The Leicester, Leicestershire and Rutland Integrated Chronic Kidney Disease (iCKD) System Programme: Implementation within a Primary Care Network

doi:10.21203/rs.3.rs-3349113/v1

Download PDF

Research Article

The Leicester, Leicestershire and Rutland Integrated Chronic Kidney Disease (iCKD) System Programme: Implementation within a Primary Care Network

https://doi.org/10.21203/rs.3.rs-3349113/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 08 Aug, 2024

Read the published version in BMC Nephrology →

You are reading this latest preprint version

Background: The optimisation of patients in primary care is a prime opportunity to manage patient care within the community and reduce the burden of referrals on secondary care. Herein we report a quality improvement clinical programme taking place within an NHS Primary Care Network as part of the wider Leicester Leicestershire Rutland integrated chronic kidney disease programme.

Method: Patients are optimised to guidelines from the National Institute for Health and Care Excellence, supported by a primary care clinical team who are in turn supported by nephrology consultants and nephrology pharmacists. The secondary care specialists undertake monthly multidisciplinary team meetings with the primary care staff where learning is passed to the community clinicians for better patient treatment locally.

Results: A total of 526 patients were reviewed under this project and following upskilling of the local clinician team in nephrology and medicine management, the total number of referrals to secondary care which were discharged following first outpatient appointment reduced from 42.9% to 10%. This reduction of 32.9% represents the sifting and optimisation of patients cases through this quality improvement programme by allowing many patients to be optimised and managed within the community and reducing the number of unnecessary referrals to secondary care, instead referring the difficult and complex cases which benefit the most from care within the Trust.

Conclusion: This programme has the potential to offer significant improvement in patient outcomes when expanded to a larger patient base, whilst optimising both the medicine management and the use of clinical staff in both primary and secondary care.

chronic kidney disease

medicines optimisation

clinical audit

renal

nephrology

primary care

Chronic kidney disease (CKD) is defined as a reduction in kidney function or structural damage (or both) present for more than 3 months[1]. It is associated with multiple complications such as acute kidney Injury, endstage kidney disease (ESKD), and cardiovascular diseases. CKD is not a standalone condition that occurs in a patient, its aetiology stems from a host of other chronic diseases a patient may suffer from such as diabetes mellitus and hypertension [2]. Furthermore, there are a number of environmental and societal factors which can catalyse CKD and associated conditions including demographics, health inequalities, genetic, cultural and biological contributors [3]. Combined with these comorbidities, CKD significantly contributes to increased mortality in patients, therefore the health implications to the health service for treating CKD appropriately are manifest [4]. Indeed, according to a recent report by Kidney Research UK, in 2023 kidney diseases account for approximately 3.2% of total NHS spending, representing £6.4bn. With CKD affecting more than 10% of the UK population, this figure is increasing proportionately with average population age [5].

For the optimal management of CKD there should be an aim to move away from treating standalone cardiovascular, kidney or metabolic pathologies and instead optimise treatment of these individuals in context of their multiple morbidities. CKD is diagnosed by measuring the Estimated Glomerular Filtration rate (eGFR) and other factors such as proteinuria and haematuria. It is classified in 5 stages based on the eGFR and Albumin Creatine ratio (ACR) [6].

CKD Stage 1: eGFR > 90ml/min/1.73m²,

CKD Stage 2: eGFR is 60-89ml/min/1.73m²,

CKD Stage 3a: eGFR is 45-59ml/min/1.73m²,

CKD Stage 3b: eGFR is 30-44ml/min/1.73m²,

CKD Stage 4: eGFR is 15-29ml/min/1.73m²,

CKD stage 5: eGFR is < 15ml/min/1.73m².

Each of the above 5 stages is further categorised by ACR levels with results given as a stage from 1 to 3:

A1 – an ACR of less than 3mg/mmol

A2 – an ACR of 3 to 30mg/mmol

A3 – an ACR of more than 30mg/mmol

The incidence and prevalence of CKD varies depending on the population studied, including ethnic group and socio-economic class. Kidney Research UK estimates that 7.2 million people currently have CKD in stages 1–5, equating to more than 10% of the population [5]. Public Health England produced a CKD prevalence model in 2014 using The Health Survey for England (HSE) 2010 report to show a clear association between increasing age and higher CKD stage 3a-5 prevalence [7]. It is likely that prevalence is rising as the population is ageing and several CKD risk factors such as obesity, type 2 diabetes, and hypertension are also increasingly common.

