Chronic Kidney Disease

@ckd_ce on Twitter

1) Welcome to a new #accredited #tweetorial on optimal deployment of the multidisciplinary, interprofessional team to ensure appropriate care of patients with type 2 diabetes #T2D & cardiac disease, #CaReMe #FOAMed. This program is accredited for 0.5h πŸ†“CE/#CME credit πŸ‡¬πŸ‡§πŸ‡ͺπŸ‡ΊπŸ‡¨πŸ‡¦πŸ‡ΊπŸ‡Έ

2) Our expert author is Hannah Beba @HannahBeba BSc Chem, BSc Biochem, MPharmS, MSc Diabetes, Consultant Pharmacist Leeds CCG: Diabetes πŸ‡¬πŸ‡§. Always great to have #pharmacist faculty! And ALWAYS great to focus on THE #HEALTHCARE TEAM!

5) A successful medical evaluation depends on beneficial interactions between the patient and the care team… who are the care team?

6) So many professions are involved in managing the care of people w/diabetes! With the patient at the centre, the team inc’s physicians, nurses, dietitians, educators, lab techs, podiatrists, family members, potentially many others depending on local organization & structure

history dream GIF by visitphilly

7) Specialist teams in all the following might help keep the heart healthy in someone living with diabetes #CaReMe

10) Answer = all of the above! You could NOT have gotten it wrong! High quality care needs to be made a priority

11) Here is the TRIAD conceptual model for relationships of system-level factors, processes, and outcomes of care. LDL-c, LDL cholesterol. ESRD, end-stage renal disease #systemfactors #processofcare #healthoutcomes
See πŸ”“

12) The TRIAD conceptual model describes relationships of patient factors & patient-system interactions with processes &outcomes of care, including #LDLC, LDL cholesterol.
Note patient-physician system interaction only noted. Is it cost-effective ? Holistic ?

13) NHSE @NHSEngland @parthakar brought together 6 representatives for the MDT together & this document was the result : πŸ”“
πŸ‘to the authors @AliRacaniere @SarahAlicea8 @DrKan @nicmiln @Lorraineavery14

14) There are many reasons why forming networks for delivery of care may be helpful #PCN #modelofcare

15) Optimized #team-based care flows throughπŸ”’tiers of care according to needs, allowing people w/T2D to remain the focus of their care, having care provided close to home but allow for readily available access to specialist care in a timely manner. SeeπŸ”“

16) A useful concept is the pyramid of care, here showing the multidisciplinary team at every tier of care
Tier 4= Foot diabetes MDT (with predefined criteria), Type 1 diabetes , CKD 4 and 5, those on renal replacement therapy, Antenatal diabetes, Adolescents, inpatients

17) Tier 3 = Targeted clinics e.g. post MI, technology (community-managed CBG & flash glucose monitoring devices), Frailty tailored to population needs, Renal: up to stable CKD 4, Type 1 needing community management (e.g. care home, learning disabilities) …

18) … People with uncertain diagnosis e.g. suspected latent autoimmune diabetes in adults (#LADA) or maturity-onset diabetes of the young (#MODY).

19) Tier 2=Injectable therapies: #GLP-1, insulin initiation/titration, inclisiran, PCSK9i. Young adults w/ diabetes, ♀️ of childbearing potential, All newly diagnosed T2D w/painful neuropathy, erectile dysfunction, or hypertension. People with diabetes & mental health problems.

20) Tier 1: basic care done well: lifestyle advice; encouragement to attend structured education; foot examination/care advice; lipids and BP management; basic CKD management; initiation of oral medications. basic pre-conception advice; …

21) … signposting to other support services (e.g. smoking cessation, wellbeing advisors, retinopathy, periodontal, weight management services); mental health and emotional wellbeing screening.

22) So let’s break here and let this sink in . . . TOMORROW we’ll address the chronic care delivery model for these patients. Don’t miss it!
@GoggleDocs @ADA_DiabetesPro @KCKlatt @NMHheartdoc @ACCinTouch #cardiotwitter #endotwitter #nephtwitter @SnayCardsPharmD @beaverspharmd

23) Welcome back! You are earning FREE CE/#CME and I am @HannahBeba #pharmacist & #diabetes specialist from Leeds πŸ‡¬πŸ‡§ as we talk about optimizing #team mgt of #T2D + cardiac disease. Kudos to @sotonDSN @Amandaepps123 @DSNforumUK @parthaskar @RichardIGHolt @set_fortess @KOBPharmD

24) Is there evidence for a #teamwork model in #chronic care? Yes ! See πŸ”“

25) Structured care management may involve using clinical guidelines, patient reminders, use of a wider MDT, use of health education resources. See πŸ”“

26) Population level care may be less effective for those disengaged from the healthcare system as a whole or disengaged from the tier of care where their care may be best managed. See πŸ”“

29) What other self-management support do you use?

30) Prioritisation tools have become common especially after #COVID19
How do we now take these prioritisation tools to the next level?

31) Smoking cessation support is best from #communitypharmacy. Social prescribers & health navigators may help ppl find a right fit to make diet & lifestyle changes. Public health authorities have a role in enabling healthy lifestyles from cycle routes to ensuring air quality

32) @goKDIGO provides guidance on building a quality orientated culture. See πŸ”“

33) This is an integrated care approach to improve outcomes, self-management, and patient–provider communication in patients with diabetes #KDIGO @goKDIGO

34) It can work! Patients who were enrolled in the #CCM experienced a ⬇️ in #cardiovascular disease risk by 56.6%, #microvascular complications by 11.9%, and mortality by 66.1%. It’s all at πŸ”“

35) There may be concerns that holistic care comes at a cost . . . but look at the savings !!! See πŸ”“

36) This was especially useful in low-resource settings … so is this a way to address variation in care? See

37) It’s all about #systems #peoplelivingwithdiabetes and #careproviders. See and

38) Does the chronic care model produce long-term improvement for people ? We need to understand the people living with diabetes more to understand who suits what approach best?
Should we be doing more qualitative research in this area?

39) Are there specific populations that might be best served with a multifaceted team approach?
Are these benefits in surrogate markers going to yield better outcomes? We need longer term studies
Is the real success here in the person with diabetes becoming more empowered ?

40) People reported a better quality of life (p<0.001), greater satisfaction was seen with care for diabetes, coronary heart disease, or both (P<0.001) and with care for depression (P<0.001).

41) Or the healthcare professional avoiding clinical inertia? Patients in the intervention group also were more likely to have 1 or more adjustments of insulin (P=0.006), antihypertensive meds (P<0.001), & antidepressant meds (P<0.001). See πŸ”“

42) Might this approach particularly lend its self to CV disease and diabetes? Check out

43) More research is needed. The quality of the evidence for these chronic care models is often rated as moderate because of indirectness, i.e. findings have extrapolated to assume applicability. See

44) And that’s it–you have just earned 0.5h CE/#CME! Go to to claim your credit, and FOLLOW US for more education by #tweetorial, all FREE, all by EXPERT authors! I am @HannahBeba of @GoggleDocs. Be sure to follow @cardiomet_CE as well!

Originally tweeted by @CKD_ce (@ckd_ce) on March 23, 2022.