Improving Primary Care Improving Primary Care Treatment of CKDTreatment of CKD

David Feldstein, MDDavid Feldstein, MDAssistant ProfessorAssistant ProfessorDepartment of MedicineDepartment of MedicineUW SMPHUW SMPH

OverviewOverview

BackgroundBackground Needs Assessment Needs Assessment CKD Management ToolCKD Management Tool Implementation Implementation QuestionsQuestions

Chronic Kidney DiseaseChronic Kidney Disease

Over 26 million cases in US and growingOver 26 million cases in US and growing Prevalence 6.6% in adults in WIPrevalence 6.6% in adults in WI Consumes 6.5% of Medicare BudgetConsumes 6.5% of Medicare Budget Progression to ESRD can be preventedProgression to ESRD can be prevented Patients currently not receiving care based Patients currently not receiving care based

on guidelineson 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.

Chronic Kidney DiseaseChronic Kidney Disease

StagesStages1.1. Kidney damage with normal GFR (>90 Kidney damage with normal GFR (>90

mL/min1.73 mmL/min1.73 m2)2)

2.2. Kidney damage with mild decrease GFR Kidney damage with mild decrease GFR (60-89)(60-89)

3.3. Moderate decrease GFR (30-59)Moderate decrease GFR (30-59)

4.4. Severe decrease GFR (15-29)Severe decrease GFR (15-29)

5.5. Kidney Failure – GFR <15 or dialysisKidney Failure – GFR <15 or dialysis

Chronic Kidney DiseaseChronic Kidney Disease

StagesStages1.1. Kidney damage with normal GFR (>90 Kidney damage with normal GFR (>90

mL/min1.73 mmL/min1.73 m2)2)

2.2. Kidney damage with mild decrease GFR Kidney damage with mild decrease GFR (60-89)(60-89)

3.3. Moderate decrease GFR (30-59)Moderate decrease GFR (30-59)

4.4. Severe decrease GFR (15-29)Severe decrease GFR (15-29)

5.5. Kidney Failure – GFR <15 or dialysisKidney Failure – GFR <15 or dialysis

ProjectProject

GoalGoal– Develop electronic tool to help PCCs care Develop electronic tool to help PCCs care

for their patients with CKDfor their patients with CKD PhasesPhases

– Needs assessmentNeeds assessment– Development of CKD management toolDevelopment of CKD management tool– Implementation of CKD management toolImplementation of CKD management tool

Needs AssessmentNeeds Assessment

9 Phone interviews9 Phone interviews 5 Focus Groups5 Focus Groups

– 26 PCCs26 PCCs QuestionsQuestions

– Barriers and Facilitators to following CKD Barriers and Facilitators to following CKD guidelinesguidelines

– Barriers and Facilitators to CKD careBarriers and Facilitators to CKD care– Ideal CKD Management ResourcesIdeal CKD Management Resources– Collaboration with subspecialistsCollaboration with subspecialists

Thematic analysisThematic analysis

CKD Management BarriersCKD Management Barriers

Clinician factorsClinician factors– ExternalExternal

Multiple demands on timeMultiple demands on time– InternalInternal

Lack of knowledgeLack of knowledge Patient factorsPatient factors

– TravelTravel– Non-adherence to treatment regimenNon-adherence to treatment regimen

Systems issuesSystems issues– Access to informationAccess to information– Lack of decision support systemsLack of decision support systems

CKD Management ToolCKD Management Tool

Based on patient centered medical homeBased on patient centered medical home ComponentsComponents

– CKD guideline checklist CKD guideline checklist Based on NKF’s KDOQI guidelinesBased on NKF’s KDOQI guidelines Individualized to patientIndividualized to patient

– Point of care educational modulesPoint of care educational modules Integrated into guideline checklistIntegrated into guideline checklist

– Electronic nephrology consultationElectronic nephrology consultation– Patient information resourcesPatient information resources

Human factors input for usabilityHuman factors input for usability

Usability TestingUsability Testing

If you build it will they come?If you build it will they come? Determine functions to testDetermine functions to test

– Develop scenariosDevelop scenarios– Develop testing scriptsDevelop testing scripts– 3 user types3 user types

Evaluate planEvaluate plan– Think aloud interviews – thematic analysisThink aloud interviews – thematic analysis– QuestionnairesQuestionnaires

Usability Testing ClipUsability Testing Clip

ImplementationImplementation

20 PCCs and their clinic support staff20 PCCs and their clinic support staff 6 month trial using tool with stage 3 CKD 6 month trial using tool with stage 3 CKD

patientspatients Proof of conceptProof of concept OutcomesOutcomes

– Changes in PCCs knowledge and self-efficacyChanges in PCCs knowledge and self-efficacy– Guideline usageGuideline usage– Tool usageTool usage

AcknowledgementsAcknowledgements

FundingFunding– UW ICTR Type 2 Translational Pilot GrantUW ICTR Type 2 Translational Pilot Grant– UW Department of Medicine R&D GrantUW Department of Medicine R&D Grant– Salary support ICTR Science Award 1KL2RR025012 Salary support ICTR Science Award 1KL2RR025012

WRENWREN– Paul Smith, MD; Mike Grasmick, PhD; Katie PronschinskePaul Smith, MD; Mike Grasmick, PhD; Katie Pronschinske

WiNHRWiNHR– Howard Bailey, MD; Laila BorokhimHoward Bailey, MD; Laila Borokhim

Industrial EngineeringIndustrial Engineering– Doug Wiegmann, PhD; Ashley Eggerman; Renaldo Doug Wiegmann, PhD; Ashley Eggerman; Renaldo

BlockerBlocker

KDOQIKDOQI

National Kidney Foundation Kidney National Kidney Foundation Kidney Disease Outcomes Quality InitiativeDisease Outcomes Quality Initiative

Evidence-based clinical practice Evidence-based clinical practice guidelines for all stages of CKD guidelines for all stages of CKD

Since 1997 developed 13 guidelinesSince 1997 developed 13 guidelines

Focus Group CharacteristicsFocus Group Characteristics

Years in practice (M, SD, Range)Years in practice (M, SD, Range) 13.8 (8.9) 13.8 (8.9)

(1-31)(1-31)

Gender (Male, %)Gender (Male, %) 13 (50%)13 (50%)

Specialty FM (#, %)Specialty FM (#, %) 18 (69%)18 (69%)

Practice location (#, %)Practice location (#, %) R – 6 (24%)R – 6 (24%)

S – 7 (28%)S – 7 (28%)

U – 12 (48%)U – 12 (48%)

CKD Management BarriersCKD Management Barriers

Patient factorsPatient factors– Multiple physiciansMultiple physicians– TravelTravel– Insurance IssuesInsurance Issues– Not adherent to treatment regimenNot adherent to treatment regimen

Lack of understanding of CKDLack of understanding of CKD

CKD Management BarriersCKD Management Barriers

Systems issuesSystems issues– Access to informationAccess to information

Can’t access information across systemsCan’t access information across systems

– No access to nephrologistsNo access to nephrologists– Lack of decision support systemsLack of decision support systems– Not set up for CKD careNot set up for CKD care

Based on acute care modelBased on acute care model Unable to monitor f/uUnable to monitor f/u