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Improving the identification and management of chronic kidney disease in primary care: lessons from a staged
Gill Harvey1, Kathryn Oliver2, John Humphreys3
1Manchester Business School, University of Manchester, Booth Street West, Manchester M15 6PB, UK School of Nursing, University of Adelaide, Eleanor Harrald Building, Frome Road, Adelaide SA5005, Australia.
Insights
An improvement collaborative increased chronic kidney disease (CKD) identification and improved blood pressure management in primary care. Further controlled studies are needed to confirm these promising findings for CKD care.
Area of Science:
- Primary care research
- Health services research
- Quality improvement science
Background:
- Undiagnosed chronic kidney disease (CKD) presents a significant cost and care burden in secondary care settings.
- Inconsistent uptake of evidence-based guidelines in primary care leads to variability in CKD detection and management.
- Current CKD prevalence in one UK region was found to be 4.1%, substantially lower than the national estimate of 8.5%, with approximately 30% of registered CKD patients receiving suboptimal care.
Purpose of the Study:
- To assess the effectiveness of an improvement collaborative in enhancing the identification and management of chronic kidney disease (CKD) within primary care.
- To evaluate the impact of an evidence-based framework and collaborative model on CKD case ascertainment and adherence to blood pressure targets.
Main Methods:
- Development of an evidence-based implementation framework to guide the intervention.
- Implementation of a two-phase improvement collaborative involving 30 general practices from September 2009 to March 2012.
- Intervention elements included learning events, specific improvement targets, Plan-Do-Study-Act cycles, benchmarking, facilitator support, and staff time reimbursement.
Main Results:
- The improvement collaborative led to a significant increase in recorded CKD prevalence, approximately doubling it in Phase 1 and quadrupling it in Phase 2 compared to comparator practices, indicating enhanced case identification.
- Management of blood pressure according to evidence-based guideline recommendations also showed improvement within the participating practices.
- The intervention demonstrated a positive impact on both the detection and management aspects of CKD care.
Conclusions:
- An improvement collaborative, supported by tailored facilitation, can effectively promote the adoption of evidence-based guidelines for CKD identification and management in primary care.
- The intervention shows promise in addressing the quality problem of undiagnosed and suboptimally managed CKD.
- A controlled evaluation study is recommended to rigorously assess the impact of this improvement intervention.
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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