Please select the eligibility criteria that correspond to the clinical trial below.
Title: A Chronic Care Model Based QI Program to Improve the Care of Patients With CKD
Brief Summary: The goal of this study is to evaluate the impact of a chronic care model (CCM) based quality improvement program on 1) outcomes for patients with chronic kidney disease (CKD) and 2) adherence to CKD guidelines. This pilot study will evaluate the feasibility of a CCM based quality improvement program for patients with CKD and assess potential mechanisms for the intervention's effect.

Hypothesis: Implementing a CCM based quality improvement program including system level support in the form of collaborative care, a CKD registry, and provider education will 1) reduce systolic BP in patients with poorly controlled hypertension, 2) increase the percentage of patients appropriately monitored for metabolic complications, and 3) decrease the rate of catheter use in patients initiating dialysis.


Options:
A: Inclusion Criteria:

* Our target population is male and female hemodialysis patients age 18 years or greater who are English speakers.

Exclusion Criteria:

* We will exclude children because they comprise a minority of the dialysis population and their enrollment would require an adult decision maker's consent.
* We will exclude patients who are significantly cognitively impaired and hence, unable to comprehend study surveys.
* Cognitive function will be assessed at baseline using the mini-Cog, a validated measure of cognitive capacity that we have used previously, and patients with scores \<3 will be excluded.
* Based on our prior studies, we estimate that approximately 5% of patients will be excluded based on this criterion.
* Similarly, non-English speakers will be excluded.
* Finally, patients undergoing active work-up for living donor kidney transplant, and/or considering transfer to peritoneal dialysis will be excluded as they are less likely to remain on hemodialysis for the duration of the study.
B: Inclusion Criteria:

* African American race
* male or female
* 21 to 80 years old
* diagnosis of ESRD
* eligible for listing on the kidney transplant waiting list at Beth Israel Deaconess Medical Center
* resides within 150 minutes of transplant center
* residential or cell phone service
* signed informed consent

Exclusion Criteria:

* Wait-listed for additional organ transplant (i.e., heart, liver)
* current substance abuse or dependency
* known or suspected psychotic disorder
* known or suspected mental retardation
C: Inclusion Criteria:

* Diabetes Type 2
* Albuminuria
* Age 30-70

Exclusion Criteria:

* Diabetes duration \< 3 years
* Preexisting non-diabetic kidney
* Psychiatric disorders
* Alcohol or drug abuse
* Malignant tumors or hematologic disorders
* Heart failure NYHA III-IV
* Acute coronary syndrome
D: Inclusion Criteria:

* receipt of primary care at a VISN 10 Northeast Ohio CBOC
* GFR (calculated according to the 4 variable Modification of Diet in Renal Disease study equation) less than 45 mL/min per 1.73m2 with a second GFR less than 60 at least 90 to 730 days prior to the index GFR (26); and
* at least one primary care visit in the year prior to study initiation.

Exclusion Criteria:

* ESRD as defined by chronic renal replacement therapy,
* receipt of a renal transplant,
* hospice care, and
* age greater than 85 years or less than 18 years at the time of study initiation.

Answer: D