Transcript Slide 1

. . . for our health
Chronic Kidney Disease Care
Quality Improvement – A WREN Project
Hannah Louks
University of Wisconsin School of Medicine and Public Health
Center for Urban Population Health
Outline
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Background
Project Overview
Objectives
Implementation
Examples
Questions
Background
• The NKF guidelines have been available since 2002,
but the adoption and implementation of these
guidelines has been inconsistent and incomplete.
• This project employs a multi-component strategy as
an approach to encourage change in practice
(includes academic detailing, performance feedback,
practice facilitation, and information technology
support).
Multi-Component Implementation Strategy
•Academic Detailing
•First meeting
•Peer-to-peer education regarding both what to do and how to
do it
•Led by PI from each participating PBRN
•Performance Feedback
•Shown to be efficacious for practice improvement in a variety
of outcomes.
•Information Technology Support
•General agreement that advanced information systems are
essential to improve the quality of primary health care.
•IT applications represent a way to enhance translation by
giving clinicians and office staff tools that both facilitate and
require them to make changes in their office system.
Multi-Component Implementation Strategy
•Practice Facilitation
•Proven useful for practice-wide implementation of preventative
services guidelines.
•Great appeal to PCPs since it adds resources to the practice
instead rather than depleting them.
•Practice facilitators (PFs) become temporary members of the
practices, acting as “change agents” and facilitating
individualized solutions through rapid quality improvement
cycles (Plan-Do-Study-Act).
•Help practices by showing them ways to do things (based
upon research and the successful methods used in other
practices), helping them to identify and overcome obstacles,
and by providing periodic performance feedback.
Project Overview
• WREN is one of 4 networks working on a 3-year
grant from the Agency for Healthcare Research and
Quality (AHRQ).
• Project is studying ways to help practices implement
the current chronic kidney disease (CKD) guidelines
developed by the National Kidney Foundation.
Requirements for Participation
• Practices receive lab data electronically in a searchable
format (including estimated GFR).
• Practices will be expected to try to implement the CKD
guidelines.
▪ In Phase I, key members of the practice will be expected to
meet with their WREN RRC for at least 1/2 hour per week to
look at performance data and plan implementation
strategies.
• Phase I practices must be willing to recruit two other
practices to participate with them in the LLC wave (Phase
II) of the project and to continue to focus on improving
implementation of CKD guidelines.
Data Collection
• Baseline:
• Enrollment information about practice and participating staff
▪ Written consent from 3 members of the practice selected to
conduct the surveys and interview
▪ A list of all patients with hypertension or diabetes seen within the
prior 12 months, so that information from randomly selected
medical records can be abstracted.
• Baseline and after each project Wave:
▪ A survey about your practice and the processes that you use for
chronic illness care (Practice Systems Survey)
▪ A survey on CKD care that will be completed by each staff
member in the project (CPCQ)
▪ A phone interview to clarify the information provided in the surveys
(with a maximum of two staff per practice).
Main Objectives
1. To use an evidence-based multi-component
implementation strategy.
2. Help primary care practices implement NKF CKD
guidelines and thereby improve their processes
and outcomes for care for patients with this
chronic condition.
Phase I: Implementation
• Each practice receives performance feedback,
educational materials, decision support tools, a
practice facilitator to help clinicians and staff with
implementation of new processes of care (WREN
Regional Research Coordinator – RRC), and health
information technology support.
• The impact of the interventions is assessed on both
practice system and guideline implementation.
Instruments
1. Practice Enrollment Form
▪ Completed by one person from each practice to provide
information about overall practice characteristics.
2.
Change Process Capability Questionnaire (CPCQ)
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Used to measure change process
Measures a practice's readiness to manage the changes needed
to implement guideline recommendations that depend upon
changing practice systems.
Incorporates items identified by a panel of experienced guideline
implementation leaders as the most important organizational
factors and strategies.
Contains 30 items measured on a 5-point scale from Strongly
Agree to Strongly Disagree.
Instruments cont’d
3. Practice Systems Survey
▪
Measures practice systems and was developed by the
NCQA to guide QI efforts
4. Interview guide
▪
Used to explore factors associated with implementing CKD
guidelines, practice characteristics and change capacity, and the
practice changes associated with the interventions.
10 key action steps in NKF guidelines:
1) Diagnosis of CKD
2) Diagnosis of anemia
3) Avoidance of unsafe medications (NSAIDS,
metformin)
4) Use of indicated medications (ACEI or ARB)
5) Use of low dose aspirin
6) Measurement of HgbA1c
7) Measurement of Hgb
8) BP < 130/80
9) HgbA1c < 7
10) LDL cholesterol < 100
Conceptual Framework for Implementation Intervention (Phase I)
CHANGE
PROCESS
CAPABILITY
PRIORITY
•Strong desire
for change
•Resource
allocation
•Freedom from
competing
priorities
•Effective
leadership
•Infrastructure to
manage
•Change
management
skills
•Time and
resources for
change process
•Teamwork and
trust
CARE PROCESS
CONTENT
•Delivery system
•Decision support
•Clinical
information
system
•Patient selfmanagement
support
QUALITY
IMPROVEMENT
•Implementation
of CKD guidelines
Solberg et al., 2007
Phase II
•Recruitment of 2 new practices and 6 months of local
learning collaborative (LLC) participation.
•Each practice will help us to identify and recruit two
additional practices in the same geographic area who
are also interested in improving care for CKD patients.
•The three practices will then work together during
monthly one-hour LLC meetings and site visits to
improve implementation of the CKD guidelines.
Impact of Implementation Strategies on Change Components
Priority
Performance
Feedback
Change Capacity
Academic
Detailing
Practice
Facilitation
Change Process Content
Local Learning
Collaboratives
IT Support
Overall Baseline Data
N
%
HTN and/or DM
4494
22.5
eGFR Recorded
3791
18.9
eGFR <60
852
4.3
Total # unique pts. seen in last 13 mos. in 3 participating clinics = 20,014
Examples of Strategies for Improving
Guideline Adherence
•Process flowchart and team protocols triggered by low
eGFR
•Nurse standing orders allowing nurses to take care of
certain tasks without clinician involvement
•Reflexive lab testing
•EHR flags
•EHR template
•Registry/panel management
Current Project Interventions
• Proper identification of patients with CKD
▪ Classified as having Stage 3 CKD if GFR <60 for at least 3
months
▪ CKD on Problem List
• Outreach
▪ Contact patients with no GFR data to come in for testing
▪ Contact patients with history of CKD, but no notification of
diagnosis in for discussion of CKD and follow-up testing
• CKD Patient Education
▪ Developing and/or implementing patient handouts & brochures
discussing ways to slow CKD progression
Example Process Flowchart
Heightened Awareness
•Despite not facilitating an individualized intervention for the
addition of Vitamin D3, we observe an increase in the
proportion of patients with CKD prescribed and/or
documented as taking Vitamin D3.
Proportion on
Vitamin D3
Baseline
0
1 mo.
.11*
3 mo.
.20**
*p=.0322
**p=.0060
Questions?