Chronic Kidney Disease (CKD) – a new challenge for primary care QUICKI – Q uality I mprovement in C hronic K idney

1. Chronic Kidney Disease (CKD) – a new challenge for primary careQUICKI – Quality Improvement in Chronic Kidney dIsease Simon de Lusignan St. George’s – University of London Kevin Harris University Hospitals of Leicester Michael Nation Kidney Research UK On behalf of the study team….

2. About Chronic Kidney Disease (CKD) • Prevalence 10% + Scope to improve quality [i] • Even minor renal impairment a risk factor for all cause mortality and cardiovascular disease [i] • estimated Glomerular Filtration Rate (eGFR) - better measure of renal function than creatinine + allows identification of people with CKD • Strong evidence strict BP control reduces rate of progression; • Target is130/80[i] • [i] de Lusignan S, Chan T, Stevens P, O'Donoghue D, Hague N, Dzregah B, Van Vlymen J, Walker M, Hilton S. Identifying patients with chronic kidney disease from general practice computer records. Fam Pract. 2005 Jun;22(3):234-41 • i] Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N.Engl.J Med 2004;351:1296-305. • [i] Wenzel RR. Renal protection in hypertensive patients: selection of antihypertensive therapy. Drugs. 2005;65 Suppl 2:29-39.

3. Quality improvement strategies in CKD • We have identified three types of quality improvement strategies for CKD: • Patient empowerment, based on the learning from the ABLE study • Audit based education based on the Primary Care Data Quality (PCDQ) renal programme • GP with special interest – referral or case finding of people with CKD • However, our first step will be to conduct a “Diagnostic Analysis”to assess the barriers to quality improvement in CKD in primary care (and if our QI interventions are likely to overcome them

4. Routinely collected GP data to monitor effectiveness of QI interventions • UK general practice is almost universally computerised • Lab results are passed automatically into the GP computer system • Data quality is good since QOF - financially incentivised quality targets measured using computer data • 75% of people with CKD have cardiovascular co-morbidities • Systolic BP will be the primary study end point • We will also measure: • Diabetes + CV co-morbidity, proteinuria, anaemia, referral rates, GP knowledge + confidence, and patient empowerment

5. T = 2yrs T = 1yr T = 0 Usual practice Patient empowerment Audit-based education Tier-2 CKD clinic Combined or continued interventions Combined or continued interventions Combined or continued interventions Combined or continued interventions Study overview: Protocol, ethics - permissions + Diagnostic analysis Process Evaluation – What happened, Intervention Exposure Write up + dissemination

6. Community Team 1: Lead GP + Renal Specialist mentor 8 planned clusters Incl PCT support Community Team 5: Lead GP + Renal Specialist mentor 8 planned clusters Incl PCT support Community Team 2: Lead GP + Renal Specialist mentor 8 planned clusters Incl PCT support Community Team 6: Lead GP + Renal Specialist mentor 8 planned clusters Incl PCT support Community Team 3: Lead GP + Renal Specialist mentor 8 planned clusters Incl PCT support Community Team 7: Lead GP + Renal Specialist mentor 8 planned clusters Incl PCT support Community Team 8: Lead GP + Renal Specialist mentor 8 planned clusters Incl PCT support Community Team 4: Lead GP + Renal Specialist mentor 8 planned clusters Incl PCT support Project management North South Project Implementation Team: Project Manager, Project co-ordinator, Data Manager and Data Co-ordinator Operational Management Group Clinical Leads, Management, Statistics, Advisory Board Chair Advisory & Dissemination Board Mentorship, Expert advice, Dissemination

7. Summary • Opportunity to compare quality improvement interventions • Help decide what is likely to improve quality most in practice • Look to improve “QOF” quality targets in future years • Excellent team work - effective partnership working • Including…. • St. George’s & SW Thames Renal Unit – Kidney Research UK – Leicester University Hospitals – PCTs and PBC clusters • Patients - Specialists – Generalists – Researchers – Commissioners

8. Thanksforlistening… • Simon de Lusignan • St. George’s – University of London • Kevin Harris • University Hospitals of Leicester • Michael Nation • Kidney Research UK • Key contacts…. • Bernie Stribling • Project Manager – Kidney Research UK • Nicki Thomas • Project Coordinator • On behalf of the study team….