Facilitated Process Improvement: An Approach to the Seamless Linkage Between Evidence and Practice in CKD

Interventions to improve referrals from primary care to outpatient specialist services for chronic conditions: a systematic review and framework synthesis update

BACKGROUND

Prior systematic reviews highlight that accessing specialist healthcare to treat chronic conditions can be obstructed by variations in referral rates, inappropriate referrals, and poor communication. Structured referral proformas, peer feedback, and educational interventions involving specialists have been identified as successful strategies for improving referral rates and appropriateness. However, the success of such interventions is often dependent on specific clinical contexts, and little is known about the practicalities of implementation. Additionally, with advancements in healthcare delivery, such as e-referral systems, there is a need to explore new interventions and how they address barriers to referral.

METHODS

This systematic review evaluated the updated evidence exploring interventions aiming to improve rates and/or appropriateness of referral from primary care to specialist services in patients with chronic conditions.Five academic databases were searched (CINAHL, MEDLINE, Embase, British Nursing Index, and Public Health Database), and studies published in English between 2013 and 2023 were included. The Joanna Briggs Institute's appraisal tool was used to assess the quality of studies, and a narrative synthesis was conducted using the TiDiER framework (template for intervention description and replication).

RESULTS

Eighteen full-text publications and five abstracts were included. A behavioral theory or framework for intervention development was used in seven studies. All interventions were based on primary care, and thirteen studies evaluated a multi-component intervention. Process and system changes were most commonly used to improve referral, including electronic health systems, referral algorithms, collaborative working, and patient direct access. Interventions targeted at patients were the least common. Staff education was often used in addition to process and system changes. When used alone, referral algorithms and staff education were less effective at improving referral rates or appropriateness. Implementation barriers included time constraints, logistical issues, and patients/staff preconceived perceptions of referral necessity.

CONCLUSION

Unsurprisingly, the success of interventions aimed at improving referral practices is based on contextual circumstances, and as with previous reviews, there is no one-size-fits-all approach.Given the challenges highlighted in this review, multi-component interventions addressing referral barriers in both primary and secondary care appear to be a successful way to improve referral practices.

REVIEW REGISTRATION

PROSPERO CRD42023480493.

Developing a toolkit for implementing evidence-based guidelines to manage hypertension and diabetes in Cambodia: a descriptive case study

BACKGROUND

In Cambodia, economic development accompanied by health reforms has led to a rapidly ageing population and an increasing incidence and prevalence of noncommunicable diseases. National strategic plans recognize primary care health centres as the focal points of care for treating and managing chronic conditions, particularly hypertension and type 2 diabetes. However, health centres have limited experience in providing such services. This case study describes the process of developing a toolkit to facilitate the use of evidence-based guidelines to manage hypertension and type 2 diabetes at the health-centre level.

METHODS

We developed and revised a preliminary toolkit based on the feedback received from key stakeholders. We gathered feedback through an iterative process of group and one-to-one consultations with representatives of the Ministry of Health, provincial health department, health centres and nongovernmental organizations between April 2019 and March 2021.

RESULTS

A toolkit was developed and organized according to the core tasks required to treat and manage hypertension and type 2 diabetes patients. The main tools included patient identification and treatment cards, risk screening forms, a treatment flowchart, referral forms, and patient education material on risk factors and lifestyle recommendations on diet, exercise, and smoking cessation. The toolkit supplements existing guidelines by incorporating context-specific features, including drug availability and the types of medication and dosage guidelines recommended by the Ministry of Health. Referral forms can be extended to incorporate engagement with community health workers and patient education material adapted to the local context. All tools were translated into Khmer and can be modified as needed based on available resources and arrangements with other institutions.

CONCLUSIONS

Our study demonstrates how a toolkit can be developed through iterative engagement with relevant stakeholders individually and in groups to support the implementation of evidence-based guidelines. Such toolkits can help strengthen the function and capacity of the primary care system to provide care for noncommunicable diseases, serving as the first step towards developing a more comprehensive and sustainable health system in the context of population ageing and caring for patients with chronic diseases.