The number of people diagnosed with CKD stages 3–5 is expected to reach 3.9 million within the next decade, with 30,000 adults and children already on dialysis through the NHS losing more than 12 hours per week of work, leisure and social time. This number could increase to 143,000 by 2023 with the annual requirement for transplantation rising to 12,000. The annual cost per person for dialysis treatment currently stands at £34,000, with the total cost burden of kidney disease being £6.4bn to the NHS; or 3.2% of the total NHS budget [5]. It therefore follows that there is a positive ripple effect from tackling CKD with optimising therapy as it will also have an impact on the cost burden of cardiovascular diseases and KRT for the NHS.

Given the significance of appropriate CKD management, the Willows Health CKD taskforce set out a quality improvement (QI) initiative designed to utilise novel multidisciplinary team (MDT) interventions aimed at improving kidney health for all by preventing progression of CKD and associated complications, improving CKD management and health outcomes and promote integration, maximising productivity and value for money across the healthcare system, and medicines optimisation in patients with CKD in order to improve patient health and outcomes.

Currently, CKD is managed via a combination of tighter blood pressure (BP) control, lipid management and lifestyle interventions (such as dietary advice, smoke cessation and exercise). Medical treatment is usually administered in the form of Angiotensin-Converting Enzyme inhibitors (ACEi) or Angiotensin Receptor Blockers (ARBs) for cardiovascular and renal protection and BP control, along with a statin for lipid control and reduction of cardiovascular disease risk.[8] In 2020, the DapaCKD study by Heerspink, et al. demonstrated positive outcomes with the use of Dapagliflozin in patients with CKD (irrespective of diabetes status). The study demonstrated “the risk of a composite of a sustained decline in the estimated GFR of at least 50%, end-stage kidney disease, or death from renal or cardiovascular causes was significantly lower with dapagliflozin than with placebo”.[9] Based on this, in November 2021, the National Institute for Health and Care Excellence (NICE) recommended the use of Dapagliflozin for people with CKD and in March 2022 released Technology appraisal guidance (TA775) providing evidence-based recommendations on its use [10].

The Willows Health CKD QI Initiative

Centred on these guidelines, the Willows Health CKD QI initiative aimed to evaluate current practice in CKD management and establish how many patients may benefit from the addition of Dapagliflozin based on the updated changes to NICE guidelines on treatment of CKD. The aims of the QI initiative were to evaluate the current practice, where patients are not yet optimised with ACEi/ARBs and statins; facilitate the optimisation and where indicated, initiate the patient on Dapagliflozin. The legacy aims of the QI initiative were to improve current practice and treatment of CKD and look to encompass the management of CKD routinely with other comorbidities, improve knowledge and understanding amongst clinicians and patients around CKD and optimise therapy where possible in line with NICE TA775.

What is the patient demographic and how are patients identified as “at risk”

The Willows PCN has a wide and diverse demographic, with a majority of patients identifying as Asian and 23% of its patients living in deprived areas (Source: M&L CSU, NHS).

Patients are identified by two means. Firstly, through the use of the AstraZeneca Nephrology Dashboard, a Microsoft Excel-based population-level spreadsheet tool which summarises patients cases by parsing data from SystmOne, processing patient data and outcomes and highlighting at-risk patients. This includes data from patient records such as user needs and eGFR and combines this in a dashboard, which calculates standard decision support metrics such as risk of kidney failure. The second identification means is the use of The Kidney Failure Risk Equation (KFRE) (REF NICE Guidelines), urinary albumin to creatinine ratio (ACR) or eGFR to identify those patients at risk.

How are cases considered?

