Abstract
Most patients with CKD are managed in the community. Whether nurse-led CKD management programs improve outcomes in patients with CKD in primary care is unclear. To assess the effect of such a program on the rate of renal function decline in patients with CKD (stages 3-5) in primary care in the United Kingdom, we conducted a cluster randomized trial, the Primary-Secondary Care Partnership to Improve Outcomes in Chronic Kidney Disease study. A software program designed for the study created a data file of patients with CKD in participating practices. In 23 intervention practices (11,651 patients), a CKD nurse practitioner worked with nominated practice leads to interpret the data file and implement guideline-based patient-level CKD management interventions. The 23 control practices (11,706 patients) received a data file but otherwise, continued usual CKD care. The primary outcome was defined at the cluster (practice) level as the change from baseline of the mean eGFR of the patients with CKD at 6-month intervals up to 42 months. Secondary outcomes included numbers of patients coded for CKD, mean BP, numbers of patients achieving National Institute for Health and Care Excellence BP targets for CKD, and proteinuria measurement. After 42 months, eGFR did not differ significantly between control and intervention groups. CKD- and proteinuria-related coding improved significantly along with the number of patients achieving BP targets in the intervention group versus usual care. CKD management programs in primary care may not slow progression of CKD, but they may significantly improve processes of care and potentially decrease the cardiovascular disease burden in CKD and related costs.
Highlights
Background Most patients withCKD are managed in the community
The Primary-Secondary Care Partnership to Prevent Adverse Outcomes in Chronic Kidney Disease (PSP-CKD) study used primary care–based informatics to support a clinical trial designed to examine the ability of a nurse-led intervention on the basis of published CKD guidelines, delivered in primary care but supported by secondary care nephrologists, to mitigate the rate of decline in renal function in the typical patients with CKD encountered in primary care
The PSP-CKD study is the largest study to evaluate the outcomes of nurse practitioner–led targeted CKD management in primary care
Summary
To assess the effect of such a program on the rate of renal function decline in patients with CKD (stages 3–5) in primary care in the United Kingdom, we conducted a cluster randomized trial, the PrimarySecondary Care Partnership to Improve Outcomes in Chronic Kidney Disease study. To assist in management of CKD, in the last 10 years, serum creatinine–derived formulaic eGFR have been widely introduced to allow for accurate classification of patients by CKD stage[5] and to support guideline-based management of patients with CKD by nonspecialists.[6,7] In the United Kingdom, the introduction of a Renal National Service Framework[8] mandated seamless CKD treatment pathways supported by financial incentives for primary care[9] to achieve key targets in CKD management. The Primary-Secondary Care Partnership to Prevent Adverse Outcomes in Chronic Kidney Disease (PSP-CKD) study used primary care–based informatics to support a clinical trial designed to examine the ability of a nurse-led intervention on the basis of published CKD guidelines, delivered in primary care but supported by secondary care nephrologists, to mitigate the rate of decline in renal function in the typical patients with CKD encountered in primary care
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