Dr. Nicholas
Welcome to another episode of our podcast series, “Diabetes and Kidneys: Unraveling T2D’s Silent Threat.” I'm one of your hosts, Dr. Susanne Nicholas, and joining me today is Dr. Jay Shubrook. Dr. Shubrook is a family physician and a diabetes specialist. Welcome, Dr. Shubrook.

Dr. Shubrook
Good morning. I'm glad to be here.

Dr. Nicholas
Thank you. Well, today's podcast is going to focus on the importance of patient education and patient activation in early chronic kidney disease management. And we'll also have a discussion on self care, disease monitoring, and adherence to treatment plans. And finally, we'll highlight patient support groups and resources for CKD associated with type 2 diabetes. I'd like to begin by saying that early identification and treatment of chronic kidney disease can result in slowing the progression of CKD and reduce its complications.¹ Therefore, patient engagement is a critical component of efforts to screen for and to treat CKD.¹ According to the Center for Disease Control and Prevention, as many as 9 in 10 adults with CKD do not know they have this diagnosis, and up to 1 in 3 adults with severe CKD do not know they have chronic kidney disease.² When we look at adults with diabetes and high blood pressure, approximately 1 in 3 adults with diabetes and 1 in 5 adults with high blood pressure may also have chronic kidney disease.² An important aspect of CKD is that it often is asymptomatic, and by the time patients develop symptoms, they're already in a much more advanced stage of chronic kidney disease.^1,3,4  

Dr. Nicholas
And this lack of symptoms in the earlier stages of CKD can really contribute to low patient awareness and difficulty for patients to fully grasp the complexity and the implications of a diagnosis of CKD.^1,3 So, with that as a background, let's start off with a scenario that you as a provider might see in your clinic. A patient walks into your clinic for their annual checkup. They've had controlled type 2 diabetes for 10 years, alongside well managed hyperlipidemia and hypertension. Their health conditions are managed by appropriate medications. However, when you last saw them 3 months ago, they had an urine albumin-to-creatinine ratio of 210 mg/g and an estimated glomerular filtration rate, or eGFR, of 75 mL/min/1.73 m². They don't complain of any new symptoms from the last time they came to see you, and according to guideline recommendations, you repeat both the UACR and the eGFR tests.⁴ And results indicate an elevated UACR, now at 220 mg/g, and an eGFR of 74 mL/min/1.73 m². So, Dr. Shubrook, given this scenario, what steps would you take?

Dr. Shubrook
So, first of all, I think it's a great job that we've ordered these labs in someone that's asymptomatic because it is important for evidence-based screening to find CKD.⁴ The first step would be then to actually make the diagnosis of CKD, because this person has persistently elevated UACR for the last three months and they meet the definition of CKD.⁴

Once we have a definition or met that definition, I think the next step is to actually start evidence-based treatments.⁴ This will include lifestyle modifications, behavioral modifications, and pharmaceutical interventions.⁴ And then finally, and certainly probably most important, we need to begin the process of patient education and discuss not only the diagnosis, but how to manage both their diabetes and kidney disease.⁴ So, one, they have the knowledge and tools to act and advocate and have a voice in these decisions.⁴  

Dr. Nicholas
Excellent. So in a nutshell then, the approach to a patient who's at risk for chronic kidney disease, such as this patient with type 2 diabetes, it's important to follow recommended guidelines regarding screening and monitoring for CKD, and initiating appropriate management, including lifestyle changes, which we talked about earlier in the previous episode, as well as education.⁴ So, now let's talk more about patient education, and as I believe this sometimes gets overlooked. Dr. Shubrook, as a family physician on the front line and as a diabetes specialist, can you tell me why patient education and patient activation are so important in early disease management?

Dr. Shubrook
Absolutely. And I think this point cannot be underestimated. Diabetes is a complicated disease and needs a lot of modifications.⁵ And so I always liken it when I speak with my patients, do you have children and do your children drive the car without driver's ed? And people usually chuckle. And I'm like, well, this is actually really important because, you know, in many places, people can figure out how to drive without driver's education, but this would be a painful process with lots of mistakes along the way. And we certainly don't want to set our patients up to have to learn diabetes management and self-care the hard way through trial and error.⁶ And so getting them off to a great start with evidence-based education, not only has been shown to be efficacious, but it also really improves the ability of the person to take care of themself.⁶ And I would just highlight that that should be done at the beginning of the diagnosis of diabetes.⁶ And probably each time there's a major change in their life or there's a major change in their condition.⁶ And so, if someone that had diabetes now has CKD, this is another great opportunity to involve diabetes education into the process.⁶  

