Summary

Dr Hellena Habte-Asres’ doctoral study identified care gaps in managing diabetes in people with advanced chronic kidney disease (CKD). She co-led a grant application in October 2022, securing funding to establish a diabetes service at the North Central London’s (NCL) Dialysis Unit. A new care model was implemented in NCL’s renal satellite unit. This multifaceted approach included self-management education, lifestyle advice, medication optimisation, cardiovascular disease prevention and psychosocial support, resulting in significant metabolic improvements, increased guideline-directed therapies and greater access to diabetes technology.

Innovation

In October 2022, Dr Hellena Habte-Asres conducted a comprehensive mapping of diabetes service provision in NCL. This revealed significant gaps in care for people with diabetes and advanced CKD. Multiple interviews were conducted with key stakeholders in diabetes and renal services and routine data was analysed to establish the service needs. The identified need was to enhance diabetes care for individuals with advanced CKD (stages 4 and 5) and those undergoing haemodialysis at a renal satellite unit in NCL. This patient population faces complex health challenges due to the overlapping conditions of diabetes and CKD, requiring specialised care beyond standard diabetes management protocols. The existing service lacked comprehensive integration and expertise in managing both conditions concurrently, leading to suboptimal health outcomes. With grant funding, the new service was implemented in March 2023. The novel diabetes care model was tailored to individuals with advanced kidney disease. This approach involved: deploying a senior diabetes nurse specialist with expertise in kidney disease to enhance the capacity of the existing CKD service; a multifaceted care approach that included self-management education, lifestyle advice, medication optimisation, cardiovascular disease prevention, and psychosocial support, plus data-driven insights, utilising health informatics from both primary and secondary care databases to see the extent to which this population was receiving guideline-directed care. This included analysing the number of people who had completed diabetes care processes at baseline. Additionally, sociodemographic and clinical data were examined to further characterise this population. Incorporating metrics such as the Index of Multiple Deprivation identified significant disparities in access to diabetes care among individuals with advanced kidney disease. These insights were crucial in developing targeted strategies to address these barriers and improve health outcomes for underserved populations. Objectives included improving metabolic outcomes, enhancing use of guideline-directed therapies and increasing access to diabetes technology.

Equality, Diversity and Variation

The insights gained from the data analysis informed the development of targeted strategies to address barriers to care. For example, focusing efforts on identified areas with low completion rates of diabetes care processes. Assigning a senior diabetes nurse specialist with expertise in kidney disease enhanced the capacity of the existing CKD service to provide comprehensive diabetes care. This role was crucial in reaching patients who had previously had limited access to specialised care. Each patient’s care plan was tailored to their specific needs, taking into account their clinical condition, socioeconomic status and personal preferences. The care model incorporated culturally sensitive practices to ensure that patients from diverse backgrounds felt respected and understood. Educational materials and communication strategies were adapted to meet the linguistic and cultural needs of the patient population. The initiative led to significant improvements in metabolic outcomes, including reductions in HbA1c, systolic blood pressure and weight among pre-dialysis patients, and similar improvements in the dialysis population. These outcomes indicated better overall management of diabetes and reduced risk of complications. There was a notable increase in the use of guideline-directed therapies, such as SGLT2 inhibitors and GLP1 receptor agonists, which are known for their cardiovascular and renal protective effects. The project significantly increased the use of continuous glucose monitoring (CGM) among the haemodialysis population, providing real-time glucose data and reducing the frequency of hypoglycaemia episodes. Through self-management education and support, patients gained greater control over their diabetes management, leading to improved health outcomes and quality of life. Identifying and targeting underserved areas, the project ensured that more patients had access to comprehensive diabetes care. This reduced geographical and socioeconomic disparities in service provision. Implementing a standardised care model that combined face-to-face and virtual reviews ensured that all patients received consistent, high-quality care regardless of their location or background. Regular monitoring of clinical outcomes and patient feedback allowed continuous improvement of the care model.

Results

Among pre-dialysis CKD patients, HbA1c levels decreased by an average of -13.0 mmol/mol (p < 0.001). In the dialysis population, mean HbA1c levels reduced from 55.3 (±23.2) to 49.6 (±15.1) at the 12-month follow-up (p < 0.004). Systolic blood pressure showed a mean reduction of -13.7 mm Hg (p < 0.0001) among pre-dialysis patients, and a reduction of 18 mm Hg in the dialysis population. Body weights showed a mean reduction of -2.9 kg (p < 0.0001) among pre-dialysis patients. A reduction in serum total cholesterol of 0.2 mmol/L (p = 0.0001) was shown in the dialysis population. SGLT2 inhibitor utilisation increased to 62.9% and GLP1 receptor agonist use to 28.4%. CGM utilisation reached 89% among the haemodialysis population. The integration of diabetes and CKD care led to more comprehensive management of both conditions, improving overall patient health. Enhanced self-management education and lifestyle advice empowered patients to manage their conditions more effectively. Increased use of SGLT2 inhibitors, GLP1 receptor agonists, and CGM technology provided patients with cutting-edge diabetes management tools. Improved diabetes management reduced the incidence of acute complications, potentially lowering hospital admission rates. Better control of metabolic parameters and blood pressure helped prevent diabetes-related complications. Integrating diabetes care into existing renal services optimised resource use and avoided duplication of services. By reducing the need for emergency care and hospital admissions, the initiative contributed to cost savings for the NHS. The project’s focus on improving quality of care while minimising costs aligns with the NHS’s goals of providing high-quality, cost-effective care.

User Feedback

The model garnered strong support from both healthcare professionals and patients. Ensuring anonymity in surveys and feedback forms encouraged honest and unbiased responses. Based on feedback, additional materials and workshops focused on nutrition were developed. Addressing concerns about virtual consultations, patients were given the option of virtual or face-to-face consultations.