Cardio–renal–metabolic integrated education for patients with heart failure, type 2 diabetes and chronic kidney disease: a pragmatic controlled cohort study

Background Patients living with concomitant heart failure, type 2 diabetes and chronic kidney disease often receive fragmented counselling across specialty pathways, potentially limiting uptake and persistence of integrated cardio–renal–metabolic care. Purpose To evaluate whether a structured cardio–renal–metabolic integrated education pathway improves clinical and patient-centred outcomes compared with usual education in routine outpatient practice. Methods In a pragmatic, prospective controlled cohort study, adults with chronic heart failure, type 2 diabetes and chronic kidney disease stage 2–4 were enrolled and allocated by alternate-week clinic scheduling to cardio–renal–metabolic integrated education or usual education (450 vs 450). Follow-up was 12 months. The primary endpoint was time to first heart failure hospitalisation or all-cause death. Secondary outcomes included change in Kansas City Cardiomyopathy Questionnaire-12 score, glycated haemoglobin, estimated glomerular filtration rate slope, and safety events. Associations were estimated using adjusted time-to-event and longitudinal models. Results Twelve-month follow-up was completed in 862/900 (95.8%). Primary events occurred in 78/450 (17.3%) with integrated education versus 111/450 (24.7%) with usual education (adjusted hazard ratio 0.68, 95% confidence interval 0.51–0.90; p=0.006). Heart failure hospitalisation was reduced (63/450 [14.0%] vs 92/450 [20.4%]) with a smaller difference in all-cause death (20/450 [4.4%] vs 29/450 [6.4%]). Health status improved more with integrated education at 6 months (Kansas City Cardiomyopathy Questionnaire-12 change +11.1 vs +5.2; between-group difference +5.8 points, 95% confidence interval +3.9 to +7.6; p<0.001). Glycaemic control improved (glycated haemoglobin change −0.71% vs −0.19%; adjusted difference −0.52%, 95% confidence interval −0.70 to −0.34; p<0.001). Kidney function decline was slower (estimated glomerular filtration rate slope difference +1.6 mL/min/1.73 m²/year, 95% confidence interval +0.8 to +2.4; p<0.001). Genital mycotic infection was more frequent (12/450 [2.7%] vs 6/450 [1.3%]). Conclusion In routine outpatient care, a pragmatic cardio–renal–metabolic integrated education pathway was associated with fewer heart failure hospitalisations and improved patient-reported health status and cardio–renal–metabolic measures, with a small increase in genital mycotic infection. These data support systematic, cross-condition education as a scalable component of integrated care for this high-risk overlap population.