Abstract

More than nine percent of the US. population – or 29.1 million people – have diabetes. Of this group, more than eight million are undiagnosed, and one in three people who have been diagnosed also have kidney disease.

Minority groups, including American Indians, Hispanics, and African Americans, continue to be the most at risk for diabetes and kidney disease. Community partnerships and physician education play major roles in awareness and education efforts. At DaVita Kidney Care, clinicians created the StepAhead program to address diabetes care management among its patients.

Background

The facts about diabetes are sobering: Diabetes is the seventh leading cause of death in the United States and is the number one driver of kidney disease, which is the eighth leading cause of death in the country.1, 2 More than 228,000 people with diabetes are either on dialysis or have received kidney transplants in the US. 3 Kidney failure is a significant risk for those with diabetes. In 2011, more than 49,000 people started treatment for end-stage renal disease (ESRD) due to diabetes.4 That same year, diabetes was the primary cause of ESRD in 44% of new cases.5 Although there was a decline in the number of new cases of ESRD in people with diabetes or high blood pressure by about 2% in 2011 compared with 2010, diabetes is still the leading cause of kidney disease.6

Minority groups, including American Indians, Hispanics and African Americans continue to be the most at risk for diabetes. Likewise, minorities are at a greater risk of developing kidney failure than their white counterparts.

While a definitive link between minorities and a higher risk of diabetes has not been found, genetics and lifestyle choices play significant roles in the development of the disease. A healthy diet and regular exercise can help prevent or slow the progression of Type 2 diabetes.

African Americans are three and a half times more likely and Hispanics are one and a half times more likely to get diabetes than whites. And even though education efforts are on the rise, minorities remain largely unaware of the alarming prevalence of diabetes and kidney disease in their communities.

Figure1

“There is a lack of knowledge within the Latino community when it comes to diabetes and kidney disease,” said Julissa Soto, director of Latino services for American Diabetes Association (ADA) in Colorado. “We need to start from the beginning, educating people on eating habits, the consequences of their lifestyle choices and how to take care of their overall health. Education and awareness are essential, and it works best one-on-one.”

High-risk minority groups can play a role in helping prevent ESRD in their communities by understanding the disease’s risk factors and warning signs. If kidney disease is caught early enough, the progression of kidney failure can be slowed down or even prevented.

Addressing the problem

As the population of those with diabetes continues to grow, the kidney care community is starting to take action. Kidney care providers and organizations are increasing education and awareness efforts and re-evaluating care for those with diabetes and kidney failure. Community partnerships play a big role in these awareness and education efforts. DaVita Kidney Care partners with the ADA, American Heart Association and minority-focused groups across the country to educate at-risk populations.

As an example, in Colorado, DaVita partnered with Por Tu Familia, ADA’s Latino-focused health initiative, to spread awareness about kidney disease in the Hispanic community and educate people about their increased risk. Kidney care educators used simple tools like a risk quiz to help assess people’s risk and start a conversation about the disease.

DaVita also partnered with the ADA in Houston to provide no-cost kidney screenings through the DaVita Village Trust at an expo that attracted thousands of participants. Kidney specialists were onsite to walk individuals through their results and talk about next steps. Those who had kidney disease were encouraged to talk with a physician and attend a Kidney Smart class to educate themselves about kidney disease.

DaVita is also trying to build awareness among physicians who treat those with diabetes. A 2010 study released by the National Kidney Foundation revealed that kidney disease is still significantly under diagnosed among those with diabetes. Of 9,307 diabetic patients studied, 5,000 (53.7%) had chronic kidney disease (based on proteinuria and eGFR). Yet prior to the study only 607 (6.5%) had been accurately identified by their physicians as having kidney disease.

Michael Corona, a kidney transplant recipient, believes that if he had been aware of the complications of his diabetes, he may have avoided kidney failure. “I was raised by a lovely, old-world, Hispanic grandmother who just didn’t take me to the doctor,” said Corona. “The consensus now is that I probably had juvenile diabetes, but I wasn’t diagnosed until I was about 22.” Corona received very little education from his doctor about managing his diabetes. “If I remember correctly, my doctor said my liver and kidney enzyme readings were a little elevated so I had to be careful with my diabetes. That was about it; that was all the education I got.” In 2011, Corona was told that he had kidney failure and needed to start dialysis immediately. In 2013, he received a kidney transplant, but is still managing his diabetes.

It is important that people with diabetes have a physician to educate them about the disease, help manage blood sugar and prevent other potential complications, such as kidney disease. Along with increased education and awareness efforts, there is a movement to care for those who already have kidney failure due to diabetes. Even though more than 228,000 people with diabetes are either on dialysis or have received kidney transplants in the United States, diabetes care can be under-delivered to patients in dialysis centers.7

Since approximately 60% of DaVita’s patients have diabetes, diabetes management is one of four key components of DaVita’s Patient-Focused Quality of Life Pyramid” (the other three components being fluid management, medication management and infection control), which was created with the goal of improving mortality rates and the patient-care experience, reducing hospitalizations and, ultimately, improving patients’ quality of life.

 

Getting help early

In support of its diabetes-management efforts, DaVita created a program called StepAhead. The program focuses on four specific areas of diabetes care.

