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Kaiser Permanente: Hawaii Nephrology EBM Guideline Project 2005

Mission: Help advance evidence- and value-based medicine in an organization that has already proved a demonstrated commitment to evidence- and value-based care by dedicating resources to EBM training and support and that now seeks to progress to an even higher level in skill, depth, application and cultural transformation.

Concept: Identify a clinical group that has ideas for a successful evidence-based clinical improvement project and provide them with training and support. Learnings will be applicable to other projects, plus team members will be able to facilitate similar projects with other clinical groups within the care system.

Delfini Role: Provide training, facilitation and support to the team to conduct the project and to effect both clinical and evidence-based process change.

This evidence-based clinical practice improvement won the Kaiser Permanente 2006 Regional Innovation Award. This award is given for innovations in providing better patient care and or improved service.

Chronic Kidney Disease Guideline materials posted with permission from Kaiser Permanente Hawaii:

• Algorithm (special recognition to Joyce Gilbert, MPH, Evidence Consultant)
• Web Documentation
• Patient Information

Note: Evidence-based process used with reliance upon some secondary sources which were not critically appraised. See Web Documentation.

Important Note: On March 9, 2007 the FDA released a Public Health Advisory stating that, “A higher chance of death was reported and an increased number of blood clots, strokes, heart failure, and heart attacks was reported in patients with chronic kidney failure when ESAs were given to maintain hemoglobin levels of more than 12 g/dL.”

This advisory was also driven by many studies of cancer patients.

Erythropoiesis stimulating agents now carry this warning in their labels: “WARNINGS: Increased Mortality, Serious Cardiovascular and Thromboembolic Events Aranesp and other erythropoiesis-stimulating agents (ESAs) increased the risk for death and for serious cardiovascular events in controlled clinical trials when administered to target a hemoglobin of greater than 12 g/dL. There was an increased risk of serious arterial and venous thromboembolic events, including myocardial infarction, stroke, congestive heart failure, and hemodialysis graft occlusion. A rate of hèmoglobin rise of greater than 1 g/dL over 2 weeks may also contribute to these risks. To reduce cardiovascular risks, use the lowest dose of Aranesp that will gradually increase the hemoglobin concentration to a level sufficient to avoid the need for RBC transfusion. The hemoglobin concentration should not exceed 12 g/dL, the rate of hemoglobin increase should not exceed 1 g/dL in any 2-week period (see DOSAGE AND ADMINISTRATION)."

The materials available above have not yet been updated with this important information.

We were pleased to learn that our Kaiser Permanente Chronic Kidney Disease Guideline Team in Hawaii is seeing improved referral rates and clinical outcomes in patients with CKD. Key elements in the success include:

• A great team with great leaders
• A 1 pager with actionable information for clinician
• An electronic system that allows:
  • Nephrologists to quickly access medical records to analyze cases and create messages with suggestions for management to primary care physicians
• Outcomes from 6/5/05 to 10/30/06 include:
• Identification and greater attention to adults not yet on dialysis with a GFR under 60 ml/min
• Protein quantification by Upr/cr, microalbum/cr or 24 hour urine protein
  • 2005: 26.8 %
  • 2006: 37.2 %

Leaders from Medical Education and the EBM Working Group solicited interest among clinical staff and identified Nephrology as the pilot group. With Delfini's guidance, a multidisciplinary team was formed including nephrologists, nutrition, primary care, pharmacy and an EBM working group leader.

Phase III: Develop Project Outline

Read Reference Letter
from Renal Nutritionist,
Carrie Mukaida, MS, RD, CSR

Existing guidelines were reviewed for applicability, validity, appropriateness and currency. Focus statements, "straw" algorithm and key statements were drafted to help frame project scope.

Team members received training in effective searching of the medical literature, critical appraisal for validity and usefulness of primary and secondary sources, measures of outcomes, "intention-to-treat analysis project rescue" and evidence grading.

The training was hugely successful and was met with great enthusiasm by both members and leadership. Members reported feeling "psyched" and motivated. Leadership expressed gratitude that Delfini was helping the group to create a workable "map" for both real life problem solving and providing "on-the-job" EBM training.

Potentially useful evidence was obtained through a systematic search and appraisal process. Following evidence evaluation, the best available valid and useful evidence was identified and prepared for evidence synthesis.

