A community-based model of care improves blood pressure control and delays progression of proteinuria, left ventricular hypertrophy and diastolic dysfunction in Maori and Pacific patients with type 2 diabetes and chronic kidney disease: a randomized controlled trial.
BACKGROUND
In this study, our main goal was to determine whether an integrated, community-based model of care using culturally appropriate health-care assistants to manage hypertension in Māori and Pacific patients with diabetes and chronic kidney disease (CKD) is more effective than conventional care in achieving blood pressure (BP) targets and delaying progression of cardiac and renal end-organ damage.


METHODS
Sixty-five Māori and Pacific patients (aged 47-75 years) with type 2 diabetes, moderate CKD (>0.5 g proteinuria/day, serum creatinine 130-300 µmol/l) and hypertension were randomized to usual care (n = 32) or community/intervention care (n = 33) for 12 months. Community care patients were visited monthly by a nurse-led health-care assistant for BP measurement. Antihypertensives were adjusted using a stepwise protocol, aiming for a BP <130/80 mmHg. Office BP and renal and echocardiographic parameters were measured at baseline and 12 months.


RESULTS
Baseline characteristics including office BP, renal and echocardiographic parameters, and number of antihypertensives were well matched in both groups. By 12 months, the community care patients had achieved a significantly greater reduction in office systolic BP (-21 ± 26 mmHg vs -12 ± 20 mmHg, P = 0.04) and in 24-h urine protein (-1.4 ± 2.6 g vs +0.1 ± 2.8 g, P = 0.04). The number of prescribed antihypertensives was greater in these patients at 12 months (3.4 ± 1.1 vs 2.3 ± 1.0, P < 0.01). Left ventricular (LV) mass and left atrial (LA) volume progressed in the usual care group, but not in the intervention group (P < 0.05).


CONCLUSIONS
This novel model of care is more effective than conventional care in lowering systolic BP and reducing cardiac and renal end-organ damage in these high-risk patients.
Hotu
Cheri
C
Department of Medicine, University of Auckland, Auckland, New Zealand.
Bagg
Warwick
W
Collins
John
J
Harwood
Lorraine
L
Whalley
Gillian
G
Doughty
Robert
R
Gamble
Greg
G
Braatvedt
Geoffrey
G
D000368:Aged; D002908:Chronic Disease; D003153:Community Health Services; D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D003928:Diabetic Nephropathies / Q000628:therapy*; D003971:Diastole; D005260:Female; D006801:Humans; D006973:Hypertension / Q000628:therapy*; D017379:Hypertrophy, Left Ventricular / Q000517:prevention & control*; D007674:Kidney Diseases / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011507:Proteinuria / Q000517:prevention & control*