Improving Primary Care Treatment of CKD

1. Improving Primary Care Treatment of CKD David Feldstein, MD Assistant Professor Department of Medicine UW SMPH

2. Overview • Background • Needs Assessment • CKD Management Tool • Implementation • Questions

3. 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. 2007;298(17):2038-2047. Shankar A, Klein R, Klein BE. Am J Epidemiol. 2006;164(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/guidelines_ckd/toc.htm.

4. Chronic Kidney Disease • Stages • Kidney damage with normal GFR (>90 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 <15 or dialysis

5. Chronic Kidney Disease • Stages • Kidney damage with normal GFR (>90 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 <15 or dialysis

6. 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

7. 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

8. 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

9. CKD Management Tool • Based on patient centered medical home • Components • CKD guideline checklist • Based on NKF’s 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

14. 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

15. Usability Testing Clip

16. 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

17. Acknowledgements • Funding • UW ICTR Type 2 Translational Pilot Grant • UW Department of Medicine R&D 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

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

19. Focus Group Characteristics

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

21. CKD Management Barriers • Systems issues • Access to information • Can’t 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