I think it's important, as we think about this, that there's plenty of evidence that shows that many patients do not receive the appropriate education about CKD, the controlling risk factors, and only a minority of patients are actually going to receive this in a timely manner.^3,7 So, one can be aware and two, they can be involved.¹  

Dr. Shubrook
In fact, there was systematic review of patient experiences after a CKD diagnosis, and there were some key themes that emerged, including concerns about CKD progression, a delayed progression, and unmet informational needs.³ This really tells us that we need to do a better job giving our patients disease specific information and practical advice that they can do, because there is a lot we can do to help patients and their clinicians manage CKD.^3,4 Let's talk about physician barriers. So, there was another study that looked at 32 primary care clinicians and their perceived barriers to helping patients with CKD.⁸ These clinicians felt like there was a lack of patient understanding of their CKD diagnosis and the implications on their health.⁸ Then, of course, that may adversely affect self-management of their CKD skills.⁸ I want to highlight that this is multifactorial.⁸ In another study, looking at physicians and patients across Canada, it found that more than half the patients were not receiving a CKD diagnosis.⁹ And even across the different stages of CKD, many patients are unaware of their diagnosis, which really leaves them unable to address and take action.⁹ So many times we think maybe patients don't want to know.⁸ Well, in fact, that has been studied as well, and most patients across the range of CKD levels would have preferred to receive that CKD diagnosis earlier.⁹

Now there is some good news a more recent study showed that more than half of patients regularly discuss kidney health with their patients.⁹ And we know that we can make major differences by giving patients information, and when we get that information to them, that improves patient outcomes such as quality of life, psychosocial function, knowledge, self-efficacy, lifestyle modifications, and even proteinuria.¹⁰  

Dr. Nicholas
Thank you for that. That's a great description. And let me just summarize quickly. What you've described is the fact that there's evidence out there, based on a number of studies, which have very nicely highlighted the importance of patient education and getting the patient directly involved in their own care.^3,8-10 Well, now that we've talked a little bit about patient education and patient activation, and why these are so important in early disease management, let's move on to specifically discuss patient self-care monitoring and adherence to treatment plans. And as we've mentioned previously, the American Diabetes Association and Kidney Disease Improving Global Outcomes, or KDIGO, both advocate for patients to take an active role in managing their CKD associated with type 2 diabetes, and to have an active voice in decisions that affect their own wellbeing.⁴ Additionally, both the ADA and KDIGO recommend that patients with diabetes should participate in what's called diabetes self-management education and support programs, or DSMES programs.^6,11 And people with diabetes who participate in these programs are more likely to follow best practice treatment recommendations, particularly those with Medicare, and have lower Medicare and insurance claims costs.⁶ So, Dr. Shubrook, have you heard about diabetes self-management education and support programs?

And if so, do you think the patient that we just discussed should be recommended for this type of program? Also, what other interventions would benefit this and similar patients?

Dr. Shubrook
Yeah, I think you bring up some really important points, and what I would take from this is you need a team approach for any chronic condition.⁴ And as I mentioned earlier, getting someone timely education early in the condition gives them the tools, and as we highlighted, it can even improve intermediate outcomes such as glucose control.^1,6 But most importantly, it activates the patient to be involved, and these are evidence based, they are supported, and they really need a strong level of support from the primary care clinician because that's one of the biggest predictors that they'll actually go on to receive this education.^6,12,13 So, I think it's our job to really highlight the necessity for that and how they can benefit from that.

And then going back to that team-based approach, in primary care, I've never felt like I had too much time on my hands for patients. Visits are short, there's a lot to cover, so you don't have to go it alone. I think it's important for us to recognize that each patient's going to need a team of people to help.¹¹ And in this scenario, diabetes health management education support is a big part of that.⁶  

So, I want to just highlight just an example. There was a large trial, randomized controlled trial, that had more than 2000 patients with moderate to severe CKD and they were getting primary care services.¹⁴ But this case had a multifactorial intervention, so it included a phone-based pharmacist intervention, pharmacist physician collaboration, patient education, and this was able to improve medication adherence and increase the number of effective antihypertensive medications prescribed in patients with challenging or poor controlled blood pressure.¹⁴ Now, in this particular intervention, blood pressure control didn't change statistically as the primary outcome.¹⁴ But I do think this allows us to have more touch points with the patient, and it allows us to actually learn more and do more for our patients and really understand their circumstances better.⁷ A team-based approach is critical, and I think this is better for the patient and better for the clinician.⁴  

