# Presentation: 227459

## Physician Practice Patterns in the Treatment of Chronic Kidney Disease.An Upstate New York Practice Based Research Network Study (UNYNET)LESSONS LEARNED FOR PBRNRESEARCH

- C. Fox MD ,A. Brooks CCIV, L. Zayas PhD, B. McClellan MD, B. Murray MD

## A fortuitous lunch
I look at myself, the picture is not pretty
I rapidly change my practice pattern. I ask myself am I unique?
Funds for small network projects become available through the AAFP

- A fortuitous lunch
- I look at myself, the picture is not pretty
- I rapidly change my practice pattern. I ask myself am I unique?
- Funds for small network projects become available through the AAFP

## A medical student eager to do research agrees to be hired as a research assistant for the project.
A Medical Anthropologist, a Nephrologist and a Family Doctor designed the study
A Qualitative study is decided upon. What are PCPs thinking about CKD?
IRB approval is obtained by expedited review

- A medical student eager to do research agrees to be hired as a research assistant for the project.
- A Medical Anthropologist, a Nephrologist and a Family Doctor designed the study
- A Qualitative study is decided upon. What are PCPs thinking about CKD?
- IRB approval is obtained by expedited review

## For $500 the Medical Student
Recruited all 10 MDs for interview
Completed the interviews
Obtained informed consents
Audio taped and transcribed the interviews
Trained in qualitative analysis and analyzed the transcripts
Wrote a manuscript for publication

- For $500 the Medical Student
- Recruited all 10 MDs for interview
- Completed the interviews
- Obtained informed consents
- Audio taped and transcribed the interviews
- Trained in qualitative analysis and analyzed the transcripts
- Wrote a manuscript for publication

## Background

- 20.3 million people in the US with CKD
- 20-30 people with CKD for every ESRD patient
- Primary Care Physicians (PCPs) are in a unique position to prevent progression to ESRD
- Over 60% of patients with mild to moderate CKD see only their PCP

## Methods

- A qualitative study of a representative sample of UNYNET
- A random purposeful sample of 10 primary care physicians
- One-on-one in-depth 45 minute interviews conducted by a third year medical student
- Exit questionnaire

## Immersion-Crystallization approach (Crabtree and Miller)
Three analysts
Family Physician
Medical Student
Medical Anthropologist

- Immersion-Crystallization approach (Crabtree and Miller)
- Three analysts
- Family Physician
- Medical Student
- Medical Anthropologist

## n=10
Location:
2 URBAN PRACTICES
4 SUBURBAN
4 RURAL
Specialties:
7 FAMILY PHYSICIANS
3 INTERNISTS

- n=10
- Location:
- 2 URBAN PRACTICES
- 4 SUBURBAN
- 4 RURAL
- Specialties:
- 7 FAMILY PHYSICIANS
- 3 INTERNISTS

- Academic vs. Community
- 8 COMMUNITY BASED MD’S
- 2 ACADEMIC MDS

## Geographic Distribution

## Results

*Use of guidelines*
- None of the physicians were aware of NKF guidelines
- Majority use guidelines for the treatment of hypertension and diabetes
- Desire for CKD guidelines

## Results

*Recognizing and Diagnosing CKD*
- Reliance on BUN and serum creatinine to diagnose
- Only one physician using calculated GFR

## Results

*Complications and Treatment of CKD*
- Concern over cardiovascular complications
- “Aggressive” treatment of hypertension and diabetes
- Variation in when to treat anemia
- Few monitoring parathyroid hormone
- Use of ACE-Is and ARBs not consistent
- Depression as a complication of CKD?
- Should we be screening for depression in these patients
- Most, but not all, avoid using NSAIDS

## Comparison to K/DOQI Guideline A and B Evidence

**Table 1.**
**Physician Practice Patterns of the Key Points **
**Of the K/DOQI Guidelines**

| GUIDELINE | QUALITATIVE INTERVIEW (n=10) | QUANTITATIVE EXIT 
SURVEY (n=10) |
| --- | --- | --- |
| Use of GFR to diagnose CKD | 1 | N/A |
| Check for microalbumin | N/A | 9 |
| Control BP to < 130/80* | 10 | 10 |
| Use ACE/ARB early | 8 | N/A |
| Treat cholesterol 
HDL> 40
LDL< 100 | N/A | 8 |
| Use Erythropoietin for anemia | 2 | N/A |
| Keep Hemoglobin > 11 | 1 | 1 |
| Check calcium, phosphorous, and PTH for bone disease | 2 | 8 |
| Refer to Nephrologist for GFR < 30*** | 0 | N/A |

## Results

*Role of the Specialist and Timing of Referral*
- Variation in time of referral
- Diabetes and advanced age cited as reasons for later referral
- Problematic relationship with the specialist: poor communication and ill-defined roles

## RESULTS

- Depression is a significant co-morbidity
- Should we be routinely screening CKD patents for depression

## Lessons Learned

- Qualitative studies can be accomplished in a PBRN at a reasonable cost
- This is good for hypothesis generation of future research.
- We found that physicians like to be asked what they think about things.
- The hardest part of recruitment was getting past the office secretary

## AAFP has small grants ($5,000) specifically available for PBRN research stimulation
Medical students are eager to be involved with PBRN research
They make inexpensive research assistants
The process is very educational for them. 
Working with a sub-specialist to do primary care translation was a powerful addition to this research
Results of these studies can be used to design larger projects (We have one started and one pending)

- AAFP has small grants ($5,000) specifically available for PBRN research stimulation
- Medical students are eager to be involved with PBRN research
- They make inexpensive research assistants
- The process is very educational for them.
- Working with a sub-specialist to do primary care translation was a powerful addition to this research
- Results of these studies can be used to design larger projects (We have one started and one pending)

## Next Steps(Started)

- As a result of this study, the regional NKF is funding a series of roundtable discussions with 5 Nephrologists and 10 PCPs to:
- Develop an educational tool to summarize the key points of the NKF guidelines for PCPs
- Develop communication and referral guidelines for PCPs and Nephrologists

## Next Steps(Pending)

- We have developed a 36 question survey for PCPs regarding CKD
- We will be testing this in 2 PBRNs (UNYNET and WREN) shortly
- Awaiting IRB approval. Funding may be available from the local NKF or a pharmaceutical firm
- If validated, we will try a national survey

## Acknowledgements

- This study was funded by a practice based research network research stimulation grant from the Joint Grant Awards Program of the American Academy of Family Physicians.