Lessons from Discover-NOW programme: Transforming chronic kidney disease care in North West London.

More than 100 million individuals in the USA have been diagnosed with a chronic disease, yet chronic disease care has remained fragmented and of inconsistent quality. Improving chronic disease management has been challenging for primary care and internal medicine practitioners. Practice facilitation provides a comprehensive approach to chronic disease care. The objective is to evaluate the impact of practice facilitation on chronic disease outcomes in the primary care setting. This systematic review examined North American studies from PubMed, EMBASE, and Web of Science (database inception to August 2017). Investigators independently extracted and assessed the quality of the data on chronic disease process and clinical outcome measures. Studies implemented practice facilitation and reported quantifiable care processes and patient outcomes for chronic disease. Each study and their evidence were assessed for risk of bias and quality according to the Cochrane Collaboration and the Grade Collaboration tool. This systematic review included 25 studies: 12 randomized control trials and 13 prospective cohort studies. Across all studies, practices and their clinicians were aware of the implementation of practice facilitation. Improvements were observed in most studies for chronic diseases including asthma, cancer (breast, cervical, and colorectal), cardiovascular disease (cerebrovascular disease, coronary artery disease, dyslipidemia, hypertension, myocardial infarction, and peripheral vascular disease), and type 2 diabetes. Mixed results were observed for chronic kidney disease and chronic illness care. Overall, the results suggest that practice facilitation may improve chronic disease care measures. Across all studies, practices were aware of practice facilitation. These findings lend support for the potential expansion of practice facilitation in primary care. Future work will need to investigate potential opportunities for practice facilitation to improve chronic disease outcomes in other health care settings (e.g., specialty and multi-specialty practices) with standardized measures.

A Decade After the KDOQI CKD Guidelines: Impact on Primary Care

Leveraging the Electronic Health Record to Optimize Chronic Kidney Disease Care

BackgroundPeer support complements traditional models of chronic kidney disease (CKD) care through sharing of peer experiences, pragmatic advice, and resources to enhance chronic kidney disease self-management and decision-making. As peer support is variably offered and integrated into multi-disciplinary CKD care, we aimed to characterize healthcare providers’ experiences and views on peer support provision for people with non-dialysis-dependent CKD within Canada.MethodsIn this concurrent mixed methods study, we used a self-administered online survey to collect information from multi-disciplinary CKD clinic providers (e.g., nurses, nephrologists, allied health professionals) on peer support awareness, program characteristics and processes, perceived value, and barriers and facilitators to offering peer support in CKD clinics. Results were analyzed descriptively. We undertook semi-structured interviews with a sample of survey respondents to elaborate on perspectives about peer support in CKD care, which we analyzed using inductive, content analysis.ResultsWe surveyed 113 providers from 49 clinics. Two thirds (66%) were aware of formal peer support programs, of whom 19% offered in-house peer support through their clinic. Peer support awareness differed by role and region, and most referrals were made by social workers. Likert scale responses suggested a high perceived need of peer support for people with CKD. Top cited barriers to offering peer support included lack of peer support access and workload demands, while facilitators included systematic clinic processes for peer support integration and alignment with external programs. Across 18 interviews, we identified themes related to peer support awareness, logistics, and accessibility and highlighted a need for integrated support pathways.ConclusionsOur findings suggest variability in awareness and availability of peer support among Canadian multi-disciplinary CKD clinics. An understanding of the factors influencing peer support delivery will inform strategies to optimize its uptake for people with advanced CKD.

BackgroundElectronic personal health records (ePHRs) are defined as electronic applications through which individuals can access, manage, and share health information in a private, secure, and confidential environment. Existing evidence shows their benefits in improving outcomes, especially for chronic disease patients. However, their use has not been as widespread as expected partly due to barriers faced in their adoption and use. We aimed to identify the types of barriers to a patient, provider, and caregiver adoption/use of ePHRs and to analyze their extent in chronic disease care.MethodsA systematic search in Medline, PubMed, Science Direct, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Central Register of Controlled Trials, and the Institute of Electrical and Electronics Engineers (IEEE) database was performed to find original studies assessing barriers to ePHR adoption/use in chronic care until the end of 2018. Two researchers independently screened and extracted data. We used the PHR adoption model and the Unified Theory of Acceptance and Use of Technology to analyze the results. The Mixed Methods Appraisal Tool (MMAT) version 2018 was used to assess the quality of evidence in the included studies.ResultsSixty publications met our inclusion criteria. Issues found hindering ePHR adoption/use in chronic disease care were associated with demographic factors (e.g., patient age and gender) along with key variables related to health status, computer literacy, preferences for direct communication, and patient’s strategy for coping with a chronic condition; as well as factors related to medical practice/environment (e.g., providers’ lack of interest or resistance to adopting ePHRs due to workload, lack of reimbursement, and lack of user training); technological (e.g., concerns over privacy and security, interoperability with electronic health record systems, and lack of customized features for chronic conditions); and chronic disease characteristics (e.g., multiplicities of co-morbid conditions, settings, and providers involved in chronic care).ConclusionsePHRs can be meaningfully used in chronic disease care if they are implemented as a component of comprehensive care models specifically developed for this care. Our results provide insight into hurdles and barriers mitigating ePHR adoption/use in chronic disease care. A deeper understating of the interplay between these barriers will provide opportunities that can lead to an enhanced ePHR adoption/use.

