Optimising blood pressure control in Maori and Pacific patients with type 2 diabetes mellitus and established diabetic nephropathy in New Zealand

Diseases Disease management Diabetes Maori Blood pressure Pacific people New Zealand
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Diabetes mellitus is having a considerable impact on the health and well-being of Māori and Pacific people in New Zealand (NZ). The prevalence of diabetic nephropathy is high in these groups, who also have a heightened risk of progression to end-stage renal disease (ESRD). Good blood pressure (BP) control is paramount to the prevention and delay of diabetic nephropathy. Success rates in achieving BP control through the utilisation of conventional healthcare approaches have been sub-optimal in comparison to the outcomes achieved in randomised controlled studies, therefore innovative and effective models of care for BP control are critically needed. The aim of this thesis is to examine whether a novel, integrated, communitybased model of care using nurse-led Māori and Pacific healthcare assistants (HCA) to manage hypertension in Māori and Pacific patients with type 2 diabetes and chronic kidney disease (CKD) is more effective than conventional care in reducing BP and delaying progression of cardiac and renal end-organ damage. The DElay Future End-stage Nephropathy due to Diabetes (DEFEND) study was a randomised controlled trial of 12 months duration that examined this model of care. Our findings showed that this model of healthcare delivery is significantly more effective than conventional care in lowering systolic BP, and reducing cardiac and renal end-organ damage in these high-risk patients. The thesis includes reviews and summaries which describe the respectively high prevalence of diabetes and diabetic nephropathy in Māori and Pacific people in NZ, and a cross-sectional analysis illustrates the high rates of Māori and Pacific people receiving renal replacement therapy (RRT), and the associated high comorbidity and mortality rates, particularly in Māori patients with ESRD. The low rate of renal transplantation in Māori and Pacific people is also highlighted. Barriers to healthcare and their impact on Māori and Pacific communities are summarised. A literature review explores the effectiveness of different antihypertensive agents to achieve good BP control and delay renal progression in diabetic nephropathy. Another review looks at different approaches to BP control in the community. The effectiveness of nurse-led hypertension clinics on BP control, cardiovascular (CV) and renal outcomes is also discussed in the thesis, and the key factors which contribute to making the nurse-led model of care effective are highlighted. The training of the DEFEND study HCAs is described and their role in the DEFEND study is discussed. A review on the benefits of 24-hour ambulatory blood pressure monitoring (ABPM) as a tool for diagnosis, treatment and CV outcome prediction precedes a discussion of the 24-hour ambulatory BP component of the DEFEND study, which was abandoned due to inadequate baseline results. The thesis concludes with a discussion on the applicability of the DEFEND study model to routine outpatient care and outlines additional measures that could be taken to further enhance the effectiveness of this innovative model of healthcare delivery. This research has added to the current knowledge of models of healthcare delivery for BP control in the community. It demonstrates the effectiveness and likely ease of applicability of a novel model of care for controlling BP in Māori and Pacific patients with type 2 diabetes and established diabetic nephropathy, who are experiencing unacceptably poor health outcomes.

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