Improving CKD Diagnosis and Blood Pressure Control in Primary Care: A Tailored Multifaceted Quality Improvement Programme

BACKGROUND

Chronic kidney disease (CKD) is a worldwide public health issue. From 2009 to 2014, the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Greater Manchester (NIHR CLAHRC GM) in England ran 4 phased, 12-month quality improvement (QI) projects with 49 primary care practices in GM. Two measureable aims were set - halve undiagnosed CKD in participating practices using modelled estimates of prevalence; and optimise blood pressure (BP) control (<140/90 mm Hg in CKD patients without proteinuria; <130/80 mm Hg in CKD patients with proteinuria) for 75% of recorded cases of CKD. The 4 projects ran as follows: P1 = Project 1 with 19 practices (September 2009 to September 2010), P2 = Project 2 with 11 practices (March 2011 to March 2012), P3 = Project 3 with 12 practices (September 2012 to October 2013), and P4 = Project 4 with 7 practices (April 2013 to March 2014).

METHODS

Multifaceted intervention approaches were tailored based on a contextual analysis of practice support needs. Data were collected from practices by facilitators at baseline and again at project close, with self-reported data regularly requested from practices throughout the projects.

RESULTS

Halving undiagnosed CKD as per aim was exceeded in 3 of the 4 projects. The optimising BP aim was met in 2 projects. Total CKD cases after the programme increased by 2,347 (27%) from baseline to 10,968 in a total adult population (aged ≥18 years) of 231,568. The percentage of patients who managed to appropriate BP targets increased from 34 to 74% (P1), from 60 to 83% (P2), from 68 to 71% (P3), and from 63 to 76% (P4). In nonproteinuric CKD patients, 88, 90, 89, and 91%, respectively, achieved a target BP of <140/90 mm Hg. In proteinuric CKD patients, 69, 46, 48, and 45%, respectively, achieved a tighter target of <130/80 mm Hg. Analysis of national data over similar timeframes indicated that practices participating in the programme achieved higher CKD detection rates.

CONCLUSIONS

Participating practices identified large numbers of "missing" CKD patients with comparator data showing they outperformed non-QI practices locally and nationally over similar timeframes. Improved BP control also occurred through this intervention, but overall achievement of the tighter BP target in proteinuric patients was notably less.

Improving care coordination between nephrology and primary care: a quality improvement initiative using the renal physicians association toolkit

BACKGROUND

Individuals at risk for chronic kidney disease (CKD), including those with diabetes mellitus and hypertension, are prevalent in primary care physician (PCP) practices. A major systemic barrier to mitigating risk of progression to kidney failure and to optimal care is failure of communication and coordination among PCPs and nephrologists.

STUDY DESIGN

Quality improvement. Longitudinal practice-level study of tool-based intervention in nephrology practices and their referring PCP practices.

SETTING & PARTICIPANTS

9 PCP and 5 nephrology practices in Philadelphia and Chicago.

QUALITY IMPROVEMENT PLAN

Tools from Renal Physicians Association toolkit were modified and provided for use by PCPs and nephrologists to improve identification of CKD, communication, and comanagement.

OUTCOMES

CKD identification, referral to nephrologists, communication among PCPs and nephrologists, comanagement processes.

MEASUREMENTS

Pre- and postimplementation interviews, questionnaires, site visits, and monthly teleconferences were used to ascertain practice patterns, perceptions, and tool use. Interview transcripts were reviewed for themes using qualitative analysis based on grounded theory. Chart audits assessed CKD identification and referral (PCPs).