Background:Risk prediction tools are used in a variety of clinical settings to guide patient care, although their use in chronic kidney disease (CKD) care is limited.Objectives:To assess the association of a risk-based model of CKD care on patient care, satisfaction, outcomes, and cost.Design:Mixed-methods with a pre-post design.Setting:We will use mixed-methods and a pre-post design to evaluate use of the Kidney Failure Risk Equation (KFRE) to guide CKD care. The KFRE will be applied to patients currently followed in nephrology multidisciplinary CKD clinics in Alberta, as well as to new patients being considered for multidisciplinary care.Patients:Patients with a 2-year risk of kidney failure ≥10% or estimated glomerular filtration rate (eGFR) ≤15 mL/min/1.73 m2 will be recommended care by a multidisciplinary team coordinated by a nurse clinician and nephrologist, with access to other multidisciplinary resources including dietitians, pharmacists, and social workers as required.Measurements/Methods:Focus groups and interviews will be conducted to qualitatively describe patient and provider perspectives of potential barriers and facilitators to implementation of the risk-based approach to CKD care. Patient and provider surveys will also be used to quantify patient and provider satisfaction before and after the intervention. Finally, administrative data will be used to evaluate the association between the risk-based approach to care and outcomes including health care resource use, frequency of testing, modality choice, and death.Conclusions:Use of a risk-based model of care has the potential to increase use of optimal treatments such as the use of home dialysis and preemptive kidney transplantation, while reducing costs and poor outcomes related to processes of care such as unnecessary laboratory testing; however, there is also potential for unintended consequences. Our mixed-methods approach will integrate perceptions and needs from key stakeholders (including patients with CKD, their families, and their providers) to guide implementation and ensure appropriate modifications.

Many patients do not receive guideline-recommended preventive, chronic disease, and acute care. One potential explanation is insufficient time for primary care providers (PCPs) to provide care. To quantify the time needed to provide 2020 preventive care, chronic disease care, and acute care for a nationally representative adult patient panel by a PCP alone, and by a PCP as part of a team-based care model. Simulation study applying preventive and chronic disease care guidelines to hypothetical patient panels. Hypothetical panels of 2500 patients, representative of the adult US population based on the 2017-2018 National Health and Nutrition Examination Survey. The mean time required for a PCP to provide guideline-recommended preventive, chronic disease and acute care to the hypothetical patient panels. Estimates were also calculated for visit documentation time and electronic inbox management time. Times were re-estimated in the setting of team-based care. PCPs were estimated to require 26.7 h/day, comprising of 14.1 h/day for preventive care, 7.2 h/day for chronic disease care, 2.2 h/day for acute care, and 3.2 h/day for documentation and inbox management. With team-based care, PCPs were estimated to require 9.3 h per day (2.0 h/day for preventive care and 3.6 h/day for chronic disease care, 1.1 h/day for acute care, and 2.6 h/day for documentation and inbox management). PCPs do not have enough time to provide the guideline-recommended primary care. With team-based care the time requirements would decrease by over half, but still be excessive.

In this study, it was aimed to determine the chronic disease care assessments and health-related quality of life (HRQoL) levels in adults with chronic kidney disease (CKD) undergoing hemodialysis and to reveal the relationship between chronic disease care assessment and HRQoL. A single-center cross-sectional design has been used. Data were collected from 105 adults with CKD, who undergoing hemodialysis. Patient Evaluation Chronic Illness Care (PACIC) scale and Kidney Disease Quality of Life Short Form-36 (KDQOL-36) were used to obtain data. The mean scale scores of PACIC were low (2.66 ± 0.891). Although participants achieved high HRQoL scores on the symptoms subdimension of the KDQoL-36 scale, they got low scores on the subdimensions of mental health, physical health, and burden of disease. Participants' HRQoL is affected significantly by gender, age, educational level, working status, income, and presence of comorbidity (especially diabetes), diagnosis time of CKD, and hemodialysis time at the hospital (p < 0.05). A positive and statistically significant relationship was found between PACIC and subdimensions of KDQoL-36 (p < 0.05). The results can be a guide for improving the quality of chronic disease care in healthcare institutions. To improve this, patients' evaluations on this issue should be taken into account.

