Improving the identification and management of chronic kidney disease in primary care: Lessons from a staged improvement collaborative

Abstract

Quality problem: Undiagnosed chronic kidney disease (CKD) contributes to a high cost and care burden in secondary care. Uptake of evidence-based guidelines in primary care is inconsistent, resulting in variation in the detection and management of CKD. Initial assessment: Routinely collected general practice data in one UK region suggested a CKD prevalence of 4.1%, compared with an estimated national prevalence of 8.5%. Of patients on CKD registers, ~30% were estimated to have suboptimal management according to Public Health Observatory analyses. Choice of solution: An evidence-based framework for implementation was developed. This informed the design of an improvement collaborative to work with a sample of 30 general practices. Implementation: A two-phase collaborativewas implemented between September 2009 and March 2012. Key elements of the intervention included learning events, improvement targets, Plan-Do- Study-Act cycles, benchmarking of audit data, facilitator support and staff time reimbursement. Evaluation: Outcomes were evaluated against two indicators: number of patients with CKD on practice registers; percentage of patients achieving evidence-based blood pressure (BP) targets, as amarker for CKD care. In Phase 1, recorded prevalence of CKD in collaborative practices increased ~2-fold more than that in comparator local practices; in Phase 2, this increased to 4-fold, indicating improved case identification. Management of BP according to guideline recommendations also improved. Lessons learned: An improvement collaborative with tailored facilitation support appears to promote the uptake of evidence-based guidance on the identification and management of CKD in primary care. A controlled evaluation study is needed to rigorously evaluate the impact of this promising improvement intervention.