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Kaiser Permanente Hawaii: Nephrology Project for Primary Care

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Guideline Materials

Update 03/01/2012

Update 01/01/2007

Project Outline

Testimonial........

Delfini provided advice and training in successful project selection. Chronic kidney disease management by primary care providers and guidance on referral to nephrology was identified as an area in which there was a gap between current and optimal care. The team agreed upon development and implementation of a clinical practice guideline as their EBM clinical improvement project.
Phase III: Develop Project Outline
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from Renal Nutritionist,
Carrie Mukaida, MS, RD, CSR

 

 

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Critical Appraisal Intensive & Evidence-based Clinical Guideline Development Project to Help Improve Care & Referral for Patients Suffering from Chronic Kidney Disease (CKD)

Clinical Guideline CKD

Mission: Help advance evidence- and value-based medicine in an organization that has already proved a demonstrated commitment to evidence based medicine (EBM), evidence based practice (EBP) and health care quality using a patient centered approach 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 healthcare quality improvement project and provide them with critical appraisal training and support by facilitating the development of clinical guidelines through scientific review of the medical literature. 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. Quality in healthcare will be enhanced through evidence based care and improved patient safety.

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

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Noteworthy

Award
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.

Publication
A quality improvement report was published in BMJ.

Practice — Quality Improvement Report

Lee BJ, Forbes K. The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease. BMJ. 2009 Jul 8;339:b2395. doi: 10.1136/bmj.b2395. PubMed PMID: 19586983.

Brian J Lee, nephrologist 1, Ken Forbes, care management analyst 2

1 Kaiser Permanente, Hawaii Region, Moanalua Medical Center, 3288 Moanalua Rd, Honolulu, HI 96819, USA, 2 Kaiser Permanente, Hawaii Region, Care Management Institute, 2828 Paa Street, Honolulu, HI 96819

Correspondence to: B J Lee — brian.j.lee@kp.org

CKD Guideline

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

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.

Update 03/01/2012: Chronic Kidney Disease (CKD) Guideline Outcomes

A recent AHRQ publication provides additional useful information regarding screening for CKD. Briefly, the evidence review concludes that—

  • No trials directly show a benefit for CKD screening or monitoring.
  • The likelihood of benefit, if present, appears to be greater in specific subgroups.
    • In patients with proteinuria, nearly all with diabetes and hypertension, angiotensin converting enzyme inhibitors (ACEIs) (relative risk [RR], 0.60, 95 percent confidence interval [CI], 0.43 to 0.83) and angiotensin receptor blockers (ARBs) (RR 0.77, 95 percent CI, 0.66 to 0.90) significantly reduced risk of end-stage renal disease (ESRD) versus placebo.
    •  In patients with microalbuminuria who had cardiovascular disease or diabetes with other cardiovascular risk factors, ACEI treatment reduced mortality risk (RR 0.79, 95 percent CI, 0.66 to 0.96) versus placebo.
    •  In individuals with hyperlipidemia and impaired estimated glomerular filtration rate (eGFR) or creatinine clearance, HMG CoA-reductase inhibitors (statins) reduced risk of mortality (RR 0.80, 95 percent CI, 0.68 to 0.95), myocardial infarction (MI), and stroke compared with placebo. However, limited data addressed whether these effects differed between patients with and without CKD or as a function of CKD severity.
    • Younger patients, and those without diabetes, hypertension, cardiovascular disease, or obesity, are the least likely to benefit from CKD screening.

The full review is available from AHRQ at:
http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=809&PCem=EN

Update 01/01/2007: Chronic Kidney Disease (CKD) GuidelineOutcomes

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 %
Project Outline

Phase I: Identify Team
.........
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 II: Select Project
.........
Delfini provided advice and training in successful project selection. Chronic kidney disease management by primary care providers and guidance on referral to nephrology was identified as an area in which there was a gap between current and optimal care. The team agreed upon development and implementation of a clinical practice guideline as their EBM clinical improvement project.

Phase III: Develop Project Outline
.........
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.

Phase IV: Obtain, Evaluate & Synthesize Evidence & Phase V: Create Clinical Recommendations
.........
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

Phase VI: Assess Impacts of Practice Change
.........
Formal impact assessment was not done.

Phase VII: Create information, Decision & Action Aids
.........
Following training in information, engagement, communication strategies, decision-making, visual display of information and tool construction, team members will select content, communication vehicles and communication formats to convey guideline information, and they will develop tools to facilitate clinical change and to provide guidance on clinical care and referral.

Phase VIII: Implement Guideline
.........
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.

Phase IX: Implement Measurement & Reporting Plan
.........
Outcomes (As of 2/15/07; for additional outcomes also see Update 7/8/09):

  • 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
.........
Strategies and techniques for keeping guideline content and tools up-to-date will be applied by the team leaders.

Published in BMJ: Quality Improvement Report The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease Article Key Points

Update 7/8/09: (BMJ: Lee BJ, Forbes K. Quality Improvement Report — The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease. BMJ 2009;339:b2395.)

Introduction
The Lee 2009 BMJ article summarizes some of the key elements of the Kaiser Permanente Hawaii (KPHI) Nephrology EBM Guideline Project.

The KPHI Chronic Kidney Disease Guideline Workgroup which was formed in January 2005 (see Web Documentation for details) with the goal of assisting with the management of stable chronic kidney disease (CKD). As described in the Lee 2009 paper, KPHI is now documenting improved referral rates and other important outcomes in CKD patients.

Late referrals of CKD patients from primary care to Nephrologists have been associated with higher mortality rates, higher hospitalization rates (if CKD patients lack permanent access for hemodialysis), higher early failure rates of arteriovenous fistulas, as well as decreased quality of life. Approximately one third or more of referrals to nephrologists are late. This article documents improved late referral rates following implementation of the CKD project initiated in 2005.

