Assistant Professor Loh Ping Tyug
Co-Director, NEMO Programme
Senior Consultant
Division of Nephrology
University Medicine Cluster
National University Health System
Professor A Vathsala
Director, NEMO Programme
Senior Consultant
Division of Nephrology
University Medicine Cluster
National University Health System
Dr Lim Chee Kong
Co-Director, NEMO Programme
Family Physician & Consultant
Deputy Director, Clinical Services
National Healthcare Group Polyclinics
Ms Ong Shih Hui, Samantha
Programme Manager, NEMO Programme
Division of Nephrology
University Medicine Cluster
National University Health System
Diabetic Kidney Disease (DKD) is the leading complication that arises from poorly controlled diabetes. Nearly one in two diabetic patients evaluated between 2006 and 2009 at the National Healthcare Group Polyclinics (NHGP) had DKD. More worryingly, DKD is the leading cause of end stage kidney failure in Singapore. Nevertheless, optimal control of diabetes, early detection and management of its complications, including DKD, at primary care can avert the progression of the disease. Previous studies have also shown that the progression of DKD can be slowed down by keeping blood pressure under control and treating albuminuria, which is elevated levels of protein in the urine, with full or maximally tolerated doses of medications such as Angiotensin Converting Enzyme Inhibitors (ACEi) or Angiotensin II Receptor Blockers (ARB).
Recognizing this, a team from the National University Health System (NUHS) and NHGP, the primary healthcare arm of the National Healthcare Group, set up a kidney disease work group in 2010 to devise a strategy to manage albuminuria and blood pressure in DKD patients and to reduce the rate of progression of DKD at primary care. With funding from the Ministry of Health, a strategy for Nephrology Evaluation, Management and Optimization (NEMO) of DKD among patients on follow-up at the NHGP was implemented in 2011.
In preparation for NEMO, the National University Hospital (NUH), the tertiary care hospital of NUHS, and NHGP leveraged on good teamwork and identified key obstacles to optimizing drug doses in patients, established drug protocols to achieve target blood pressure, to reduce albuminuria and to deal with complications of treatment, and developed tailored solutions for individual polyclinics. In addition, the team shared valuable knowledge on kidney disease management with stakeholders by holding talks on DKD and its management for physicians at all nine polyclinics under NHGP. Through its efforts, selected polyclinic doctors became designated renal champions in each polyclinic to help drive NEMO.
10 Allied Health personnel, known as NEMO Coordinators, were also trained and a Coordinator deployed to each of the polyclinics under NHGP to help coordinate care. With the help of Information Technology, the NEMO Coordinators screened and identified patients with early DKD for recruitment into the NEMO programme; counseled the recruited patients on DKD, its risks and the need for the treatment to prevent progression; assisted doctors at NHGP in coordinating the drug optimization and tracked the results and outcomes.
As a result of these efforts, 54% of the 9,015 patients who had enrolled since 2011, have undergone drug optimization. Of these, 20% saw normalization of urine albumin levels while 10% saw an improvement and went from having late to early stage DKD.
Overall, the NEMO programme has demonstrated that medications such as ACEi or ARBs can be used safely in primary care to delay progression of DKD and significant proportions of DKD patients may be averted from the ravages of kidney failure requiring dialysis or kidney transplantation. More importantly, the programme has demonstrated that by focusing on goals and by developing a management plan, a team comprised of doctors and coordinators can implement changes in patient care to improve outcomes.
Following this success, plans are underway to roll out NEMO beyond polyclinics under NHGP to those which are under the SingHealth Group. In early 2016, NEMO was rolled out to Queenstown Polyclinic under the SingHealth Group. The team also hopes to expand the strategy to other healthcare institutions subsequently.
For their outstanding contributions and achievements in developing a collaborative approach to providing optimal care for Diabetic Kidney Disease patients at the primary care level and finding ways to slow down the progression of the disease to end stage kidney failure, the team from NUHS and NHGP is awarded the National Clinical Excellence Team Award 2016.