title: Long-term effectiveness of a community-based model of care in Māori and Pacific patients with type 2 diabetes and chronic kidney disease: a 4-year follow up of the DElay Future End Stage Nephropathy due to Diabetes (DEFEND) study.
abstract: OBJECTIVE
  The Delay Future End Stage Nephropathy due to Diabetes study was a randomised controlled trial of Māori and Pacific patients with advanced diabetic nephropathy, comparing a community-based model of care with usual care. The intervention group achieved lower blood pressure (BP), proteinuria and less end-organ damage. After the intervention ended, all patients reverted to usual care, and were followed to review the sustainability of the intervention.
  
  
  METHODS
  A retrospective observation of 65 patients (aged 47-75 years) with type 2 diabetes, hypertension, chronic kidney disease 3/4 and proteinuria (>0.5 g/day) previously randomised to intervention/community care or usual care for 11-21 months. Follow up thereafter was until death, end-stage renal disease (ESRD) (estimated glomerular filtration rate (eGFR) ≤ 10 mL/min/1.73 m(2) )/dialysis or 1 February 2014. Primary end-points were death and ESRD/dialysis. Secondary outcomes were annualised glomerular filtration rate decline, non-fatal vascular events and hospitalisations.
  
  
  RESULTS
  Median (interquartile ranges (IQR)) post-trial follow up was 49 (21-81) months and similar in both groups. The median (IQR) eGFR decline was -3.1 (-5.5, -2.3) and -5.5 (-7.1, -3.0) mL/min/year in the intervention and usual care groups respectively (P = 0.11). Similar number of deaths, renal and vascular events were observed in both groups. At the end of follow up, the number of prescribed antihypertensive medications was similar (3.4 ± 1.0 vs 3.3 ± 1.4; P = 0.78). There were fewer median (IQR) hospital days (8 (3, 18) vs 15.5 (6, 49) days, P = 0.03) in the intervention group.
  
  
  CONCLUSIONS
  Short-term intensive BP control followed by usual care did not translate into reduction in long-term mortality or ESRD rates, but was associated with reduced hospitalisations.
authors: Auckland Diabetes Centre, Auckland District Health Board, Auckland, New Zealand.|Department of Renal Medicine, Auckland District Health Board, Auckland, New Zealand.
authors: J
authors: J
authors: Tan
authors: Department of Renal Medicine, Auckland District Health Board, Auckland, New Zealand.
authors: P
authors: P
authors: Manley
authors: Auckland Diabetes Centre, Auckland District Health Board, Auckland, New Zealand.
authors: G
authors: G
authors: Gamble
authors: Department of Renal Medicine, Auckland District Health Board, Auckland, New Zealand.
authors: J
authors: J
authors: Collins
authors: Auckland Diabetes Centre, Auckland District Health Board, Auckland, New Zealand.|Department of Medicine, University of Auckland, Auckland, New Zealand.
authors: W
authors: W
authors: Bagg
authors: Department of Renal Medicine, Auckland District Health Board, Auckland, New Zealand.|Department of Medicine, University of Auckland, Auckland, New Zealand.
authors: C
authors: C
authors: Hotu
authors: Department of Medicine, University of Auckland, Auckland, New Zealand.
authors: G
authors: G
authors: Braatvedt
mesh_terms: D000368:Aged; D003153:Community Health Services / Q000458:organization & administration*; D003924:Diabetes Mellitus, Type 2 / Q000208:ethnology / Q000401:mortality / Q000628:therapy*; D005500:Follow-Up Studies; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D006973:Hypertension / Q000517:prevention & control; D007676:Kidney Failure, Chronic / Q000517:prevention & control*; D008875:Middle Aged; D017146:Models, Organizational; D015397:Program Evaluation; D011507:Proteinuria / Q000517:prevention & control; D051436:Renal Insufficiency, Chronic / Q000208:ethnology / Q000401:mortality / Q000628:therapy*; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: community care; dialysis; hypertension; survival; type 2 diabetes