Key Outcome Measures in the Lee 2009 Paper

  • Rate of late referrals to nephrology care, defined as occurring within four months of end stage renal disease;
  • The proportions of patients starting hemodialysis with a mature arteriovenous fistula and starting dialysis in the outpatient setting; and,
  • The proportion of patients starting hemodialysis as outpatients.

Results

  • Between 2004 and 2008, the proportion of referrals occurring within four months of onset of end stage renal disease dropped from 37 of 116 (32%) to 10 of 84 (12%), P=0.001;
  • The proportion of patients starting hemodialysis with a mature arteriovenous fistula increased from 19 of 108 (18%) to 27 of 76 (36%), P=0.006;
  • The proportion of patients who started hemodialysis as outpatients increased from 39 of 113 (35%) to 47 of 84 (56%), P=0.003.
  • In 2004, the percentage of low risk CKD patients referred to nephrology (frequently best managed in primary care) was 50%. As the primary care physicians learned the criteria for referral and gained more expertise in the management of early chronic kidney disease, the total number of referrals dropped. In 2007 the percentage of low risk referrals had dropped to 30%; P value for difference between 2004 and 2007 was 0.0001;
  • Starting in late 2007, low risk patients returned to primary care were monitored. After an average follow-up 409 days none of the patients reached end stage renal disease or were referred to Nephrology a second time; and,
  • In 2004, the percentage of high risk CKD patients referred to Nephrology (frequently best managed by nephrologists) was 16%. In 2007 the percentage of high risk CKD patients increased to 35%; P value for difference between 2004 and 2007 was 0.0001.

Key Points and Conclusions

  • The KPHI CKD Guideline demonstrates how an evidence-based QI approach can be used by health care organizations and other groups to improve health care quality and outcomes for patients;
  • The CKD project utilized the principles, methods and tools of applied EBM and included key questions, a literature search, critical appraisal of the relevant literature, evidence grading, “tagged” clinical recommendations based on the evidence and judgments of the guideline team and carefully developed implementation and measurement strategies;
  • A team composed of engaged stakeholders using transparent EBM processes including posing key questions to the medical literature, effective searching, critical appraisal of medical literature for validity and usefulness, evidence grading, interpreting results, creating evidence statements and a synthesis of the evidence, crafting clinical recommendations and other decision-support materials for targeted groups and creating administrative, system and measurement processes to ensure effective implementation and ongoing improvement;
  • A unique feature of the evidence-based QI project is the innovative use of KP’s electronic medical system, KP HealthConnect (see Lee 2009 for details). The system includes electronic registration and scheduling, billing, clinical information systems — both inpatient and outpatient, laboratory and X-ray information, pharmacy records, the ability to annotate for individualized care, alert and flagging features and staff messaging.
    • The system allows primary care physicians rapid access to important CKD decision-support and management information such as lab testing recommendations, blood pressure management recommendations, use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers, avoiding nephrotoxic drugs, etc. (See Algorithm.)
    • The system also allows nephrologists to stratify KPHI CKD patients by risk category and provide electronic or real-time consults, resulting in ongoing, efficient management of low-risk patients in primary care with solicited and unsolicited consultations, mentoring and avoidance of inappropriate referrals but prompt referral of higher risk or more complicated patients to nephrology and retraction of premature referrals;
    • Nephrologists use the KP CKD Population Management System to target every CKD patient not optimally managed.
  • The Lee 2009 paper documents (see above) some of the improved outcomes seen following the implementation of this evidence-based CKD quality improvement project.
  • Evidence-based decision support together with risk driven consultations and educational mentoring of primary care physicians using their own patients and enabled by KP HealthConnect provide a novel and effective method of improving care in CKD.
    This evidence-based approach could be used in other conditions (e.g., in diabetes, heart failure) where there are gaps between optimal and current clinical care.
  • BMJ: The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease
  • BMJ Delfini Rapid Response Letter: Re: The role of specialists, information systems and an evidence-based approach in managing the health of populations with chronic illness

Delfini Response Letter Key Points

  • This work represents an important contribution to the evidence-based quality improvement (QI) literature. Lee and Forbes report success in the use of an evidence-based QI approach that can be used by others health care quality and patient outcomes including patient safety for patients using implementation strategies consistent with what is currently reported in the literature as most effective.
  • A combination approach was utilized.
  • Importantly,the information upon which the guidelines were based was developed through a systematic approach to obtaining potentially relevant clinical trials and evaluating them through a rigorous critical appraisal approach.
  • An evidence-based process is important to provide patients with the best available care.
  • An evidence-based process is important for effective implementation. Rigorously appraised evidence can increase trust by providing tags that clearly label information as being based on high quality evidence or expert opinion.
  • Process information, decision support materials, documentation and tools used by Kaiser Permanente Hawaii are available here: www.delfini.org/Showcase_Project_NephrologyCPG.htm and http://www.delfini.org/delfiniTools.htm.
  • In addition, key features appear to be a combination of unsolicited, risk-driven nephrology consultations enabled by the innovative use of Kaiser Permanente’s electronic medical system not only to improve referrals to nephrology but also to provide evidence-based decision-support to generalists.
  • This system allows nephrologists to stratify CKD patients by risk category and provide electronic or real-time communications, resulting in ongoing, efficient management of low-risk patients in primary care using solicited and unsolicited consultations, mentoring and avoidance of inappropriate referrals.
  • Kaiser Permanente’s electronic medical system allows generalists rapid access to important evidence-based CKD decision-support and management information.

BMJ Delfini Rapid Response Letter: Re: The role of specialists, information systems and an evidence-based approach in managing the health of populations with chronic illness

 

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