Integrating Risk-based Care for Patients With CKD in the Community Navdeep Tangri MD PhD FRCPC Associate Professor, Division of Nephrology Dept. of Medicine and Dept. of Community Health Sciences Seven Oaks General Hospital, University of Manitoba Adjunct Associate Professor, Division of Nephrology Tufts Medical Center, Tufts University
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Integrating Risk-based Care for Patients With CKD in the Community
Navdeep Tangri MD PhD FRCPC Associate Professor, Division of Nephrology Dept. of Medicine and Dept. of Community Health Sciences Seven Oaks General Hospital, University of Manitoba Adjunct Associate Professor, Division of Nephrology Tufts Medical Center, Tufts University
Background
• About 600,000 Canadians with Stage G3 CKD
• Most managed in primary care
• Some patients progress quickly
• In other, kidney function can remain stable for years
Background
• Low risk individuals
– Unnecessary anxiety – Burden of the chronic disease label – Psychological distress, absenteeism from work, & diminished quality of
life
Background
• Higher risk individuals who are under-recognized
– Limited opportunity to learn about CKD & take actions to control risk
factors & delay or prevent progression to kidney failure
– Less likely to choose home dialysis or a permanent vascular access
– Higher risk of hospitalizations & early mortality
Background
• Health system
– Increased wait times for urgent cases
– More rapid disease progression
– Inadequate preparation for dialysis and/or kidney transplant
• The KFREs accurately predict the risk of kidney failure requiring dialysis in patients with CKD Stages 3-5 for up to 5 years
• Risk prediction is accurate across multiple countries & subpopulations
• The KFRE is simple & highly accurate, & can be integrated into clinical practice
• It is accessed online > 30,000 times a month
4 Variable Equation
Published Online First April 11, 2011
Available at
www.jama.com
Knowledge Translation
Risk Factor Units (Type Over Placeholder Values in
Each Cell) Notes Age years 50 Sex male (m) or female (f) m Estimated GFR ml/min/1.73 m2 30 Urine Albumin Creatinine Ratio mg/g 50 Calcium mg/dl 9.8 Phosphorous mg/dl 3.8 Albumin g/dl 4 Bicarbonate meq/l 26
– Albuminuria & ACEi/ARB • % of patients with albuminuria • % of patients with albuminuria on ACEi/ARB
– Management of diabetes • Hemoglobin A1C in target, < 8%
– Management of hypertension • Blood pressure (BP) in target, office BP < 130/80 for patients with diabetes, 140/90
for those without
– Decline in eGFR • 30% decline over 3 years of follow up
Primary Outcomes
• Health System
– Appropriate referral for patients at high risk for kidney failure
– Cost of CKD care
• Data from electronic medical records, comparison with provincial guidelines, & linkages with provincial administrative data
Secondary Outcomes
• Patient – CKD-specific health literacy – Trust in physician care
• Provider
– Satisfaction with the risk prediction tools & clinical decision aids
• Data from a sub-study using surveys & Likert scale
Patient Partner Involvement
• Study protocol refinement
• Clinical decision aid refinement
• Data analysis
• Interpretation of study findings
• Moving results to practice
Progress to Date
• Clinical decision aids developed
• Feasibility assessment completed – 461,383 patients with a measured eGFR – 146,224 with measured albuminuria – 65,021 have CKD Stage 3 or higher & would be impacted by our
intervention
Progress to Date
• CPCSSN Data Presentation Tool
– Available in all CPCSSN clinic electronic medical records
– Best platform for integration of the KFRE
– Clinicians can identify all patients with CKD Stage G3 or higher & rank them by risk of kidney failure using the KFRE
– Patients at high/low risk can be identified & targeted for further intervention
Impact
• Integration of the KFRE in primary care – Reduced anxiety – Improved health literacy – More appropriate referral
• Broader uptake
– Reduction in wait times – Improved access to specialist care for high risk patients