Chronic kidney disease (CKD) is a major public health problem imposing a substantial burden on the health-care systems in worldwide. The majority of patients with chronic kidney disease (CKD) stages 3–4 in Thailand are managed by nurse practitioner in primary care. Early intervention may can reducing the progression of disease and decreased mortality. We describe the effects of CKD management program based on chronic care model.
Methods. Patients within Taraue Primary Care Nakhon si thammarat, Thailand, population 150 with CKD stage 3 or 4 were enrolled within the chronic kidney disease management program. An intervention had to integrate all of the six areas of chronic care model: self-management support, decision support, delivery system design, clinical information systems, health care organization, and community resources. The program between August 2016 and January 2017. We have analysed the performance against clinical targets looking at a change in renal function prior to and following joining the program the proportion of patients achieving clinical targets for score of Self-Care Behavior and blood pressure control.
Results one hundred and fifty patients with CKD stage 3 or 4 were enrolled in the program. There were significant improvements in the following after 6 months in the program, compared to baseline and percentage values patients achieving target at 6 months: systolic blood pressure and diastolic blood pressure were decreased (P < 0.05).
Ninety-two patients experienced a fall in eGFR of ≥4 ml/min/1.73 m2 were increasing eGFR after 6 months. The samples were increasing significantly in perception ,knowledge and skill in Self-care Behavior (P-value < 0.05)
Conclusions. These data suggest that chronic disease management by nurse practitioner in primary care base on chronic care model is an effective method for managing patients with CKD in Thailand. The improvement in risk factors and reduction in the rate of decline of renal function potentially have significant health benefits for the patients and should result in cost effectiveness in health care system.
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