The Effect of Applying a Chronic Care Model in Patients with Uncontrolled Hypertension and Type 2 Diabetes Mellitus on Delaying Chronic Kidney Disease Progression in Primary Care, Ubon Ratchathani Province

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waratip kankarn
Parkorn Homchampa


Background and Objective: Patients with uncontrolled hypertension (HT) and type 2 diabetes (T2D) increases risk for kidney disease. The purpose of this study was to study the effect of applying a chronic care model in patients with uncontrolled hypertension and diabetes mellitus on delaying chronic kidney disease progression in primary care.

Methods: This study was a randomized controlled trial. The sample consisted of patients with uncontrolled HT and T2D in primary care and selected by random. They were divided into experimental group and control group of 50 persons each. A chronic care model was applied for 8-month follow-up. The intervention included caring by multidisciplinary team, database for patient problem on case management, educating and building skills for self-management. Evaluated by using the self-management behavior scale to delay chronic kidney disease, clinical outcomes, and quality of life measure. Data were analyzed using descriptive statistics. chi square and


independent t-test.


Results:  At the end of the study, the experimental group had statistically significant higher score of self-management behavior, glomerular filtration rate and quality of life and had statistically significant lower blood pressure level and HbA1c than the control group (p<.05).

Conclusion: Chronic disease care model affects self-management behaviors, clinical outcomes, and quality of life of patients with uncontrolled HT and T2D improved.


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kankarn waratip, Homchampa P. The Effect of Applying a Chronic Care Model in Patients with Uncontrolled Hypertension and Type 2 Diabetes Mellitus on Delaying Chronic Kidney Disease Progression in Primary Care, Ubon Ratchathani Province. SRIMEDJ [Internet]. 2022 Jun. 24 [cited 2022 Oct. 5];37(3):261-7. Available from:
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