Original Investigation
Pathogenesis and Treatment of Kidney Disease
Improving Care of Patients With Diabetes and CKD: A Pilot Study for a Cluster-Randomized Trial

https://doi.org/10.1053/j.ajkd.2007.12.039Get rights and content

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.

Study Design

Pilot study for a cluster-randomized trial.

Setting & Participants

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.

Intervention

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.

Outcomes

Clinical competence of family physicians and kidney function of patients.

Measurements

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 m2 (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.

Limitations

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.

Section snippets

Methods

The present is a pilot study performed July 2005 to July 2006 with the intention of collecting information and testing procedures in preparation for a larger cluster-randomized trial. A flow diagram summarizing recruitment and follow-up of physicians and patients is shown in Fig 1. Health care is provided by different systems in Mexico.22 People with the highest purchasing power have access to private medicine (∼3% of the total population). Workers in the formal economy (∼40%) and their nuclear

Results

Forty family physicians were included, 21 in the study group that received the educative intervention and 19 in the control group that did not receive it. In the intervention group, each physician treated 2.2 ± 0.6 patients, whereas in the control group, each physician treated 2.4 ± 0.6 patients. All physicians in the study group attended 90% or more of the training sessions. Age, sex, and labor experience were not different between family physicians of both groups (Table 1).

Discussion

The present study shows for the first time, to the best of our knowledge, that family physicians with adequate training can achieve good preservation of kidney function of patients with DM2. Martínez-Ramírez et al12 showed in a previous study that nephrologists preserved kidney function and improved blood pressure significantly better than family physicians, but this was more remarkable in patients with early nephropathy than overt nephropathy. Because referral of all patients with DM2 and

Acknowledgements

Author affiliations are as follows: Unidad de Investigación Médica en Enfermedades Renales: Laura Cortés-Sanabria, MD, PhD, Alfonso M. Cueto-Manzano, MD, PhD, and Enrique Rojas-Campos, MD, MSc; Dirección de Educación e Investigación, Unidad Médica de Alta Especialidad Hospital de Especialidades, Centro Médico Nacional de Occident: Carlos E. Cabrera-Pivaral, MD, PhD; Unidad de Medicina Familiar (UMF) No. 3: Graciela Barragán, MD; UMF No. 93: Moisés Hernández-Anaya, MD; and Unidad de

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