Patient cases are initially brought to CKD clinical sessions where a consultant nephrologist and nephrologist pharmacist discuss cases with the primary care team in a virtual MDT. In the first MDT session, the primary care team consisting of the lead clinical pharmacist and support staff brought forward a range of patients. Following the MDT, it was clear that significant multidisciplinary learning had taken place and the primary care team understood that many of these patients were not in fact complex and could be managed in the community with medicine optimisation. These learnings led to optimisation clinics in the primary care network led by the clinical pharmacist where ACE inhibitor and STLG2 dosage was optimised leading to improved local management.

Operational requirements and results

MDT meetings were initially scheduled for every 8 weeks with patient cases being considered at each meeting. However, after the initial MDT where collaborative learning took place between the secondary and primary care teams, patients are now initially managed within the PCN through ACE and STLG2 optimisation, with only complex patients being referred to secondary care. The turnaround of patient cases has now reduced to 2 weeks from internal referral to a medicines optimisation with a clinical pharmacist within the PCN team. The confidence and experience in the clinical team within the PCN has now been sufficiently upskilled to see a significant reduction in cases referred to secondary care. Indeed, from a cohort of 526 patients where previously 30 patients were being referred to secondary consults each month, this has now reduced to 2.

Patients with CKD Stages 1–5 were identified through two means and had their current health status analysed. Data metrics such as patient’s hypertension status/treatment, their latest eGFR, ACR and diabetic status were compiled. Using this data and looking into the patient’s an action plan was formulated for each patient. This including optimising BP where indicated and optimising ACEi/ARBs if indicated, initiating statins if indicated, providing lifestyle advice, optimising diabetic management if indicated and finally, initiating on Dapagliflozin if indicated. Each patient was then booked into a specialist cardiovascular-renal-metabolic (CVRM) clinic to carry out these recommendations and ensure appropriate management and follow up was in place. Where patients proved more complex or there was uncertainty around the appropriate management of a patient, this was discussed at integrated renal MDT between primary and secondary care clinicians.

A total of 526 patients were reviewed under this quality improvement project within the Willows PCN in Leicester. Of these, 407 were undergoing treatment for diabetes mellitus, 18 heart failure and 101 were classified as under treatment for CKD alone with no associated complications or additional morbidities. Of the 526 patients reviewed, 371 were eligible for interventions. The remaining patients were either unsuitable for optimisation due to frailty, were under specialist care, or declined intervention. 329 patients were then optimised according to NICE guidelines (Fig. 1) with 298 having their blood pressure (BP) brought within target range. The remaining patients were not at target range but managed to their lowest tolerated BP. A total of 339 patients were optimised to the maximum tolerated RAASi therapy, where the remainder of patients were deemed unsuitable for RAASi according to NICE guidelines. Of the 329 patients who were optimised according to NICE guidelines, 100% tolerated and were optimised to addition of SGLT2i (Table 1).

Table 1

Summary of patient numbers within the quality improvement framework undertaken where DM: diabetes mellitus, HF: heart failure.
Number of patients reviewed under CKD quality improvement initiative	526
With DM	407
With HF	18
With CKD alone	101
Interventions	371
Number of patients who had optimisation of treatment as per NICE guidelines	329
BP bought in target range	298
Max tolerated RAASi therapy	339
Addition of SGLT2i	329

Indeed, whilst the percentage of OP discharged at first attendance in secondary care nephrology clinics was 42.9% in 2021/22, this has reduced to 10% in 2022/23. This reduction of 32.9% can be attributed to improved management of patients in our primary care setting, improved nephrology medicines management and learning by the primary care clinical team and thereby only more complex and less traditional cases being referred to secondary care. This demonstrates that the MDT support and nephrology pharmacist support can lead to improved patient care in the community, whilst reducing the burden of unmanaged and unoptimized referrals to secondary care.

Implementation into PCN Digital Health Services

Based on the tools and learning developed through application of the iCKD programme within the PCN, the pharmacy team was able to design and implement a series of decision-support and clinical management tools within the PCNs clinical management system, SystmOne.

Case Finding and Patient Identification

This consists of two elements: (i) the identification of patients with potentially undiagnosed CKD, and (ii) identifying patients who would benefit from SGLT2i based on local CKD or NICE NG28 T2DM guidelines.

