LOOKING UNDER THE HOOD:Renal Physicians Association

Field Test of the Advanced CKD Patient

Management Toolkit

Remy R. Coeytaux, MD, PhDMarch 22, 2009

Chapters of the Story

1. The Challenge

2. The Protagonists

3. The Plot

4. The Toolkit

5. The Study

6. Looking Under the Hood

7. Insights

8. The Future

The Challenge

• Epidemiology of advanced CKD

• Timely diagnosis

• Comorbidities and competing demands

• Co-management of patients across medical specialties

• Access to, and cost of, nephrology specialty care

• Imperfect/incomplete evidence to inform management decisions

• Practice variations

• Time and resource constraints

• Access to appropriate technology and tools

• Limitations of health information technology

The Protagonists

• Renal Physicians Association (RPA)

• Duke Center for Clinical Health Policy Research (DCCRP)

• 10 nephrology sites across the U.S.

• Patients with chronic kidney disease

The Plot (RPA-DCCHPR collaboration)

• 2000 – RPA funds clinical practice guideline for advanced CKD

• 2003-2004 – Advanced CKD Patient Management Toolkit developed and

disseminated

• 2006– Toolkit pilot tested in 2 practices in North Carolina– Revised toolkit issued

• 2008– Field test of 10 nephrology practices launched

The Plot

Appropriate Patient Preparation for Renal Replacement Therapy CPG– Multidisciplinary workgroup chaired by Kline Bolton, MD– Report released in October, 2002– Patient population: adults with GFR < 30, not on dialysis

7 goals of care– Optimal management of anemia– Bone disease prevention and management– Control of blood pressure– Maintenance of adequate nutrition– Management of lipid disorders– Timing of RRT and vascular access– Appropriate and timely patient education

The Toolkit

The Advanced CKD Toolkit

• Adaptable and Customizable

• Consider tools appropriate for the practice’s needs

• Select tool versions per individual preference

• Customize tools (e.g. change lab values, modify letters)

What Practical Approaches/Tools Can We Use?

Physician tools Patient tools

1. Identify Identification tools

2. Plan and communicate

Communication and reminder tools

Education resources

CKD classes

3. Manage Management tools Diary

Identification Tools

• CKD Identification and Action Plan (card and poster)

• GFR calculator (slide-rule, resources for calculations on Palm/hand-held PC device/Web sites)

• Chart stickers

Planning & Communication Tools

• Awareness Letter from nephrologist to referring physician

• Referring Physician Faxback Form

• Post-Consult Letter

Management Tools

• Management Flow Sheet– Reminder– Information on target levels– Data repository for performance measurement

• Algorithms– Anemia – Hypertension– Nutrition– Dyslipidemia– Bone disease

• Patient diary– Initiates discussion– Educational tool– Patient-initiated physician reminder

The Study: Title

Field Test of the Advanced CKD Patient Management Toolkit

a.k.a.

RPA 10-Site Toolkit Implementation Study

The Study: Investigators

Duke Center for Clinical Health Policy Research

Renal Physicians Association (RPA)

Dale Singer, MHA

(Executive Director, RPA)

Amy Beckrich

(Project Manager, RPA)

William E Haley, MD

(RPA Consultant)

David Matchar, MD (Principal Investigator)

Remy Coeytaux, MD, PhD(Acting Principal Investigator)

Gregory Samsa, PhD(Biostatistician)

Uptal Patel, MD(Nephrologist)

Meenal Patwardhan, MD, MHSA (Consultant)

Jameta Barlow, MPH(Project Manager)

Julian Irvine(Project Coordinator)

The Study: Continuum of Activities

1) Evidence Report on Appropriate Patient Preparation for Renal Replacement TherapyMcCrory D, et al. Evidence Report: Appropriate Patient Preparation for Renal Replacement Therapy. Rockville, MD, RPA, 2002.

2) Clinical practice guideline and performance measures (CPG and CPMs) RPA. The RPA Advanced CKD Patient Management Toolkit: Improving Management and Care of Advanced Chronic Kidney

Disease Patients. Rockville, MD; 2004.

3) “Advanced CKD Patient Management Toolkit” Matchar D, et al. Facilitated Process Improvement: An approach to the seamless linkage between evidence and practice. American

Journal of Kidney Diseases. 2006; 47(3): 528-538.Patwardhan MB et al. Opportunities for Improving Management of Advanced Chronic Kidney Disease. American Journal of Medical

Quality.2008; 23: 184-192 Patwardhan MB, et al. Advanced Chronic Kidney Disease Practice Patterns among Nephrologists and Non-Nephrologists: A

Database Analysis. Clin.J. Am. Soc. Nephrol. 2007 2: 277-283.Patwardhan MB, et al. Non-nephrologist and nephrologist perspectives on implementing a chronic kidney disease guideline. 2007

Journal of Healthcare Quality. Web exclusives.Patwardhan MB, et al. Opportunities for improving management of advanced chronic kidney disease: current practice patterns.

American Journal of Medical Quality. 2008. Vol. 23, No. 3, 184-192. Patwardhan MB, et al. Utility of the advanced chronic kidney disease patient management tools: case studies. American Journal of

Medical Quality. 2008. Vol. 23, No. 2, 105-114.

4) Pilot test of toolkit Utility of the Advanced Chronic Kidney Disease Patient Management Tools: Case Studies. Patwardhan et al. American

College of Medical Quality, Vol. 23, No. 3, > 184-192 (2008)

5) Field test of toolkit in 10, real-world practice settings

The Study: Specific Aims

1. Evaluate the utility of the Advanced CKD Patient Management Toolkit

2. Assess care patterns and changes in processes required to improve care

3. Evaluate the impact of the implementation exercise on improved conformance to guideline recommendations.

The Study: 10 Sites

• Nephrophiles, LLC, Santa Fe, NM Site champion: Robert Kossmann, MD

• Long Island Hypertension & Nephrology, Port Washington, NY Site champion: Teresa Alfano, NP-CNN

• Western New England Renal and Transplant Associates, Springfield, MA Site champion: Michael Germain, MD

• Renal Associates of Baton Rouge, Baton Rouge, LA Site champion: Jaimie Smith, BSW, RSW

• The Center for Kidney Care, Mt Laurel, NJ Site champion: Dan Strauch, MHA, CMPE

• Renal Medicine Associates, Albuquerque, NM Site champion: Elizabeth Evans, CNP

• Associates in Kidney Care, Des Moines, IASite champion: TBD

• Indiana Medical Associates, Fort Wayne, IN Site champion: TBD

• Boise Kidney and Hypertension Institute, Meridian, ID Site champion: Kirsten Vanderhalf, BS CRC

• North Houston Nephrology, Houston, TXSite champions: Toni Ambrosy and Debbie McCarthy, LVN

The Study: Research Plan

• 10 nephrology sites across the country selected

• Randomly divided into two groups

• Group 2 serves as a comparator for Group 1

• Level of conformance to guidelines will be measured

• 7 goals of care (anemia, HT, bone disease, nutrition, dyslipidemias, education, timing of RRT)

• Toolkit will be implemented

• Level of conformance to guidelines will be measured post implementation

• Change in conformance will be measured

• Sustainability of change will be assessed

Looking Under the Hood

Unique opportunity:

• 10 nephrology practices• Different patient populations; different regions in the U.S.• Variety of tools and technology• Shared goals• Universal challenges• Unique set of expertise & perspectives:

– RPA: interface of science, management, and policy– DCCHPR: health policy; practice guideline implementation– Practicing physicians: real-world issues

Insights

(To be presented live)

The Future

(To be presented live)

Thank you.

Time for questions and discussion