&#x0D; Strategies to contain the cost of chronic kidney disease (CKD) care and to improve patient outcomes were found across the continuum of care, from prevention and early disease management through later-stage interventions such as conservative management, dialysis, and transplantation. A variety of health system strategies, including funding reform, were identified to help support and enable sustainable CKD care.&#x0D; For those at risk of CKD or in early stages of the disease, public health interventions to support healthy behaviours and ensure access to primary health care seem crucial to preventing or delaying disease progression.&#x0D; For later-stage patients requiring renal replacement therapy, enhancing access to transplantation and home-based dialysis has the potential to reduce costs while improving outcomes and quality of life. Conservative management without dialysis is an option for those who may not be good candidates for renal replacement therapy or who wish to choose a less-invasive care option.&#x0D; From a health system policy perspective, funding reform may be warranted to enhance team-based CKD care with good continuity. Policy-makers should also consider the ways in which improving financial supports for caregivers, providing travel and expense reimbursement for home dialysis patients and living organ donors, and providing support for utility and ancillary costs of home dialysis could incentivize sustainable CKD care.&#x0D;

Resolved: The Case for CKD Clinics

Moving Beyond Tools and Building Bridges: Lessons Learned From a CKD Decision Support in Primary Care

To review the current literature on care of hypertension and chronic kidney disease for people who are currently and formerly incarcerated, and to make recommendations for improving outcomes. There is a growing body of literature describing care for kidney disease and hypertension for incarcerated and formerly incarcerated individuals that documents the provision of care itself, notably that many jails contract with private companies; the system is not designed to provide sustained, chronic disease care; and the transition from incarceration to community is fraught with gaps in care. However, deficiencies in data collection and regulation still limit our understanding of the quality of care provided in jails and prisons. Furthermore, more data is needed to understand the impact of structural racism in the criminal legal system on overall disparities in care for hypertension and kidney disease. Insurance coverage rates for people who were formerly incarcerated continue to be lower than the general population despite Medicaid expansion in many states. There is little recent data regarding kidney replacement therapy for this population despite known variation in dialysis modalities and transplant programs by state. Transitions clinics, which connect people who were formerly incarcerated with care in the community upon release, are growing and are important avenues by which to deliver care. People who are incarcerated are disproportionately affected by hypertension and kidney disease, yet data regarding the extent of these inequities and availability of quality care is lacking. More work is needed to understand the care of individuals with kidney disease and hypertension in prisons and to improve outcomes for these common chronic conditions. Both providing effective treatment of kidney disease and hypertension in prisons and jails and providing coordinated, quality transition to community care upon release represents an important opportunity for reform in care for a marginalized population.

ObjectivesTo investigate the effect of the Early Chronic Kidney Disease (CKD) Care Programme on CKD progression in patients with CKD stage I–IIIa.DesignObservational cohort study.SettingTaipei Medical University Research Database from three...

To analyze the effects of chronic kidney disease (CKD) care programs on clinical outcomes. An observational, retrospective study with medical record review. Kaohsiung Chang Gung Memorial Hospital. Patients diagnosed with CKD. CKD care programs conducted by nephrologists-based team from 2006 to 2013 in our hospital. We set 10 goals with treatment target ranges based on the guidelines suggested by the following organizations: Kidney Disease Improving Global Outcomes (2012) and the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (2003). In total, 1486 patients were enrolled. Their average estimated glomerular filtration rate (ml/min/1.73 m2) was 31.9 at baseline and declined to 28.9 in Year 3 (P < 0.001). The all-goals attainment rate increased from 59.4% at baseline to 60.5% in Year 3, with an especially significant improvement for low-density lipoprotein (from 46.8% to 67.0%) and glycated hemoglobin (from 55.0% to 64.0%). Achievement rates decreased for hemoglobin (from 34.2% to 31.0%), calcium (from 94.6% to 92.3%) and phosphate (from 89.9% to 82.5%) between baseline and Year 3. Albuminuria was the least achieved goal (from 23.4% to 24.0%). Subgroup analysis revealed that estimated glomerular filtration rate did not decline in patients who had a good achievement rate, but decreased significantly in patients with a poor achievement rate. Enrolment in CKD care programs resulted in a significant improvement in goal attainment by patients. Further, a good achievement rate was associated with better preservation of residual renal function.

Background: Late referral to nephrologists is common and associated with increased morbidity and mortality. We aimed to analyze the prevalence rates, predictors and consequences of late referral to nephrologists by primary care physicians for chronic kidney disease (CKD) care. Methods: A retrospective analysis of 204 patients started on dialysis for CKD in two community hospitals between March 2003 and March 2005 was conducted. Relevant clinical and laboratory data were obtained from the patient records of the nephrology clinics and dialysis units. Patients referred in CKD stage 5 (estimated glomerular filtration rate <15 ml/min) were defined as late referral and patients in CKD stage 1–4 (estimated glomerular filtration rate >15 ml/min) as early referral. Results: Forty-five (22%) of the 204 patients were referred late. In the multivariate analysis, non-diabetic kidney disease (odds ratio = 2.46, p = 0.02) and Charlson comorbidity index (odds ratio = 1.17, p = 0.009) were significantly associated with late referral. The late referral group had lower hematocrit and serum calcium levels, and higher serum phosphorus and parathyroid hormone levels than the early referral group (p ≤0.05) at the time of referral. Late referral resulted in less permanent vascular access for initiation of dialysis (p = 0.03). Even though there was twice the number of deaths in the late referral group in 1 year (18 vs. 9%), this was not statistically significant (p = 0.07). Conclusion: Referring physicians should pay special attention to patients with non-diabetic kidney disease and patients with multiple comorbidities since delayed referral to nephrologists may result in poorer patient-related outcomes. Larger and long-term prospective studies analyzing the long-term consequences of late referral to nephrologists are needed.