In an on-site working session, and following the working session, team members reviewed, discussed, made decisions about and created —

• Draft Evidence Synthesis (Delfini)
• Secondary Studies: Cochrane & Clinical Evidence Review (Team)
• Primary Studies: Included and Excluded Studies Summary Tables (Team)
• Listing of K/DOQI Guidelines ("seed" guideline) Statements Voted on by Team Members (Team)
• Draft "Straw" Clinical Recommendations (Delfini)
  Draft Evidence Tagging Statements (Delfini)
  Draft Algorithm (Team modified algorithm created by Delfini

Team members graded the evidence and converted evidence synthesis statements into clinical recommendations that will serve as the basis for the guideline.

Formal impact assessment was not done.

The following implementation strategies have been used and additional strategies will be added as necessary depending upon performance measurements:

• Approved by KP Hawaii Quality Council –Jan 2006
• All Hawaii KP physicians notified of guidelines via e-mail in January 2006
• Guidelines have been posted on the Kaiser intranet
• Clinician Education is being conducted through CME and other educational initiatives
• Family Practice Grand Rounds Honolulu –May 2006
• Family Practice Grand Rounds-Maui – July 2007
• Regional Dietitians’ Meeting – August 2006
• Internal Medicine Grand Rounds – Sept 2006
• Presentation of the guideline at an evidence-based CME conference conducted Nov 6-9, 2006 in Maui
• Patient Care Material – “Chronic Kidney Disease Checklist”
• Anemia Management Service – renal clinical pharmacists
• Health connect integration (referral criteria are now listed on the electronic nephrology referral form)
• Decision support in Panel Support Tool
• The use of administrative and clinical databases to create a registry used by the guideline leaders. Basically this consists of pro-actively emailing or phoning primary care physicians to assist with care.

Outcomes (As of 2/15/07)

• Decrease in rate of late referrals
• Increase in Arterio-venous fistula (AVF) rate
• Increase in outpatient/inpatient starts
• Decrease ESRD rate
• Decrease ESRD prevalence
• Increase in urine protein testing (Adults not yet on dialysis with a GFR under 60 ml/min within the last 2 yrs)
  • 2005: 26.8 %
• 2006: 37.2 %

Measures being considered

• Number of patients with up/c over 1 and GFR less than 60 ml/min on ACEI or ARB
• Number of patients with GFR under 60 ml/min with blood pressure under 130/80
• Anemia management service referrals from PCPs

Phase X: Continuous Improvement

Kaiser Permanente: Hawaii Nephrology EBM Guideline Project 2005

At the beginning of the year, we were invited to work with Kaiser Permanente Hawaii to help advance EBM within their organization. KP Hawaii has a strong committment to evidence- and value-based care. Their leaders are committted and support EBM. They frequently sponsor outstanding EBM conferences and retreats which are very well attended, and they have an impressive and active EBM working group.

They were desirous of taking EBM to a new level and expanding and embedding evidence-based clinical improvement skills and techniques more solidly and more broadly into their culture. We came up with an idea for a working project that would provide just-in-time practical training, advance clinical care and help further "seed" cultural change. Thus the Hawaii Nephrology EBM Guideline Project 2005 was conceived. We are working with an incredible team, and the project is well underway and progressing nicely.

We live for projects like this. It is exciting to us to be able to combine our training and facilitation expertise, project management know-how and EBM skills and tools in a real-world setting and over a truly compelling clinical challenge where we can help effect real change.

The benefits of this project are numerous:

• Chronic kidney disease patients will be helped and will receive care based on the best available valid and useful evidence combined with clinical expertise and judgment.
• Primary care physicians will receive clear and practical help in a challenging area.
• The renal care team will extend its help and expertise into other disciplines — and will directly benefit by patients being referred to them at the most appropriate time.
• Team members will both directly and indirectly help expand EBM clinical improvement methods and solutions further into other clinical areas within their organization — this project will help further "seed" an evidence-based culture throughout.
• By operating as an evidence-based organization, this health care system will further its ability to provide evidence- and value-based care to its members, reducing waste and harms and improving the quality of care.

From Kaiser Permanente Hawaii leadership to team members to support staff, Delfini is impressed with the level of enthusiasm and commitment for the principles of evidence-based medicine and for this project. The group is dedicated, responsive and delightful to work with. We are grateful for this wonderful experience. We are honored to serve. We are gratified when we can help others learn and apply their learnings. And as continuous learners, we too learn.

Mahalo,
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