Dr. Nicholas
Excellent. And I so agree with you that the team-based approach can be highly effective.⁴ In addition to what we've just described, I'd like to delve a little bit more into other strategies that you may have used in your clinic. For example, have you utilized behavioral interventions in your practice? Do you find that patients are talking about monitoring their kidney health in your practice? And finally, do you feel like your patients are adherent to your treatment plans?

Dr. Shubrook
Well, I love that last question, because I think that it always is a challenge to take medicines, particularly multiple medications. And I think maybe I start with your questions, I start with my patients. One, I want to give them information so they know why they're taking what they're taking. And then when I see them, I will ask not, are you taking your medicines, but I ask, how often do you end up missing your medicines? And is there anything I'm doing that would make it easier for you to be able to stay on schedule? And often, I think giving the patient the leeway to say that life is imperfect and sometimes you'll miss medicines is the first place to start. I also think we do a lot of written instructions, so patients know exactly why they're taking medications, because most medicines for diabetes and CKD don't change symptoms.^15,16 And so it may not be obvious to the patient why they're taking it.^15,16

And I think that because someone has multiple chronic conditions, we want to have that team again.⁴ And a big part of that team can be behavioral interventions, could be mental health support and a team.⁴ And so, I often ask the patients who helps you in the management of your chronic kidney disease and diabetes, and often it can be a family member, it can be someone in the community, it could be a religious leader, it could be a community health worker, it could be a health coach, it could be the person at the coffee shop. But I wanna know who those people are that have positive influences and help them to take care of themselves. Equally well, if there's people that make management more challenging, we talk about ways, how to handle them. So, I think that multidisciplinary approach is critically necessary. And I do think that when you give people information, you give them room to be imperfect, and you know that you're going to be an advocate for them, then they're much more likely to be talking about their kidney health, their progression, and what they can do about it.

Dr. Nicholas
That's great. And I think what I'm also hearing from you is engaging with the patient and providing a platform where there's mutual trust that can open the door for the patient to be open to you, so that you can identify gaps that can be filled in to improve overall patient management. So, to close it all out, let's talk about support groups and other resources for our patients with CKD associated with type 2 diabetes. Dr. Shubrook, tell me about some of the other resources that are available that you also use in your clinic.

Dr. Shubrook
Yes, so I think it is important for patients that have information not only at the time of the visit, but even between, because often those questions come between visits. And so there are many sources of information I think, in fact, the kidney organizations have been kind of leaders in the healthcare space in terms of patient advocacy and involvement.^4,17-19 So, we do have plenty of handouts from the ADA, American Diabetes Association, the Centers for Disease Control and Prevention, KDIGO, and even the National Kidney Foundation and the American Society of Nephrology.^7,20-23 All of these have some really great patient focused and facing education tools.^7,20-23 And I think it's great to give your patients trusted, reliable resources that they can go to when they have questions, because there's plenty of information out there that is maybe not so helpful.²⁴ Then I think having pairs of people is great in teams. I often ask someone, would you be willing to talk to someone else that's maybe on the same pathway as you, and tell them about your experience, what hasn't worked? Because I think particularly community and partner engagement can make a big difference, and that can be even at the neighborhood level, the community level, or even at the national level with many of the advocacy groups. But there are resources so patients don't feel alone and can talk to others who are experiencing similar challenges.^7,24  

Dr. Nicholas
Thank you for that, Dr. Shubrook, and to talk about some of the other resources that are available for patients. So, for today, let me summarize the many things that we've talked about. We discussed the patient education and patient activation approaches and how important tools these are in the care and management of CKD in patients with type 2 diabetes. We talked about the important role that the American Diabetes Association and KDIGO play in promoting self-care monitoring and adherence to treatment plans.⁴ And we discussed the impact of diabetes self-management education and support programs, and finally, the contribution of patient support groups and resources for both providers and patients with CKD. So, with that, I'd like to thank you again, Dr. Shubrook, for this very engaging conversation. And also, I'd like to thank the audience for their attention.

Dr. Shubrook
Thank you very much. It's been a pleasure.