RESULTS

PCPs improved processes for CKD identification, referral to nephrologists, communication, and execution of comanagement plans. Documentation of glomerular filtration rate was increased significantly (P=0.01). Nephrologists improved referral and comanagement processes. PCP postintervention interviews documented increased awareness of risk factors, the need to track high-risk patients, and the importance of early referral. Final nephrologist interviews revealed heightened attention to communication and comanagement with PCPs and increased levels of satisfaction among all parties.

LIMITATIONS

Nephrology practices volunteered to participate and recruit their referring PCP practices. Audit tools were developed for quality improvement assessment, but were not designed to provide statistically significant estimates.

CONCLUSIONS

The use of specifically tailored tools led to enhanced awareness and identification of CKD among PCPs, increased communication between practices, and improvement in comanagement and cooperation between PCPs and nephrologists.

Perceptions and use of the national kidney foundation KDOQI guidelines: a survey of U.S. renal healthcare providers

Background

The National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) developed guidelines to care for patients with chronic kidney disease (CKD). While these are disseminated through the NKF’s website and publications, the guidelines’ usage remains suboptimal. The KDOQI Educational Committee was formed to identify barriers to guideline implementation, determine provider and patient educational needs and develop tools to improve care of patients with CKD.

Methods

An online survey was conducted from May to September 2010 to evaluate renal providers’ familiarity, current use of and attitudes toward the guidelines and tools to implement the guidelines.

Results

Most responders reported using the guidelines often and felt that they could be easily implemented into clinical practice; however, approximately one-half identified at least one barrier. Physicians and physician extenders most commonly cited the lack of evidence supporting KDOQI guidelines while allied health professionals most commonly listed patient non-adherence, unrealistic guideline goals and provider time-constraints. Providers thought that the guidelines included too much detail and identified the lack of a quick resource as a barrier to clinical implementation. Most were unaware of the Clinical Action Plans.

Conclusions

Perceived barriers differed between renal clinicians and allied health professionals; educational and implementation tools tailored for different providers are needed.

Comprehensive public health strategies for preventing the development, progression, and complications of CKD: report of an expert panel convened by the Centers for Disease Control and Prevention

Chronic kidney disease (CKD) is a public health threat in the United States, with increasing prevalence, high costs, and poor outcomes. More widespread effort at the prevention, early detection, evaluation, and management of CKD and antecedent conditions could prevent complications of decreased kidney function, slow the progression of kidney disease to kidney failure, and reduce cardiovascular disease risk. In 2006, the Centers for Disease Control and Prevention (CDC) launched an initiative on CKD. As part of this initiative, the CDC convened an expert panel to outline recommendations for a comprehensive public health strategy to prevent the development, progression, and complications of CKD in the United States. The panel adapted strategies for primary, secondary, and tertiary prevention for chronic diseases to the conceptual model for the development, progression, and complications of CKD; reviewed epidemiological data from US federal agencies; and discussed ways of integrating public health efforts from various agencies and organizations. The panel recommended a 10-point plan to the CDC to improve surveillance, screening, education, and awareness directed at 3 target populations: people with CKD or at increased risk of developing CKD; providers, hospitals, and clinical laboratories; and the general public. Cooperation among federal, state, and local governmental and private organizations will be necessary to carry out these recommendations.

Hypertension Improvement Project (HIP): study protocol and implementation challenges

BACKGROUND

Hypertension affects 29% of the adult U.S. population and is a leading cause of heart disease, stroke, and kidney failure. Despite numerous effective treatments, only 53% of people with hypertension are at goal blood pressure. The chronic care model suggests that blood pressure control can be achieved by improving how patients and physicians address patient self-care.

