Improving Chronic Kidney Disease Care in Primary Care Practices: An Upstate New York Practice-based Research Network (UNYNET) Study

Abstract

Background: With the prevalence of chronic kidney disease (CKD) in the United States rising from 10% to 13%, implementation of the evidence-based Kidney Disease Outcomes Quality Initiative guidelines, which were developed for the delay of progression of CKD, is of increasing importance in primary care offices. Previous studies have shown limited knowledge and uptake of Kidney Disease Outcomes Quality Initiative guidelines by primary care physicians. CKD and its complications are still largely under-diagnosed and under-treated. A multifaceted quality improvement study was undertaken to test if these guidelines could be implemented to improve CKD care in underserved practices.Methods: Using a combination of practice enhancement assistants, computer decision-making support, and academic detailing, we sought to increase physician awareness and care of CKD in 2 inner-city practices. Using these 3 modalities, a rapid-cycle quality improvement process was implemented.Results: One hundred eighty-one patients met the inclusion criteria of having a glomerular filtration rate <60. This represented a 100% sample of patients with CKD at baseline. Recognition of CKD improved significantly from 30 (21%) to 114 (79%) (P < .001). Diagnosis of anemia also increased significantly from 26 (33%) to 53 (67%) (P < .001). Angiotensin-converting enzyme inhibitor and aspirin use did not change significantly (P ‫؍‬ .31 and P ‫؍‬ .233, respectively). Changes in medications that did show significance were metformin use, which decreased 50% from 12 to 6 patients (P < .001), and nonsteroidal anti-inflammatory drug use, which decreased 41% from 23 to 14 patients (P < .001). Mean glomerular riltration rate increased significantly from 45.75 to 47.34 (P < .001).Discussion: Recognition and treatment of CKD and its complications can be markedly improved in primary care offices using a combination of practice enhancement assistants, computer decision-making support, and academic detailing. A significant rise in glomerular riltration rate, although small, was a surprising and encouraging result. Larger studies in a more geographically spread region are needed to confirm these preliminary results.

Implementation of a CKD Checklist for Primary Care Providers

“…Southern California Kaiser Permanente developed an initiative to identify patients with CKD on the basis of KDOQI guidelines and alert PCPs, and found that nephrology visits increased modestly from 20% to 24% (42). The Upstate New York Practice-Based Research Network study examined computer decision-making support based on guidelines in primary care clinics and found that the recognition of CKD and diagnosis of anemia improved substantially (43). These two studies focused on improving recognition of CKD as opposed to addressing comprehensive CKD guidelines.…”

No Longer Simply a Practice-based Research Network (PBRN): Health Improvement Networks

“…[9][10][11][12][13][14] Other PBRNs have adopted this focus on quality improvement as well. 15 Elsewhere in the Journal, we present evidence suggesting that participation in PBRN studies can lead to long-term change in clinical practice behavior. 16 Although this work is preliminary, it raises intriguing questions about the potential for networks to create lasting change in the primary care clinical encounter, when they focus their research on topics of interest to the clinician and when they provide useful and feasible clinical tools to the clinician.…”

Primary Care Management of Chronic Kidney Disease

“…12 We defined PCP recognition as documentation of a CKD diagnosis on the electronic problem list. [21][22][23] We defined the degree of nephrology involvement as (1) active co-management (nephrology visit within the prior 12 months), (2) past nephrology care (nephrology visit more than 12 months prior), or (3) no prior nephrology visits.…”