Improving the Identification and Management of Chronic Kidney Disease in Primary Care: Lessons From a Staged Improvement Collaborative

Gill Harvey; Kathryn Oliver; John Humphreys; Katy Rothwell; Janet Hegarty

Int J Qual Health Care. 2015;27(1):10-16.

Abstract and Introduction

Abstract

Quality problem Undiagnosed chronic kidney disease (CKD) contributes to a high cost and care burden in secondary care. Uptake of evidence-based guidelines in primary care is inconsistent, resulting in variation in the detection and management of CKD.

Initial assessment Routinely collected general practice data in one UK region suggested a CKD prevalence of 4.1%, compared with an estimated national prevalence of 8.5%. Of patients on CKD registers, ~30% were estimated to have suboptimal management according to Public Health Observatory analyses.

Choice of solution An evidence-based framework for implementation was developed. This informed the design of an improvement collaborative to work with a sample of 30 general practices.

Implementation A two-phase collaborative was implemented between September 2009 and March 2012. Key elements of the intervention included learning events, improvement targets, Plan-Do-Study-Act cycles, benchmarking of audit data, facilitator support and staff time reimbursement.

Evaluation Outcomes were evaluated against two indicators: number of patients with CKD on practice registers; percentage of patients achieving evidence-based blood pressure (BP) targets, as a marker for CKD care. In Phase 1, recorded prevalence of CKD in collaborative practices increased ~2-fold more than that in comparator local practices; in Phase 2, this increased to 4-fold, indicating improved case identification. Management of BP according to guideline recommendations also improved.

Lessons learned An improvement collaborative with tailored facilitation support appears to promote the uptake of evidence-based guidance on the identification and management of CKD in primary care. A controlled evaluation study is needed to rigorously evaluate the impact of this promising improvement intervention.

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Table 1. Classification of stages for CKD [1]
Stage of CKD	Description	Glomerular filtration rate (GFR)
1.	Kidney damage with normal or raised GRF	>90
2.	Kidney damage with mildly reduced GFR	60–89
3.	Moderately reduced GRF	30–59
4.	Severe reduction in GFR	15–29
5.	Kidney failure	<15

Table 2. Comparison of diagnosed CKD patients within one geographical region treated to national pay-for-performance (QOF) blood pressure targets by involvement in the improvement collaborative
Time period	% achievement of target BP in CKD collaborative practices	% achievement of target BP in non-CKD collaborative practices
2010–11	83	74
2011–12	82	73
2012–13	82	75

The difference between the QOF and NICE blood pressure targets was that testing for proteinuria was a pre-requisite of meeting the NICE target. This accounts for the lower baseline figures reported in the collaborative sites when comparing against NICE targets.

Box 1 Guideline recommendations for the identification and management of adult patients with CKD in primary care
In primary care in the UK, NICE CKD guidelines (2008) recommend that: People should be offered testing for CKD whether they have risk factors such as diabetes, hypertension, cardiovascular disease, family history of Stage 5 CKD or hereditary kidney disease or whether there is opportunistic detection of haematuria or proteinuria; Testing should include obtaining a minimum of three estimated glomerular filtration rates (eGFR) over a period of <90 days; Identified CKD patients coded at Stage 3A/B should be monitored every 6 months in general practice by eGFR testing. This is adjusted to every 3 months or every 6 weeks, if the patient is coded at Stages 4 or 5, respectively; For CKD patients without proteinuria, BP should be managed within the range <140/90; for patients with proteinuria, the range should be <130/80; Stable Stage 4 cases should ideally be managed within primary care, whereas more complicated cases and those at Stage 5 should be monitored by renal specialists; Proteinuria status and BP should be monitored for all CKD patients at least annually.
Source: NICE (2008) [6].

Box 2 Description of the improvement collaborative approach [14]
Based on the Institute for Healthcare Improvement breakthrough series approach; Brings together subject matter experts and practitioners to test and implement changes in care within a structured, experiential learning framework; Teams commit to working on a common topic over a period of ~12 months, with shared goals and an agreed measurement strategy; Teams alternate between shared learning events (to exchange ideas and encourage learning across teams) and action periods (using the Model for Improvement to test small ideas in the workplace); An agreed change package is used, with regular monitoring and feedback of progress against targets.

Box 3 Qualitative experiences of participants in the Phase 2 collaborative
Enablers of improvement: 'We had the long first session, which was great, but for the other people (the facilitator) did a half an hour with them to get them up to speed with what was going on…. We could have probably done this ourselves, but having someone come in from outside made it clearer to them that it wasn't just something that we decided to do on a whim, but that it was actually part of a bigger project we were involved in'. (Clinical coordinator) '(The support has been) excellent. I've really enjoyed it. I have found the support excellent from both of them. I am the only practice nurse in the practice, so it's been nice that (the clinical facilitator) has come in from a practice nurse point of view and she's been a fantastic support. Really, in a way, it's a bit like clinical supervision as well because we've discussed other things'. (Practice Nurse) 'I feel that with the support I've had, I am more confident talking to patients. When we sent the initial letters out some patients were coming in and saying I haven't got kidney disease. It hadn't been discussed with them previously. So that needed a little bit of work around and explaining about what chronic means because a lot of people thought it meant severe, whereas to us it's chronic, long term'. (Practice Nurse) 'There's a kind of structure to it and I think it needs that really. You need to have certainty to get the building blocks in place. But, I think that once you've got those building blocks in place and because of the knowledge that you get over time going through the year, when you come to sort of taking things on yourself, it's all in place for you to continue'. (GP) Barriers to improvement: 'It was the initial education and time needed to get the register validated and then put a protocol together (that took the time)…. But that initial work is done now, it wouldn't need to be repeated again and it's just a routine thing that everyone does now, so it's paid off in the end'. (Practice Nurse) 'I tried to coordinate (the project) really, blocking out time so that people had time to devote to it. There was a bit of a battle over the time at first and management just thought that it could just happen in clinic time and we have had to fight for that'. (Practice Administrator) 'If I was ever involved in a project like this again, it's one of the things that I would really stick my neck out on is that the rest of the practice wasn't involved early enough. If we'd had more involvement from the others earlier it would have saved us a lot of work because a lot of the results and things that were coming in that we'd instigated weren't necessarily coming through to us so again, they were being filed as normal or weren't being coded. It was then just double work'. (Practice Nurse) 'It's no use (the practice nurse) and I going through all these codes if the rest of the practice (team) aren't going to do it. For me that was the most importa…nt thing. It can't just be two people doing it. It has to be the whole practice staff…. Every single person that sees patients needs to have some grasp of what's going on, even to the point of the admin staff because they are sending out letters for annual reviews'. (GP)