METHODS AND DESIGN

This paper describes the protocol of a nested 2 x 2 randomized controlled trial to test the separate and combined effects on systolic blood pressure of a behavioral intervention for patients and a quality improvement-type intervention for physicians. Primary care practices were randomly assigned to the physician intervention or to the physician control condition. Physician randomization occurred at the clinic level. The physician intervention included training and performance monitoring. The training comprised 2 internet-based modules detailing both the JNC-7 hypertension guidelines and lifestyle modifications for hypertension. Performance data were collected for 18 months, and feedback was provided to physicians every 3 months. Patient participants in both intervention and control clinics were individually randomized to the patient intervention or to usual care. The patient intervention consisted of a 6-month behavioral intervention conducted by trained interventionists in 20 group sessions, followed by 12 monthly phone contacts by community health advisors. Follow-up measurements were performed at 6 and 18 months. The primary outcome was the mean change in systolic blood pressure at 6 months. Secondary outcomes were diastolic blood pressure and the proportion of patients with adequate blood pressure control at 6 and 18 months.

DISCUSSION

Overall, 8 practices (4 per treatment group), 32 physicians (4 per practice; 16 per treatment group), and 574 patients (289 control and 285 intervention) were enrolled. Baseline characteristics of patients and providers and the challenges faced during study implementation are presented. The HIP interventions may improve blood pressure control and lower cardiovascular disease risk in a primary care practice setting by addressing key components of the chronic care model. The study design allows an assessment of the effectiveness and cost of physician and patient interventions separately, so that health care organizations can make informed decisions about implementation of 1 or both interventions in the context of local resources.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT00201136.

Recommendations for a clinical decision support for the management of individuals with chronic kidney disease

BACKGROUND AND OBJECTIVES

Care for advanced CKD patients is suboptimal. CKD practice guidelines aim to close gaps in care, but making providers aware of guidelines is an ineffective implementation strategy. The Institute of Medicine has endorsed the use of clinical decision support (CDS) for implementing guidelines. The authors' objective was to identify the requirements of an optimal CDS system for CKD management.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

The aims of this study expanded on those of previous work that used the facilitated process improvement (FPI) methodology. In FPI, an expert workgroup develops a set of quality improvement tools that can subsequently be utilized by practicing physicians. The authors conducted a discussion with a group of multidisciplinary experts to identify requirements for an optimal CDS system.

RESULTS

The panel considered the process of patient identification and management, associated barriers, and elements by which CDS could address these barriers. The panel also discussed specific knowledge needs in the context of a typical scenario in which CDS would be used. Finally, the group developed a set of core requirements that will likely facilitate the implementation of a CDS system aimed at improving the management of any chronic medical condition.

CONCLUSIONS

Considering the growing burden of CKD and the potential healthcare and resource impact of guideline implementation through CDS, the relevance of this systematic process, consistent with Institute of Medicine recommendations, cannot be understated. The requirements described in this report could serve as a basis for the design of a CKD-specific CDS.

A process for developing an implementation intervention: QUERI Series

Background

This article describes the process used by the authors in developing an implementation intervention to assist VA substance use disorder clinics in adopting guideline-based practices for treating depression. This article is one in a Series of articles documenting implementation science frameworks and tools developed by the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI).

Methods

The process involves two steps: 1) diagnosis of site-specific implementation needs, barriers, and facilitators (i.e., formative evaluation); and 2) the use of multi-disciplinary teams of local staff, implementation experts, and clinical experts to interpret diagnostic data and develop site-specific interventions. In the current project, data were collected via observations of program activities and key informant interviews with clinic staff and patients. The assessment investigated a wide range of macro- and micro-level determinants of organizational and provider behavior.

Conclusion

The implementation development process described here is presented as an optional method (or series of steps) to consider when designing a small scale, multi-site implementation study. The process grew from an evidence-based quality improvement strategy developed for – and proven efficacious in – primary care settings. The authors are currently studying the efficacy of the process across a spectrum of specialty care treatment settings.

Reporting of estimated GFR in the primary care clinic

BACKGROUND

Because serum creatinine is an insensitive measure of kidney dysfunction, guidelines have advocated routine use of estimated glomerular filtration rate (eGFR) to identify patients with chronic kidney disease (CKD). Patients with early (stage 3) CKD remain undiagnosed in primary care clinics; therefore, we hypothesized that routine reporting of eGFR in outpatient clinics would improve the recognition and treatment of CKD.

