Table 4 Characteristics of studies addressing question 1

Tan et al. (2014) [23]

To determine the effectiveness of a PHC-based, nurse-led CKD program with Tongan staff can improve medication adherence and clinical outcomes

2-year prospective uncontrolled cohort study, conducted 2011 – 2013

NZ urban area, PHC service in Auckland with Tongan-speaking staff

Nurse-led with input from GP and diabetologist when necessary. Focus on prescribing antihypertensives and improving adherence. BP measured 2–6 weekly. Some outreach and lifestyle, dietary and self-care education.

No comparator.

43 Pasifika patients with type 2 diabetes, CKD (mostly stages 2 and 3) and hypertension. Mean age 53 years, 77 % male. 39 available for follow-up at ≥17 mths.

BP, no. antihypertensives, eGFR, ACR, HbA1c

Walker et al. (2013, 2014) [24, 25]

To test feasibility and effectiveness of a specialist renal nurse-led self-management intervention to slow progression of CKD.

1 year prospective uncontrolled cohort study, conducted 2011–2012.

NZ, rural area; two PHC practices in Hawke’s Bay.

Specialist nurse-led partnership with primary care clinicians. Focus on coaching to improve self-management. Individual educational and clinical care plans developed followed by 12 weeks of fortnightly self-management sessions, with monitoring to 12 months. Some outreach and free care, medications and transport.

No comparator.

52 patients (37 NZ Māori, 10 Cook Island Māori/Samoan and 5 NZ European) with type 2 diabetes, CKD

BP, no. antihypertensives, eGFR, ACR, HbA1c, self-management.

Hotu et al. (2010) [22]

To determine whether a nurse-led community-based CKD program involving a Māori or Pasifika health care assistant (HCA) (‘community care’; CC) is more clinically effective than ‘usual care’ (UC).

1 year RCT, conducted 2004–2006.

NZ, urban area; hospital clinics and PHC services in Auckland.

Nurse-led with focus on prescribing antihypertensives and improving adherence. Monthly outreach by HCA to monitor BP, promote adherence and provide free transport. Lifestyle, dietary and self-care education. Received routine care as necessary.

Lifestyle, dietary and self-care education. Usual care by GP and renal clinic.

65 Māori and Pasifika patients with type 2 diabetes, CKD (mostly stage 3) and hypertension (CC: n = 33; UC: n = 32). Mean age: CC: 63; UC: 60 years; % male: CC: 55 %; UC: 53 %. 58 available for follow-up at 12 months (CC: n = 30; UC: n = 28).

BP, no. antihypertensives, adherence, eGFR, ACR, HbA1c.

Shephard et al. (2006) [27]

To determine the clinical effectiveness (and acceptability- see below) of the Umoona Kidney Project, a PHC-based partnership between the local Aboriginal community controlled health service (ACCHS) and visiting specialists from Adelaide.

2 year prospective uncontrolled cohort study, conducted 1998–2000.

Australia, remote area; ACCHS in Coober Pedy.

Specialist-run with focus on prescribing antihypertensives, delivering ACR point of care tests (POCT) and ascertaining acceptability of project. Regular visits by nephrologists and 6-monthly monitoring of clinical parameters. Lifestyle and dietary education provided. Some outreach.

No comparator.

35 Aboriginal patients with hypertension and with or at risk of CKD (20 had albuminuria). Mean age 49 years, 54 % male. Patients followed for a mean of 15 months with none lost to follow-up.

BP, no. antihypertensives, adherence, eGFR, ACR, program acceptability.

Kondalsamy-Chennakesavan (2003) [26]

1) To determine whether improvements in BP and metabolic control were sustained following the handover of the visiting specialist-run MRTP to the local THB.

2) To compare the effectiveness of the pre-handover MRTP to the concurrently run THB-managed CCT.

2.5 and 5.5 year retrospective uncontrolled cohort study, comparing cohorts:

1) 66 month MRTP cohort (n = 101) comparing pre-handover (1995–1999) and post-handover (2000–2001).

2) 30 month MRTP (n = 149) and CCT (n = 89) cohorts comparing pre-handover MRTP to CCT (1997–2000).

Australia, remote area; ACCHS on the Tiwi Islands, 80 km north of Darwin.

The MRTP was a specialist-run project that ran alongside the local health care facilities. The focus was prescribing antihypertensives. Lifestyle and dietary education delivered and individual treatment plans developed. Systematic recalls and active follow-up to monitor BP.

CCT patients assigned a chronic disease care plan and were managed in routine PHC setting. No specific resources for renal patients, opportunistic follow-up, less systematic medical oversight.

238 Aboriginal patients with hypertension and/or CKD (mostly stages 1 and 2). Mean age: MRTP: 44; CCT: 42 years; % male: MRTP: 45 %; CCT: 44 %.

BP, HbA1c.