Problem A significant proportion of patients with diabetes mellitus do not get the benefit of treatment that would reduce their risk of progressive kidney disease and reach a nephrologist once significant loss of kidney function has already occurred.

Design Systematic disease management of patients with diabetes and kidney disease.

Setting Diverse population (approximately 800 000) in and around Birmingham, West Midlands, UK.

Key measures for improvement Number of outpatient appointments, estimated glomerular filtration rate (eGFR) at first contact with nephrologist, number of patients starting kidney replacement therapy (KRT) and mode of KRT at start.

Strategy for change Identification of patients with low or deteriorating trend in eGFR from weekly database review, specialist diabetes–kidney clinic, self-management of blood pressure and transfer to multidisciplinary clinic >12 months before end-stage kidney disease.

Effects of change New patients increased from 62 in 2003 to 132 in 2010; follow-ups fell from 251 to 174. Median eGFR at first clinic visit increased from 28.8 ml/min/1.73 m² (range 6.1–67.0) in 2000/2001 to 35.0 (11.1–147.5) in 2010 (p<0.006). In 2010, the number of patients starting KRT fell 30% below the projected activity using 1993–2003 data as baseline (p<0.003). The proportion starting KRT with either a kidney transplant, peritoneal dialysis or haemodialysis via an arteriovenous fistula increased from 26% in 2000 to 55% in 2010.

Lessons learned Systematic disease management across a large population significantly improves patient outcomes, increases the productivity of a specialist service and could reduce healthcare costs compared with the current model of care.