1- Qualitas Medical Practice Clayton, Department of General Practice, Monash University, Melbourne, Australia
2- Department of Nursing, Faculty of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran ,a_sanagu@yahoo.com
2- Department of Nursing, Faculty of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran ,
Keywords: Letter to the Editor
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Dear Editor
Chronic diseases account for 87% of deaths and 61% of the disease burden in Australia, with diabetes, chronic kidney disease (CKD), and hypertension among the most prevalent (1). These conditions demand ongoing management, integrating medical, lifestyle, and educational interventions. General practitioners (GPs) are central to Australia’s primary care system, acting as the first point of contact and care coordinators (2). However, effective management requires collaboration with nurses and other healthcare professionals. As a GP in Melbourne, the first author has witnessed the transformative impact of GP-nurse partnerships in managing chronic conditions. This article explores this collaboration, focusing on diabetes, CKD, and hypertension, and advocates for integrated care to enhance patient outcomes.
The role of the GP in chronic disease management
GPs manage a broad spectrum of conditions but are pivotal in chronic disease care, overseeing diagnosis, treatment, and long-term monitoring (3). In Australia, over 1.3 million people live with diabetes, 1 in 10 have CKD, and 1 in 3 adults have hypertension (1,3). These conditions require personalized plans tailored to patients’ medical histories, lifestyles, and social determinants. GPs leverage tools like Medicare’s Chronic Disease Management (CDM) plans to coordinate allied health services, ensuring holistic care (4). For example, a Melbourne patient with diabetes may receive a CDM plan involving a dietitian and nurse-led education, coordinated by the GP.
Diabetes management: a multidisciplinary approach
Diabetes management exemplifies the need for interdisciplinary care. GPs diagnose and initiate treatment, prescribing medications and setting glycemic targets (5). However, nurses are instrumental in-patient education, teaching insulin administration, blood glucose monitoring, and dietary adherence (6). In a case from the first author’s practice, a 55-year-old patient with type 2 diabetes struggled with insulin compliance. Nurse-led sessions on injection techniques and meal planning improved adherence, reducing the patient’s HbA1c from 8.5% to 7.0% over six months. Collaboration with dietitians and endocrinologists further enhances outcomes, preventing complications like neuropathy or cardiovascular disease (5).
Chronic kidney disease: Early intervention and teamwork
CKD often presents asymptomatically in early stages, necessitating proactive screening, especially for patients with diabetes or hypertension (3). GPs order tests (e.g., eGFR, albuminuria) and prescribe medications to manage risk factors (7). Renal nurses educate patients on dietary restrictions (e.g., low sodium) and fluid management, critical for slowing disease progression (7). In advanced CKD, nurses support dialysis patients, while nephrologists provide specialist input. For instance, a Melbourne patient with stage 3 CKD benefited from a nurse-led education program, maintaining stable kidney function through dietary changes and medication adherence.
Hypertension: Vigilance and patient empowerment
Hypertension, affecting 34% of Australian adults, is a leading risk factor for heart disease and stroke (1). GPs prescribe antihypertensives and monitor blood pressure, but patient adherence is challenging (8). Nurses teach home monitoring techniques and lifestyle modifications (e.g., exercise, reduced salt intake (8). In the first author’s practice, a nurse’s follow-up calls helped a hypertensive patient maintain adherence, lowering blood pressure from 150/90 mmHg to 130/80 mmHg over three months. This partnership ensures continuous support between GP visits.
The GP-nurse partnership: A cornerstone of care
Nurses complement GPs by providing ongoing support, education, and follow-up, particularly in community settings (9). In Australia, practice nurses and community health nurses alleviate GP workloads by managing routine tasks, such as wound care or health assessments (4). Their close patient relationships foster trust, improving adherence. For example, nurses often identify barriers (e.g., cultural beliefs, financial constraints) and tailor interventions, enhancing CDM plan effectiveness. This partnership is vital in Melbourne’s diverse population, where language and cultural barriers can complicate care.
Challenges in chronic disease management
Despite Australia’s robust healthcare system, challenges persist. Patient adherence remains a barrier, with 50% of chronic disease patients not following treatment plans (8). Rural and remote communities, including some Victorian regions, face limited access to specialists (1). Nurses address these issues through telehealth and community outreach, but workforce shortages strain capacity (4). Cultural factors in Melbourne’s multicultural population (e.g., South Asian patients’ dietary preferences) require tailored education, which GP-nurse teams can deliver effectively.
Conclusion
Managing chronic diseases in Australia demands a multidisciplinary approach, with GP-nurse collaboration at its core. Nurses’ roles in education, monitoring, and support complement GPs’ clinical expertise, ensuring comprehensive care for diabetes, CKD, and hypertension. To strengthen this model, policymakers should invest in nurse training, telehealth, and culturally sensitive programs. By fostering integrated care, Australia can reduce chronic disease burdens and improve patients’ quality of life. Future research should explore scalable GP-nurse models to address workforce and access challenges.
Acknowledgments
The authors thank Qualitas Medical Practice Clayton and Monash University.
Funding sources
No funds were obtained for this manuscript.
Conflicts of interest
The authors declare no conflicts of interest.
