Achieving clinical blood pressure and blood glucose control in patients with chronic kidney disease and diabetes mellitus: adherence and barriers

Introduction Poor adherence to guideline recommendations of blood pressure (BP) and blood glucose levels (BGLs) leads to microvascular and macrovascular damage, which contributes to cardiovascular disease (CVD) and chronic kidney disease (CKD). The aim of this thesis was to determine the adherence and barriers to achieving clinical blood pressure and blood glucose control in patients with chronic kidney disease and diabetes mellitus. This study sought to understand whether BP and glucose level recommendations are achieved or not, and identify whether clinical inertia is a potential barrier to adherence. Further, this study sought to determine if chronic disease services contribute to chronic disease management. The significance of this thesis is considerable as the impact of failure to control BGL and BP can lead to renal damage, which impacts on patient quality of life and puts pressure on the healthcare system. Methods This project was conducted on five separate study sites, all located in Canberra, ACT: Calvary Public Hospital Bruce, Cardiac Rehabilitation Outpatient Program Belconnen, Calvary Outpatient Endocrine Clinic Belconnen, Calvary Public Hospital’s Diabetes Inpatient Service, and the Chronic Disease Service at Calvary Hospital’s Emergency Department. Key patient data, including patient demographic, health status, medical history, and pathology information, were collected retrospectively over a seven-year period, from 1 January 2010 to 31 January 2016. To answer the following research questions, a combination of descriptive statistics, t-Tests, MANOVA/ANOVA, Fisher’s Exact Test, and linear regression analysis were used, with significance determined at p < 0.05: Were the targets for BP and/or BGL control in patients with CKD and DM achieved? To what extent did clinical inertia affect BP and glucose level control in patients with CKD and DM? and, To what extent did hospital chronic disease services contribute to controlling DM, patient BP and glucose levels? Results A total of 9 006 patients were included and the results indicate that the average clinical BP ranged from 126/68.8 to 130.2/71.3 mmHg. The average overall HbA1c result ranged from 7.6% to 10.45% with adherence to guideline recommendations (<8.0%, 64.0 mmol/mol) achieved inconsistently across the study sites. Results indicated that patients adhered to BP and BGL guideline recommendations, although clinical inertia (clinical inertia is associated with a clinician failing to escalate care in the presence of competing demands from multiple comorbidities) affected the consistency of their adherence, with 9.8% of patients affected by clinical inertia within specialised endocrinology care, as compared to 20.7% within general hospital care (p < 0.05). There were significant hospital discharge differences (p < 0.05) between those subject to clinical inertia and non-clinical inertia patient systolic BP (144.2 versus 132.8 mmHg), deranged BGL (66.7% versus 35.3%), and reduction in kidney function (83.3% versus 30.9%). In addition, it was determined that chronic disease services positively contributed to controlling CKD and DM patient BP and BGLs. This was highlighted in the cardiac rehabilitation (CR) program analysis, with results indicating that significant reductions (p < 0.05) were made in the patients’ (n=18) diastolic BP, depression and anxiety, while increases were made in their physical abilities. Of those that participated in the program survey (n=279), 96.1% indicated they received benefits from attending the CR program, with 96.8% identifying significant positive changes to their lifestyle (p < 0.01) and improvement in their sense of well-being (p < 0.001) as key benefits, in addition to perceived quicker recovery. Furthermore, it was demonstrated that the emergency department’s Chronic Disease Management Service (CDMS) contributed to chronic disease management by identifying those patients with DM, CVD, and/or CKD and managing them according to the evidence-based guidelines. Based on 8 392 patients, 7 975 (74%) CRP pathology requests adhered to the clinical guidelines. With regard to appropriate testing, 406 patients were monitored in the CDMS, including 87 with type two diabetes mellitus (T2DM), 35 renal disease patients and 1 600 patients assessed for risk of myocardial infarction. The patients who had inappropriate indication for a CRP test had an average result level of 18.2 mg/L, compared to the patients who had an appropriate indication and resulting level of 28.0 mg/L, with 33.3 mg/L among T2DM and 45.5 mg/L among renal disease patients. These results were significant (p < 0.001), and confirm the hypothesis that CRP results are high in the patients who had the test requested appropriately. Conclusion The studies described in this thesis have determined that clinicians are able to maintain the recommended BP levels and BGLs in their patients, although the consistency of adherence to the guidelines is affected by clinical inertia. Further, I have determined that chronic disease services significantly contribute to improving DM and CKD patient medical outcomes. No previous Australian studies have investigated BP and BGL control, in relation to adherence rates, in DM and CKD patients; nor have there been any publications in the Australian literature determining the effectiveness of patient services at adhering to DM or CKD patient recommendations. The literature has not addressed barriers to adherence, such as clinical inertia, and its impact on chronic disease. The strength of this thesis is that it provides evidence on how patients and clinicians are effectively adhering to BP and glucose recommendations in DM and CKD populations. The clinical and public health implications of understanding the level of BGP and BP guideline adherence is important, as it will provide policy makers with a clear evidence on the control rates and the programs that are contributing to good clinical outcomes. These programs, can then be promoted to at risk population groups, such as those from rural or remote areas of Australia. Furthermore, the results from this thesis will be used in the development and subsequent publication of a large Royal Flying Doctor Service (RFDS) report, which aims to determine the epidemiology of rural and remote Australians who suffer from DM, HT, CKD, and CVD. This will then allow the RFDS to determine the type and location of services it employs in reducing poor CKD outcomes in the bush.