  1. Make sure patients have a doctor to manage their diabetes. Many patients have multiple physicians who care for different needs. Diabetes management can often be overlooked in the care plan. Having one physician focused on this particular issue helps ensure that patients with diabetes have the support they need to successfully manage their diabetes.
  2. Work with patients to schedule annual eye exams.Those with diabetes are more at risk of developing eye disorders and blindness than people without diabetes. People with diabetes are 40% more likely to develop glaucoma and 60% more likely to develop cataracts than those without diabetes.8 Diabetic retinopathy is one of the leading causes of blindness that can be prevented with early eye exams. Regular check-ups can help treat these complications.
  3. Ensure patients have a working glucometer.Monitoring blood glucose levels is essential to managing both Type 1 and Type 2 diabetes. Patients must keep these levels from going too high or too low. Having access to the right tools can help patients more easily monitor these levels.
  4. Perform monthly foot checks.Those with diabetes are highly susceptible to different foot problems, most commonly due to neuropathy. Patients can also develop ulcers and that, if left untreated, can result in infections and possible amputations.

DaVita piloted the StepAhead program over an 18-month period in select dialysis centers across the country. During that time, there was a significant improvement in each focus area. Initially, less than 50% of the patients actually had a doctor managing their diabetes. Today, over 90& of the patients have a doctor managing their diabetes. Similar results were found for the retinal exams and for the presence of a glucometer. There was also success in the reduction of amputations. In the first 12 months of the program, DaVita’s amputation rate was 2.7 amputations per 100 patient-years, compared to a national average of 4.6 amputations per 100 patient-years.9 In the final six months, DaVita’s amputation rate decreased to 1.6 amputations per 100 patient-years.

StepAhead – which will be available to patients in every DaVita center in the future – aims to advance the care of diabetes in patients whose medical attention might have shifted to kidneys when they developed ESRD. This kind of integrated care program can help decrease the overall cost of care and provide a better quality of life for those with diabetes. Care teams also encourage patients to manage their diabetes through other methods including physical activity, taking medication if needed, and healthy eating.

Nutrition and diet are important factors for patients managing diabetes and kidney failure. DaVita offers an online tool called DaVita Diet Helper that provides 1,000+ kidney-friendly recipes (most of which are also diabetes-friendly) and tracks potassium, phosphorus and sodium levels. Various cookbooks are also available as additional resources.

 

A united effort

There are a variety of ways to get involved in diabetes awareness, education and prevention initiatives. The kidney care community has a strong voice in the fight against diabetes and will continue to join efforts to stop the progression of the disease. A decline in diabetes might just mean a decline in kidney disease. And that would be a win for everyone.


Landing on your feet

Monthly foot checks are an essential part of DaVita’s StepAhead diabetes management program. There were 228 patients who underwent foot checks during the 18-month pilot program. Ninety-five percent had at least six foot checks; 80% had at least 12 foot checks; and 26% had at least 18 foot checks. DaVita saw a significant reduction in amputation rates among these patients (from 2.7 to 1.6 amputations per 100 patient-years).

One patient experienced overwhelming gratitude when a DaVita nurse discovered a callous on his foot that turned out to be a mass growing into his bone. When the nurse referred him to a podiatrist, he was able to have surgery that prevented infection and possible amputation. This patient had already had two toes amputated. The patient has become an advocate for the program and encourages fellow patients to get their feet checked regularly.

After two months of getting foot checks with no signs of ulcers or any other issues, another patient developed a large ulcer with infected tissue on top of his foot. The nurse that discovered it immediately involved his nephrologist, podiatrist and vascular surgeon to get proper treatment. This patient is partially blind and already had a below-the-knee amputation. The quick response from the foot check may have prevented a second amputation.

 

Resources available from DaVita Kidney Care

You do not have to be a DaVita patient or professional to access these tools and resources.

 

DaVita Risk Quiz for Diabetes

www.davita.com/education/what-is-kidney-disease

DaVita Village Trust

davitavillagetrust.org

DaVita KidneySmart classes

www.kidneysmart.org

DaVita DietHelper

www.davita.com/diethelper


References

1.             Murphy SL, Xu J, Kochanek KD. National Vital Statistics Reports, Death: Final Data for 2010, 2013. Centers for Disease Control and Prevention http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf accessed June 23, 2014

2.             Murphy SL, Xu J, Kochanek KD. National Vital Statistics Reports, Death: Final Data for 2010, 2013. Centers for Disease Control and Prevention http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf accessed June 23, 2014

3.             National Chronic Kidney Disease Fact Sheet, 2014. Centers for Disease Control and Prevention http://www.cdc.gov/diabetes/pubs/pdf/kidney_factsheet.pdf accessed June 23, 2014

4.             National Diabetes Statistics Report, 2014. Centers for Disease Control and Prevention http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf accessed June 23, 2014

5.             National Diabetes Statistics Report, 2014. Centers for Disease Control and Prevention http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf accessed June 23, 2014

6.             National Chronic Kidney Disease Fact Sheet, 2014. Centers for Disease Control and Prevention http://www.cdc.gov/diabetes/pubs/pdf/kidney_factsheet.pdf accessed July 16, 2014

7.             National Diabetes Statistics Report, 2014. Centers for Disease Control and Prevention http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf accessed June 23, 2014

8.             Eye Complications, 2014. American Diabetes Association http://www.diabetes.org/living-with-diabetes/complications/eye-complications/ accessed June 23, 2014

9.             Combe C, Albert JM, Bragg-Gresham JL, et al. The burden of amputation among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 54:680-92, 2009