Title: Improving Primary Care Treatment of CKD
1Improving Primary Care Treatment of CKD
- David Feldstein, MD
- Assistant Professor
- Department of Medicine
- UW SMPH
2Overview
- Background
- Needs Assessment
- CKD Management Tool
- Implementation
- Questions
3Chronic 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.
4Chronic 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
5Chronic 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
6Project
- 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
7Needs 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
8CKD 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
9CKD 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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14Usability 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
15Usability Testing Clip
16Implementation
- 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
17Acknowledgements
- 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
18KDOQI
- National Kidney Foundation Kidney Disease
Outcomes Quality Initiative - Evidence-based clinical practice guidelines for
all stages of CKD - Since 1997 developed 13 guidelines
19Focus 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)
20CKD Management Barriers
- Patient factors
- Multiple physicians
- Travel
- Insurance Issues
- Not adherent to treatment regimen
- Lack of understanding of CKD
21CKD 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