Background Undiagnosed chronic kidney disease (CKD) leads to a high cost and care burden in secondary care. Current stage 3–5 prevalence is estimated at 6.35%, but recorded prevalence in primary care is often significantly lower. Increasing the prevalence of diagnosed CKD in primary care would allow management and prevention of deterioration, but detection rates for CKD remain low. We developed a primary care quality improvement intervention to help identify and manage CKD patients.
Methods A 2x12-month improvement project using financial incentives and structured facilitation was carried out in 30 general practices in Greater Manchester. Practices were helped to identify improvement objectives tailored to their context, (such as validating and updating practice registers) and were monitored by the improvement team. In the first 12 months, practices were provided with in-depth facilitation by knowledge transfer associates. The second phase was less resource-intensive; seconding a clinical facilitator, developing a change package, replacing collaborative meetings with fewer web seminars, and introduction of a CKD audit tool. Key indicators of change were: number of recorded patients with CKD on practice registers: percentage of patients on registers achieving nationally recognised blood pressure targets. Data were collected by practice staff. Practices also received a readiness to change questionnaire to assess practice culture and flexibility.
Results Baseline prevalence across the practices was 4.2%. By the end of the project, recorded prevalence reached 5.4%. Practice registers recorded an increase of 22% of patients with CKD, indicating improved identification of cases. Overall, 2042 patients were added to registers, although taking miscoded patients into account the true number of newly identified patients is likely to be higher. Management of patients also improved from 38% managed to blood pressure target at baseline increasing to 64%. Wide variation amongst practices was accounted for by readiness to change. The two-stage project allowed learning, knowledge and skills to be developed in phase 1, which could then be streamlined and put into practice in phase 2.
Discussion The quality improvement project was associated with a 22% increase in identification of CKD patients, and a 170% increase in patients managed to NICE recommended blood pressure targets. These represent a potential huge saving for the NHS in estimated avoided vascular events. Clinical facilitation and use of a structured audit tool were associated with accelerated and sustained improvement in case finding, building on an earlier phase of experimentation and relationship-building.
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