Once patients are identified through these searches (Figure 2a), their record has a pop-up message attached when opened which prompts the clinician based on the results of the search (Figure 2b).

A CKD Home Page has been created for clinicians, which facilitates their decision making and parsing of clinical records through each stage of the CKD care pathway. Sections are attributed to diagnosis, review, referral, additional notes and MDT, as well as a useful resources section (Figure 2c).

The diagnosis tab is based on the KDIGO head map [11] which allows for early diagnosis and prompt management of the condition (Figure 3).

Once diagnosis has been completed, a review page supports monitoring by automatically calculating KFRE through a single click-through option (Figure 3b). This allows for seamless data gathering and capturing additional clinical data for these patients within the pathway. It also enables factors such as medication and lifestyle to be included and codes for these within SystmOne appropriately. Currently, we include: Lifestyle advice, ACEi/ARB optimisation, SGLT2 optimisation, and Lipid management.

Additionally, the template also allows the clinician to code any leave guidance such as sick days which have been recommended, as well as DKA and SGLT2 education and allows for the production of patient leaflets and letters in an automated fashion and improves the safety of prescribing such medications (Figure 3c).

Referral criteria (Figure 3d) within the “Referral” tab of the CKD Homepage on SystmOne have been designed to (a) aid the clinician in ensuring the necessity of referral is fully justified and (b) highlighting that optimisation and other support measures have either been unsuccessful or inappropriate for the specific case within the PCN and thereby necessitating support from secondary care.

As part of the integration within the wider continuous management workstream, the CKD digital tools described herein are also included within our chronic disease management toolkit (Figure 3e) which allows for more holistic review of such often complicated clinical cases.

This initiative is an ongoing project but early data shows that there is a need for this type of activity across early nephrology care. Prior to review in CVRM clinics, patients were rarely optimised to gold-standard therapies with the correct polypharmacy and target cardio-metabolic readings. Of the 526 patients in the project, only approximately 20% of patients were already optimised to the stage where Dapagliflozin would be the only step in medicines optimisation. All other patients were in need of multiple levels of optimisation and were therefore booked in to enhanced CVRM clinics to facilitate this. Furthermore, the MDT pathway has proven to be of great utility, by reduced unnecessary referrals into secondary care as well as expediting those who needed to be seen promptly. Easy to obtain advice and guidance and case discussions with secondary care consultants has improved CKD understanding and management amongst primary care clinicians and their teams. Overall outcomes will be established as analysis of patient outcomes will be undertaken as part of the collating of project work packages across the different NHS environments and sites involved. Furthermore, the limited time requirement by primary and secondary care staff to work within the MDT is economically mitigated by the time saving of the improved optimisation of patients in the community, as well as the development and implementation of the digital tools and case forms described herein.

This early data is highly promising and demonstrates the need to see this QI project further develop and to ensure there is a legacy effect in place for future CKD patients. If our initial findings are representative of CKD management nationally, further work and roll out of such QI initiatives will be of significant importance. Indeed, such capabilities as outlined herein are now available to all primary care networks within the LLR region.

Chronic Kidney Disease (CKD)

Quality Improvement (QI)

National Institute for Health and Care Excellence (NICE)

Endstage Kidney Disease (ESKD)

Estimated Glomerular Filtration rate (eGFR)

Albumin Creatine Ratio (ACR)

Health Survey for England (HSE)

Kidney Replacement Therapy (KRT)

Blood Pressure (BP)

Angiotensin-Converting Enzyme Inhibitors (ACEi)

Angiotensin Receptor Blockers (ARBs)

Technology appraisal guidance (TA775)

Cardiovascular-Renal-Metabolic (CVRM)

The Kidney Failure Risk Equation (KFRE)

Renin-angiotensin-aldosterone system inhibitors (RAASi)

Diabetes Mellitus (DM)

Heart Failure (HF)

Sodium-glucose co-transporter-2 inhibitors (SGLT2i)

Outpatient (OP)

Urine Albumin-Creatinine Ratio (uACR)

