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A QUALITY IMPROVEMENT PROJECT TO IMPLEMENT

Vivian Chukwuani, Sumeet Chavan, Olgun Esra, Shivani Bishnoi, Mahesh Borhade, Kavitha Kesari,Parul Sud. Department of Internal Medicine,

Mclaren Regional Medical Center, Flint, MI. Background: Chronic kidney disease (CKD) is a worldwide public health problem affecting more than 26 million Americans, with millions more at increased risk. It is the 9th leading cause of death in the United States. In February 2002, The National Kidney Foundation set up a Kidney Disease Outcome Quality Initiative (K/DOQI) guideline, which was updated in 2006. Studies show that primary care physicians are unaware of these guidelines and there are limited studies documenting physician adherence to the guidelines in outpatient practices. Aim :Within 3 months, we hope to achieve 60% adherence to K/DOQI guidelines by our physicians at the internal medicine clinic (IMC).PDSA: Weekly meetings of the quality improvement (QI) group were scheduled. After IRB approval we assessed physicians’ awareness to K/DOQI guidelines using CKD protocol sheets .We reviewed 209 charts of patients seen during the 30-day study period.Results: The etiologies for chronic kidney disease were hypertension (74%) and diabetes (28%). For all the stages of CKD, the best-controlled factor in descending order was; maintenance of normal low density lipoprotein (LDL -55.7%), blood pressure control (54%) and cigarette smoking cessation (40%). For stages 3 and 4, the best-controlled factor in descending order was maintenance of hemoglobin ≥11g/dl (45%), maintenance of phosphorus levels (35%). For referrals, 28% were appropriately referred to a nephrologist, 3% to a dietician but none was referred for vascular access. Only 15% of the patients received Influenza, pneumococcal and TdaP vaccination.Conclusion: The implementation and achievement of K/DOQI guidelines by the primary care physicians was sub-optimal. The QI group identified this problem, created awareness by physician education, and designed a protocol sheet to enhance physician implementation and achievement of the guidelines. We have subsequently created personalized formative feedback to the individual physicians to achieve better results.

Further surveys will assess the compliance to the feedback.

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EFFICACY OF INCORPORATING CRITERIA FOR CINACALCET (SENSIPAR) USE INTO A PARICALCITOL (ZEMPLAR) PROTOCOL IN SECONDARY HYPERPARATHYROIDISM Barbara Clark, Bruno Lima, Piyush Lohiya, Dept of Nephrology, Allegheny General Hospital, Pittsburgh, PA, USA We recently revised our Paricalcitol (Zemplar) protocol to incorporate cinacalcet (Sensipar) use in hopes of findng more patients achieving target PTH (150-300) and with less elevations in Cax P product. We recommend initiation of Sensipar when intact parathormone (PTH) levels >400 pg/ml and Calcium X Phosphorus (Ca X P) product >60 despite use of Zemplar at > 5 mcg per treatment. We now report outcomes after changing the protocol. A total of 55 patients were identified from our unit with enough data to evaluate (from a year before and a year after the protocol change). 12 of the 55 patients were initiated on Sensipar as defined by the protocol. In these patients, after changing the protocol mean PTH and Ca X P product fell significantly (p<0.02) (see graphs) Transient asymptomatic hypocalcemia occurred in 2 patients who improved with increased Zemplar dosing. Oversuppression occurred in 1 patient (PTH<80) and Sensipar was held. In the entire population, prior to changing the protocol 31/55 (56.4%) patients met goal PTH (<400) and 39/55 (70.9%) had Ca X P product <60. After changing the protocol 41/55 (74.5%) met goal PTH (p<0.05) and 39/55 (70.9%) had Ca X P <60. In summary, PTH goals are easier to achieve with protocols involving use of both Vitamin D analogues and calcimimetics. However there is persistent difficulty with elevated Ca X P which is likely related to patient driven diet and binder compliance issues. There may be a need to incorporate calcimimetic use at an even lower Ca X P product limit in an attempt to better achieve KDOQI guidelines. We have now further revised our protocol to recommend Sensipar use when PTH remains >400 (with Zemplar >5 mcg) and Ca x P product exceeds 55.

