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Improving CKD Diagnosis and Blood Pressure Control in Primary Care: A Tailored Multifaceted Quality Improvement
John Humphreys1, Gill Harvey2,3, Janet Hegarty4
1NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester (GM), Salford Royal NHS Foundation Trust, Salford, UK.
Insights
Quality improvement projects in primary care successfully identified many undiagnosed chronic kidney disease (CKD) patients and improved blood pressure (BP) control. However, achieving tight BP targets for proteinuric CKD patients remained a challenge.
Area of Science:
- Public Health
- Nephrology
- Health Services Research
Background:
- Chronic kidney disease (CKD) presents a significant global health challenge.
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Greater Manchester (NIHR CLAHRC GM) implemented four quality improvement (QI) projects across 49 primary care practices in England between 2009 and 2014.
- Key objectives included reducing undiagnosed CKD and optimizing blood pressure (BP) control in patients with CKD.
Purpose of the Study:
- To assess the effectiveness of QI interventions in increasing CKD detection rates within primary care settings.
- To evaluate the impact of these interventions on achieving target blood pressure control for CKD patients.
- To compare the performance of participating practices against national data.
Main Methods:
- Multifaceted intervention strategies were developed based on practice-specific support needs.
- Data collection involved facilitators at baseline and project conclusion, with ongoing self-reported data from practices.
- Four sequential projects (P1-P4) were conducted with varying numbers of participating practices.
Main Results:
- Three of the four projects exceeded the goal of halving undiagnosed CKD.
- The overall number of identified CKD cases increased by 27% (2,347 cases).
- The percentage of patients achieving target BP increased significantly, ranging from 74% to 83% across projects. However, achieving the tighter BP target (<130/80 mm Hg) for proteinuric CKD patients was less successful, with rates between 45% and 69%.
Conclusions:
- Primary care practices involved in the QI program successfully identified a substantial number of previously undiagnosed CKD patients.
- The interventions led to improved blood pressure control among CKD patients.
- Optimizing blood pressure to the stricter target for proteinuric CKD patients proved challenging, indicating an area for future focus.
Background:
Chronic kidney disease (CKD) is a worldwide public health issue. From 2009 to 2014, the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Greater Manchester (NIHR CLAHRC GM) in England ran 4 phased, 12-month quality improvement (QI) projects with 49 primary care practices in GM. Two measureable aims were set - halve undiagnosed CKD in participating practices using modelled estimates of prevalence; and optimise blood pressure (BP) control (<140/90 mm Hg in CKD patients without proteinuria; <130/80 mm Hg in CKD patients with proteinuria) for 75% of recorded cases of CKD. The 4 projects ran as follows: P1 = Project 1 with 19 practices (September 2009 to September 2010), P2 = Project 2 with 11 practices (March 2011 to March 2012), P3 = Project 3 with 12 practices (September 2012 to October 2013), and P4 = Project 4 with 7 practices (April 2013 to March 2014).
Methods:
Multifaceted intervention approaches were tailored based on a contextual analysis of practice support needs. Data were collected from practices by facilitators at baseline and again at project close, with self-reported data regularly requested from practices throughout the projects.
Results:
Halving undiagnosed CKD as per aim was exceeded in 3 of the 4 projects. The optimising BP aim was met in 2 projects. Total CKD cases after the programme increased by 2,347 (27%) from baseline to 10,968 in a total adult population (aged ≥18 years) of 231,568. The percentage of patients who managed to appropriate BP targets increased from 34 to 74% (P1), from 60 to 83% (P2), from 68 to 71% (P3), and from 63 to 76% (P4). In nonproteinuric CKD patients, 88, 90, 89, and 91%, respectively, achieved a target BP of <140/90 mm Hg. In proteinuric CKD patients, 69, 46, 48, and 45%, respectively, achieved a tighter target of <130/80 mm Hg. Analysis of national data over similar timeframes indicated that practices participating in the programme achieved higher CKD detection rates.
Conclusions:
Participating practices identified large numbers of "missing" CKD patients with comparator data showing they outperformed non-QI practices locally and nationally over similar timeframes. Improved BP control also occurred through this intervention, but overall achievement of the tighter BP target in proteinuric patients was notably less.
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