METHODS

A retrospective review of primary care patients was undertaken at the Bronx Veterans Affairs Medical Center, Bronx, New York, before and after the institution of routine eGFR reporting. We evaluated the achievement of diagnostic and therapeutic treatment goals based on the Kidney Disease Outcomes Quality Initiative guidelines (documentation of CKD, urinalysis assessment, blood pressure < 130/80 mm Hg, and renin-angiotensin system blockade) for patients with stage 3 CKD during each period.

RESULTS

Overall, patients with diabetes with early-stage CKD achieved superior treatment rates than similar patients without diabetes. Routine reporting of eGFR improved the documentation and identification of CKD by almost 50%, although absolute improvement was modest. Use of renin-angiotensin system blockers improved minimally, as did blood pressure control. Patients with documented CKD achieved treatment goals more frequently than patients without documented CKD.

CONCLUSION

Routine reporting of eGFR alone modestly improved the identification of patients with CKD without a clinically significant effect on care. For Modification of Diet in Renal Disease Study calculation of eGFR reporting to effect improvements in CKD care, it will be necessary to pair eGFR reporting with provider education to identify these patients and treat them effectively.

Advanced chronic kidney disease practice patterns among nephrologists and non-nephrologists: a database analysis

Chronic kidney disease (CKD) outcomes, including progression to end stage, is influenced by patient treatment and is known to be suboptimal. A commercial database was analyzed to assess practice patterns and conformance to clinical practice guidelines among nephrologists and non-nephrologists who care for patients with advanced CKD (estimated GFR [eGFR] < or = 30 ml/min per 1.73 m2). Data from 1933 adults with advanced CKD on the basis of prestipulated inclusion criteria were analyzed. Individuals were designated as in a nephrologist or non-nephrologist group depending on whether a nephrologist was involved in their care. With the use of published guidelines, conformance to 10 recommendations was assessed for all patients and separately for the nephrologist and non-nephrologist groups. The average eGFR of included individuals was 23.6 ml/min per 1.73 m2. A majority were female and older than 65 yr. Non-nephrologists treated approximately half of all patients and a greater number of women and patients who were older than 65 yr. Nephrologists treated patients with a lower eGFR, equal numbers of men and women, and an equal number of individuals younger and older than 65 yr. Nephrologist conformance to guidelines was systematically better than that of non-nephrologists. These analyses reveal that a large number of patients with advanced CKD are being treated solely by non-nephrologists and that nephrologists treat patients with more advanced disease. Management of advanced CKD is suboptimal for all patients but is particularly poor for patients who are treated solely by non-nephrologists.

Chronic kidney disease care delivered by US family medicine and internal medicine trainees: results from an online survey

BACKGROUND

Complications of chronic kidney disease (CKD) contribute to morbidity and mortality. Consequently, treatment guidelines have been developed to facilitate early detection and treatment. However, given the high prevalence of CKD, many patients with early CKD are seen by non-nephrologists, who need to be aware of CKD complications, screening methods and treatment goals in order to initiate timely therapy and referral.

METHODS

We performed a web-based survey to assess perceptions and practice patterns in CKD care among 376 family medicine and internal medicine trainees in the United States. Questions were focused on the identification of CKD risk factors, screening for CKD and associated co-morbidities, as well as management of anemia and secondary hyperparathyroidism in patients with CKD.

RESULTS

Our data show that CKD risk factors are not universally recognized, screening for CKD complications is not generally taken into consideration, and that the management of anemia and secondary hyperparathyroidism poses major diagnostic and therapeutic difficulties for trainees.

CONCLUSION

Educational efforts are needed to raise awareness of clinical practice guidelines and recommendations for patients with CKD among future practitioners.