Author contributions
Both authors contributed to drafting, revising, and approving the manuscript, meeting the International Committee of Medical Journal Editors’ criteria for authorship.
Chronic diseases account for 87% of deaths and 61% of the disease burden in Australia, with diabetes, chronic kidney disease (CKD), and hypertension among the most prevalent (1). These conditions demand ongoing management, integrating medical, lifestyle, and educational interventions. General practitioners (GPs) are central to Australia’s primary care system, acting as the first point of contact and care coordinators (2). However, effective management requires collaboration with nurses and other healthcare professionals. As a GP in Melbourne, the first author has witnessed the transformative impact of GP-nurse partnerships in managing chronic conditions. This article explores this collaboration, focusing on diabetes, CKD, and hypertension, and advocates for integrated care to enhance patient outcomes.
The role of the GP in chronic disease management
GPs manage a broad spectrum of conditions but are pivotal in chronic disease care, overseeing diagnosis, treatment, and long-term monitoring (3). In Australia, over 1.3 million people live with diabetes, 1 in 10 have CKD, and 1 in 3 adults have hypertension (1,3). These conditions require personalized plans tailored to patients’ medical histories, lifestyles, and social determinants. GPs leverage tools like Medicare’s Chronic Disease Management (CDM) plans to coordinate allied health services, ensuring holistic care (4). For example, a Melbourne patient with diabetes may receive a CDM plan involving a dietitian and nurse-led education, coordinated by the GP.
Diabetes management: a multidisciplinary approach
Diabetes management exemplifies the need for interdisciplinary care. GPs diagnose and initiate treatment, prescribing medications and setting glycemic targets (5). However, nurses are instrumental in-patient education, teaching insulin administration, blood glucose monitoring, and dietary adherence (6). In a case from the first author’s practice, a 55-year-old patient with type 2 diabetes struggled with insulin compliance. Nurse-led sessions on injection techniques and meal planning improved adherence, reducing the patient’s HbA1c from 8.5% to 7.0% over six months. Collaboration with dietitians and endocrinologists further enhances outcomes, preventing complications like neuropathy or cardiovascular disease (5).
Chronic kidney disease: Early intervention and teamwork
CKD often presents asymptomatically in early stages, necessitating proactive screening, especially for patients with diabetes or hypertension (3). GPs order tests (e.g., eGFR, albuminuria) and prescribe medications to manage risk factors (7). Renal nurses educate patients on dietary restrictions (e.g., low sodium) and fluid management, critical for slowing disease progression (7). In advanced CKD, nurses support dialysis patients, while nephrologists provide specialist input. For instance, a Melbourne patient with stage 3 CKD benefited from a nurse-led education program, maintaining stable kidney function through dietary changes and medication adherence.
Hypertension: Vigilance and patient empowerment
Hypertension, affecting 34% of Australian adults, is a leading risk factor for heart disease and stroke (1). GPs prescribe antihypertensives and monitor blood pressure, but patient adherence is challenging (8). Nurses teach home monitoring techniques and lifestyle modifications (e.g., exercise, reduced salt intake (8). In the first author’s practice, a nurse’s follow-up calls helped a hypertensive patient maintain adherence, lowering blood pressure from 150/90 mmHg to 130/80 mmHg over three months. This partnership ensures continuous support between GP visits.
The GP-nurse partnership: A cornerstone of care
Nurses complement GPs by providing ongoing support, education, and follow-up, particularly in community settings (9). In Australia, practice nurses and community health nurses alleviate GP workloads by managing routine tasks, such as wound care or health assessments (4). Their close patient relationships foster trust, improving adherence. For example, nurses often identify barriers (e.g., cultural beliefs, financial constraints) and tailor interventions, enhancing CDM plan effectiveness. This partnership is vital in Melbourne’s diverse population, where language and cultural barriers can complicate care.
Challenges in chronic disease management
Despite Australia’s robust healthcare system, challenges persist. Patient adherence remains a barrier, with 50% of chronic disease patients not following treatment plans (8). Rural and remote communities, including some Victorian regions, face limited access to specialists (1). Nurses address these issues through telehealth and community outreach, but workforce shortages strain capacity (4). Cultural factors in Melbourne’s multicultural population (e.g., South Asian patients’ dietary preferences) require tailored education, which GP-nurse teams can deliver effectively.
Conclusion
Managing chronic diseases in Australia demands a multidisciplinary approach, with GP-nurse collaboration at its core. Nurses’ roles in education, monitoring, and support complement GPs’ clinical expertise, ensuring comprehensive care for diabetes, CKD, and hypertension. To strengthen this model, policymakers should invest in nurse training, telehealth, and culturally sensitive programs. By fostering integrated care, Australia can reduce chronic disease burdens and improve patients’ quality of life. Future research should explore scalable GP-nurse models to address workforce and access challenges.
Acknowledgments
The authors thank Qualitas Medical Practice Clayton and Monash University.
Funding sources
No funds were obtained for this manuscript.
Conflicts of interest
The authors declare no conflicts of interest.
Author contributions
Both authors contributed to drafting, revising, and approving the manuscript, meeting the International Committee of Medical Journal Editors’ criteria for authorship.
Type of study: Letter to Editor |
Subject:
Nursing
References
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