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STRATEGIES TO IMPROVE PHOSPHORUS CONTROL IN PATIENTS WITH CHRONIC SEVERE HYPERPHOSPHATEMIA Barbara Clark MD , Ankur Patel DO, Lori Groves-Seaman RD, Jessica Palombine RD, and Richard Marcus MD. Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, PA, USA. Hyperphosphatemia in the dialysis population remains a significant problem in spite of dietician counseling and phosphorus binding agents. The present study was designed to see if intensive physician directed education would have any additional benefit in lowering phosphorus levels in patients with persistent hyperphosphatemia. Eligible patients were those with a serum phosphorus levels of >6.5 for > 3 consecutive months. The intervention group met with the study physician monthly for 3 consecutive months with review of food diaries, binder use and compliance, pictorial and written proper diet choices and pictorial and verbal description of potential vascular complications (in addition to the standard dietician visit). The control group met with the dietician monthly with review of labs and diet. Both groups were also seen monthly by their individual nephrologists with ESRD management at their discretion. 12 randomly assigned patients have completed the study, 6 in the intervention group and 6 in the control. Average PO4 levels in the intervention group were 7.5 + 0.75 at baseline, fell to 6.65+0.61 during intervention months (p<0.05) and were 6.81+1.3,NS during the 4 months post intervention. Calcium phosphorus product was 73+9 at baseline, 62+11 (p=0.058) during intervention and 63+15 (NS) 4 months post intervention. In the control group phosphorus levels were 7.14+1.36 at baseline, 6.6+1.27 from months 3-7 and 6.25+1.4 (NS) during the subsequent 4 months. Calcium phosphorus product in the control group was 63+14, 59+12 and 57+13 at each time point (NS). In summary, intensive regular education with physician involvement can improve phosphorus even in patients with notoriously high levels. However, this was only partially effective, was time consuming and did not persist after intensive education was discontinued. We conclude that regular physician involvement with reinforcement of dietician counseling, review of binder use and education about possible cardiovascular consequences is important. However, ongoing strategies for simpler, more effective and less time consuming tools should be developed.

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CORRELATION BETWEEN ROUTINE PERI-HEMODIALYSIS BLOOD PRESSURE MEASUREMENTS AND AMBULATORY BLOOD PRESSURE MEASUREMENT IN PATIENTS WITH END-STAGE RENAL DISEASE. Adrian Cosmin., Nahid Islam, Catherine Wells, Tibor Fulop, Department of Internal Medicine, Division of Nephrology. University of Mississippi Medical Center, Jackson, MS. Nephrologists routinely use blood pressure (BP) measurements during hemodialysis (HD) to assess BP control in patients with End-Stage Renal Disease (ESRD) on dialysis. Our study objective was to assess correlation between routine pre/post BP values on HD and results on 48-hour ambulatory blood pressure monitoring (ABPM). Forty-three patients were recruited from the University of Mississippi Medical Center Outpatient Hemodialysis Unit. Data obtained included: age, race, gender, co-morbid illnesses vintage on dialysis, last 6 previous dialysis logs and 48 hour ambulatory blood pressure measurements. Data are presented as either percentage or means with ±SD and analyzed with SPSS v.16 using ANOVA and logistic regression Statistical significant correlation existed between diastolic pre-HD BP, systolic and diastolic post-HD BP and average systolic and diastolic BP on ABPM (p 0.01, <0.001 and 0.037 respectively). Systolic BP on ABPM and pre-HD did not correlate Post-HD BP measurements correlate with ABPM measurements and should be used preferentially when assessing BP control in ESRD patients.

NKF 2010 Spring Clinical Meetings Abstracts A49