Management of patients with chronic kidney disease at Kaiser Permanente

Area of Science:

• Nephrology
• Healthcare Management
• Public Health

Background:

• Serum creatinine testing is a routine diagnostic procedure.
• Chronic Kidney Disease (CKD) management requires timely identification and intervention.
• Integrated healthcare systems offer opportunities for streamlined patient care pathways.

Purpose of the Study:

• To describe a system for automated GFR reporting and CKD staging.
• To outline a care model involving PCPs and nephrologists for CKD patients.
• To promote patient engagement in self-care for chronic kidney disease.

Main Methods:

• Automated reporting of Glomerular Filtration Rate (GFR) from serum creatinine measurements.
• Classification of patients into five stages of CKD.
• Defined referral criteria for nephrology consultation based on CKD stage and risk factors.
• Provision of educational resources and clinical guidelines to primary care physicians (PCPs).

Main Results:

• All patients with serum creatinine tests have their GFR automatically reported.
• Reduced GFR triggers CKD staging and facilitates care management.
• PCPs are engaged in managing early-stage CKD (stages 1-3).
• Nephrology referrals are implemented for high-risk stage 3 and all stage 4-5 CKD patients.

Conclusions:

• Automated GFR reporting enhances CKD identification and management.
• A structured approach involving PCPs and specialists improves care coordination for CKD.
• Patient education and participation are integral to managing chronic kidney disease effectively.