 2 diabetes mellitus with early nephropathy. It is therefore important to determine the clinical competence of family physicians in preserving renal function of patients. The aim of this study is to evaluate the effect of an educational intervention on family physicians' clinical competence and subsequently determine the impact on kidney function of their patients with type 2 diabetes mellitus.


METHODS
Pilot study for a cluster-randomized trial.


METHODS
Primary health care units of the Mexican Institute of Social Security, Guadalajara, Mexico. The study group was composed of 21 family physicians from 1 unit and a control group of 19 family physicians from another unit. 46 patients treated by study physicians and 48 treated by control physicians also were evaluated.


METHODS
An educative strategy based on a participative model used during 6 months in the study group. Allocation of units to receive or not receive the educative intervention was randomly established.


RESULTS
Clinical competence of family physicians and kidney function of patients.


METHODS
To evaluate clinical competence, a validated questionnaire measuring family physicians' capability to identify risk factors, integrate diagnosis, and correctly use laboratory tests and therapeutic resources was applied to all physicians at the beginning and end of educative intervention (0 and 6 months). In patients, serum creatinine level, estimated glomerular filtration rate, and albuminuria were evaluated at 0, 6, and 12 months.


RESULTS
At the end of the intervention, more family physicians from the study group improved clinical competence (91%) compared with controls (37%; P = 0.001). Family physicians in the study group who increased their competence improved renal function significantly better than physicians in the same group who did not increase competence and physicians in the control group (with or without increase in competence): change in estimated glomerular filtration rate, 0.9 versus -33, -21, and -16 mL/min/1.73 m(2) (P < 0.05); and change in urinary albumin excretion of -18 versus 226, 142, and 288 mg/d, respectively (P < 0.05). Compared with other groups, study family physicians with clinical competence also controlled systolic blood pressure significantly better and were more likely to increase the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and statins and to discontinue nonsteroidal anti-inflammatory drugs.


CONCLUSIONS
Our analysis did not adjust for clustering. Physicians in only 2 units were randomly assigned; thus, it is not possible to distinguish the effect of the intervention from the effect of the unit.


CONCLUSIONS
Educative intervention to primary physicians is feasible. Our data may be the basis for additional prospective studies with a cluster-randomized trial design and larger numbers of centers, physicians, and patients.
Cortés-Sanabria
Laura
L
Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, CMNO, IMSS, Belisario Domínguez No. 1000, Col. Independencia, Guadalajara, Mexico.
Cabrera-Pivaral
Carlos E
CE
Cueto-Manzano
Alfonso M
AM
Rojas-Campos
Enrique
E
Barragán
Graciela
G
Hernández-Anaya
Moisés
M
Martínez-Ramírez
Héctor R
HR
D000328:Adult; D002983:Clinical Competence; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000628:therapy*; D003928:Diabetic Nephropathies / Q000503:physiopathology / Q000628:therapy*; D018450:Disease Progression; D004502:Education, Medical, Continuing; D004521:Educational Measurement; D005194:Family Practice / Q000193:education*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D051436:Renal Insufficiency, Chronic / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D012307:Risk Factors; D011795:Surveys and Questionnaires