# Presentation: 752806

## Making Chronic Kidney Disease Guidelines Work in Underserved Practices

- Chet Fox MD
- Linda Kahn PhD
- Katheryn Glaser BS
- UNYNET

- AHRQ R03 H5016031

## BACKGROUND

- CKD is an increasingly serious problem especially in patients with HTN and DM

- USRDS 2000

## Only 10% of practices in UNYNET were aware of existence of CKD guidelines
A national study showed PCP unaware of CKD guidelines
AND HAVE COMPETING DEMANDS
7.9 hours for screening 
3.5 hours chronic disease management 

- Only 10% of practices in UNYNET were aware of existence of CKD guidelines
- A national study showed PCP unaware of CKD guidelines
- AND HAVE COMPETING DEMANDS
- 7.9 hours for screening
- 3.5 hours chronic disease management

## Fox, C. H., A. Brooks, et al. (2006). "Primary care physicians' knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study." Journal of the American Board of Family Medicine: JABFM 19(1): 54-61
Boulware, L. E., M. U. Troll, et al. (2006). "Identification and referral of patients with progressive CKD: a national study." American Journal of Kidney Diseases 48(2): 192-204.
Ostbye, T., K. S. Yarnall, et al. (2005). "Is there time for management of patients with chronic diseases in primary care?" Annals of Family Medicine 3(3): 209-14.
Yarnall, K. S., K. I. Pollak, et al. (2003). "Primary care: is there enough time for prevention?" American Journal of Public Health 93(4): 635-41.

- Fox, C. H., A. Brooks, et al. (2006). "Primary care physicians' knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study." Journal of the American Board of Family Medicine: JABFM 19(1): 54-61
- Boulware, L. E., M. U. Troll, et al. (2006). "Identification and referral of patients with progressive CKD: a national study." _American Journal of Kidney Diseases_ **48**(2): 192-204.
- Ostbye, T., K. S. Yarnall, et al. (2005). "Is there time for management of patients with chronic diseases in primary care?" _Annals of Family Medicine_ **3**(3): 209-14.
- Yarnall, K. S., K. I. Pollak, et al. (2003). "Primary care: is there enough time for prevention?" _American Journal of Public Health_ **93**(4): 635-41.

## Virtual Care management:
Based on Cooperative Extension model
Combination of proven interventions
Practice Enhancement Assistants (PEA) to work with office staff on QI
Creation of Registries (Can be created easily from paper records using fax machine as optical character recognition
Evidence Based Computer Decision Support
PCP DIRECTED nurse case management

- Virtual Care management:
- Based on Cooperative Extension model
- Combination of proven interventions
- Practice Enhancement Assistants (PEA) to work with office staff on QI
- Creation of Registries (Can be created easily from paper records using fax machine as optical character recognition
- Evidence Based Computer Decision Support
_**PCP DIRECTED **_nurse case management

## 2 Intervention and 2 control sites
All Family Medicine
All predominantly African American
1 intervention and 1 control site has EMR 
100% of patients with CKD in all practices are assessed for outcomes

- 2 Intervention and 2 control sites
- All Family Medicine
- All predominantly African American
- 1 intervention and 1 control site has EMR
- 100% of patients with CKD in all practices are assessed for outcomes

## Dx of CKD (GFR < 60)
Proteinuria level
Glucose control
Lipid control
Recognition and treatment of anemia
Dx disorders of bone metabolism
Stopping harmful meds
Metformin, NSAIDS, Allopurinol and Bisphosphanates

- Dx of CKD (GFR < 60)
- Proteinuria level
- Glucose control
- Lipid control
- Recognition and treatment of anemia
- Dx disorders of bone metabolism
- Stopping harmful meds
- Metformin, NSAIDS, Allopurinol and Bisphosphanates

## At end of project at all sites
2 year retrospective look at outcome
By research associate who was not a PEA
This gives 1 year baseline data at all sites
Followed by 1 year of intervention v. usual care 
Comparison sites agreed to be part of the study, but no education or other intervention was done

- At end of project at all sites
- 2 year retrospective look at outcome
- By research associate who was not a PEA
- This gives 1 year baseline data at all sites
- Followed by 1 year of intervention v. usual care
- Comparison sites agreed to be part of the study, but no education or other intervention was done

## The Virtual Care Process  (Plan)

- MEDICAL RECORD

- Fax or EMR

- PEA

- REGISTRY AND DATABASE CREATED

- COMPUTER DECISION SUPPORT ALGORITHM

- CLINICAL SUPPORT SERVICES TM

- REPORT TO PCP WITH CARE RECOMMENDATION*

- *CONTAINS LAB RESULTS; OTHER DATA; AND RESPONSE REQUEST

- PEA ASSURES DATA FLOW

- CLINICAL SUPPORT SERVICES TM

- PCP OFFICE

- PCP ACCEPTS, REJECTS OR MODIFIES RECOMMENDATION

- NURSE CASE MGR CARRIES OUT MD REC AND EDUCATES PATIENT. ALSO GATHERS MSSING DATA

- PATIENT

## Report to PCP (DO)

- Signature: ___________________

## The QI Cycle

- Data is aggregated
- PEA presents data and change over time to MD and office staff (Study)
- PEA shares insights from other practices working on the same project
- Discussion of what worked and what didn’t is done and appropriate modifications are made (Act)

## Preliminary Results

- 130 patients are enrolled
- Only 50 (38%) were dx with CKD in billing or progress notes
- 33 (25%) did not check Hb
- 31 (32%) had anemia;of these only
- 12 (39%) were diagnosed
- <1% (one patient) had PTH, PO4, or vitamin D levels drawn

## Conclusions 

- CKD, anemia, and bone disease are widely under recognized
- PEAS are readily accepted in PCP offices for improvement of patient care
- The Virtual Care process is capable of rapidly creating disease registries
- Effectiveness of virtual care will be known by next year

## Future Directions

- If effective, Virtual Care will be used for other disease states
- This model for CKD will be tested in rural areas
- Eventually, this can be used for multiple co-morbidities simultaneously

## Thanks!!