Improving Primary Care Treatment of CKD

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Improving Primary Care Treatment of CKD

• David Feldstein, MD
• Assistant Professor
• Department of Medicine
• UW SMPH

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Overview

• Background
• Needs Assessment
• CKD Management Tool
• Implementation
• Questions

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Chronic Kidney Disease

• Over 26 million cases in US and growing
• Prevalence 6.6 in adults in WI
• Consumes 6.5 of Medicare Budget
• Progression to ESRD can be prevented
• Patients currently not receiving care based on
  guidelines

Coresh J, Selvin E, Stevens LA, et al. JAMA.
2007298(17)2038-2047. Shankar A, Klein R, Klein
BE. Am J Epidemiol. 2006164(3)263-271. U.S.
Renal Data System. USRDS 2007 Annual Data Report.
MD 2007. KDOQI Clinical Practice Guidelines for
Chronic Kidney Disease Evaluation,
Classification, and Stratification
http//www.kidney.org/professionals/KDOQI/guidelin
es_ckd/toc.htm.
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Chronic Kidney Disease

• Stages
• Kidney damage with normal GFR (gt90 mL/min1.73
  m2)
• Kidney damage with mild decrease GFR (60-89)
• Moderate decrease GFR (30-59)
• Severe decrease GFR (15-29)
• Kidney Failure GFR lt15 or dialysis

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Chronic Kidney Disease

• Stages
• Kidney damage with normal GFR (gt90 mL/min1.73
  m2)
• Kidney damage with mild decrease GFR (60-89)
• Moderate decrease GFR (30-59)
• Severe decrease GFR (15-29)
• Kidney Failure GFR lt15 or dialysis

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Project

• Goal
• Develop electronic tool to help PCCs care for
  their patients with CKD
• Phases
• Needs assessment
• Development of CKD management tool
• Implementation of CKD management tool

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Needs Assessment

• 9 Phone interviews
• 5 Focus Groups
• 26 PCCs
• Questions
• Barriers and Facilitators to following CKD
  guidelines
• Barriers and Facilitators to CKD care
• Ideal CKD Management Resources
• Collaboration with subspecialists
• Thematic analysis

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CKD Management Barriers

• Clinician factors
• External
• Multiple demands on time
• Internal
• Lack of knowledge
• Patient factors
• Travel
• Non-adherence to treatment regimen
• Systems issues
• Access to information
• Lack of decision support systems

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CKD Management Tool

• Based on patient centered medical home
• Components
• CKD guideline checklist
• Based on NKFs KDOQI guidelines
• Individualized to patient
• Point of care educational modules
• Integrated into guideline checklist
• Electronic nephrology consultation
• Patient information resources
• Human factors input for usability

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Usability Testing

• If you build it will they come?
• Determine functions to test
• Develop scenarios
• Develop testing scripts
• 3 user types
• Evaluate plan
• Think aloud interviews thematic analysis
• Questionnaires

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Usability Testing Clip
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Implementation

• 20 PCCs and their clinic support staff
• 6 month trial using tool with stage 3 CKD
  patients
• Proof of concept
• Outcomes
• Changes in PCCs knowledge and self-efficacy
• Guideline usage
• Tool usage

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Acknowledgements

• Funding
• UW ICTR Type 2 Translational Pilot Grant
• UW Department of Medicine RD Grant
• Salary support ICTR Science Award 1KL2RR025012
• WREN
• Paul Smith, MD Mike Grasmick, PhD Katie
  Pronschinske
• WiNHR
• Howard Bailey, MD Laila Borokhim
• Industrial Engineering
• Doug Wiegmann, PhD Ashley Eggerman Renaldo
  Blocker

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KDOQI

• National Kidney Foundation Kidney Disease
  Outcomes Quality Initiative
• Evidence-based clinical practice guidelines for
  all stages of CKD
• Since 1997 developed 13 guidelines

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Focus Group Characteristics
Years in practice (M, SD, Range) 13.8 (8.9) (1-31)
Gender (Male, ) 13 (50)
Specialty FM (, ) 18 (69)
Practice location (, ) R 6 (24) S 7 (28) U 12 (48)
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CKD Management Barriers

• Patient factors
• Multiple physicians
• Travel
• Insurance Issues
• Not adherent to treatment regimen
• Lack of understanding of CKD

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CKD Management Barriers

• Systems issues
• Access to information
• Cant access information across systems
• No access to nephrologists
• Lack of decision support systems
• Not set up for CKD care
• Based on acute care model
• Unable to monitor f/u