Cardiovascular (CV)

Calcium-Channel Blocker (CCB)

Hypertension (HTN)

Ambulatory Blood Pressure Monitoring (ABPM)

Home Blood Pressure Monitoring (HBPM)

Mineralocorticoid Receptor Antagonists (MRA)

Kidney Disease Improving Global Outcomes (KDIGO)

Primary Care Network (PCN)

Diabetic Ketoacidosis (DKA)

Ethics approval

This work was undertaken as a service evaluation and therefore internal ethical approval was obtained with Reference: EB/14-40-2019. Care team-anonymised information was used in this health and care research to support public health surveillance and wider clinical decision-making, therefore consent was not required for de-identified data.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

Conflicts of interest

The authors declare no competing interests.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors

Authors' contributions

Authors are designated herein by their initials.

Design: FR, NL, LO, TK, PBW; supervision: FR, TK, PBW; methodology: FR, NL, PBW; formal analysis: SR, TK, NL; writing - first draft: NL, SR; editing - final draft: all.

Levey AS, Coresh J. Chronic kidney disease. The Lancet 2012;379:165–80.
Kalantar-Zadeh K, Jafar TH, Nitsch D, Neuen BL, Perkovic V. Chronic kidney disease. The Lancet 2021;398:786–802.
Metcalfe W. How does early chronic kidney disease progress? A background paper prepared for the UK Consensus Conference on early chronic kidney disease. Nephrology Dialysis Transplantation 2007;22:ix26–30.
Kerr M, Bray B, Medcalf J, O’Donoghue DJ, Matthews B. Estimating the financial cost of chronic kidney disease to the NHS in England. Nephrology Dialysis Transplantation 2012;27:iii73–80.
Tomlinson L, Basoah A, Bell S, Christian M, Gale D, Graham-Brown M, et al. Kidney disease: A UK public health emergency. 2023.
Hill CJ, Cardwell CR, Patterson CC, Maxwell AP, Magee GM, Young RJ, et al. Chronic kidney disease and diabetes in the national health service: a cross‐sectional survey of the UK national diabetes audit. Diabetic Medicine 2014;31:448–54.
Public Health England. Chronic kidney disease prevalence model. London: 2014.
National Collaborating Centre for Chronic Conditions (Great Britain). Chronic kidney disease: national clinical guideline for early identification and management in adults in primary and secondary care, Royal College of Physicians; 2008.
Heerspink HJL, Stefánsson B V, Correa-Rotter R, Chertow GM, Greene T, Hou F-F, et al. Dapagliflozin in patients with chronic kidney disease. New England Journal of Medicine 2020;383:1436–46.
Martinez Y V, Benett I, Lewington AJP, Wierzbicki AS. Chronic kidney disease: summary of updated NICE guidance. Bmj 2021;374.
Levey AS, Eckardt K-U, Dorman NM, Christiansen SL, Cheung M, Jadoul M, et al. Nomenclature for kidney function and disease—executive summary and glossary from a Kidney Disease: Improving Global Outcomes (KDIGO) consensus conference. Eur Heart J 2020;41:4592–8.

No competing interests reported.

Download PDF

Journal Publication

published 08 Aug, 2024

Read the published version in BMC Nephrology →

Editorial decision: Revision requested
16 Nov, 2023
Reviews received at journal
31 Oct, 2023
Reviewers agreed at journal
31 Oct, 2023
Reviewers agreed at journal
31 Oct, 2023
Reviewers invited by journal
25 Oct, 2023
Editor assigned by journal
25 Oct, 2023
Editor invited by journal
10 Oct, 2023
Submission checks completed at journal
10 Oct, 2023
First submitted to journal
12 Sep, 2023

You are reading this latest preprint version

The Leicester, Leicestershire and Rutland Integrated Chronic Kidney Disease (iCKD) System Programme: Implementation within a Primary Care Network

Status:

Journal Publication

Version 1

Abstract

Figures

Introduction

Aim

The Willows Health CKD QI Initiative

Participants

What is the patient demographic and how are patients identified as “at risk”

Method

How are cases considered?

Operational requirements and results

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1