1. Improving Primary Care Treatment of CKD David Feldstein, MD Assistant Professor Department of Medicine UW SMPH

2. Overview Background Background Needs Assessment Needs Assessment CKD Management Tool CKD Management Tool Implementation Implementation Questions Questions

3. Chronic Kidney Disease Over 26 million cases in US and growing Over 26 million cases in US and growing Prevalence 6.6% in adults in WI Prevalence 6.6% in adults in WI Consumes 6.5% of Medicare Budget Consumes 6.5% of Medicare Budget Progression to ESRD can be prevented Progression to ESRD can be prevented Patients currently not receiving care based on guidelines Patients currently not receiving care based on guidelines Coresh J, Selvin E, Stevens LA, et al. JAMA. 2007;298(17):2038-2047. Shankar A, Klein R, Klein BE. Am J Epidemiol. 2006;164(3):263-271. U.S. Renal Data System. USRDS 2007 Annual Data Report. MD; 2007. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification http://www.kidney.org/professionals/KDOQI/guidelines_ckd/toc.htm.

4. Chronic Kidney Disease Stages Stages 1.Kidney damage with normal GFR (>90 mL/min1.73 m 2) 2.Kidney damage with mild decrease GFR (60-89) 3.Moderate decrease GFR (30-59) 4.Severe decrease GFR (15-29) 5.Kidney Failure – GFR <15 or dialysis

5. Chronic Kidney Disease Stages Stages 1.Kidney damage with normal GFR (>90 mL/min1.73 m 2) 2.Kidney damage with mild decrease GFR (60-89) 3.Moderate decrease GFR (30-59) 4.Severe decrease GFR (15-29) 5.Kidney Failure – GFR <15 or dialysis

6. Project Goal Goal –Develop electronic tool to help PCCs care for their patients with CKD Phases Phases –Needs assessment –Development of CKD management tool –Implementation of CKD management tool

7. Needs Assessment 9 Phone interviews 9 Phone interviews 5 Focus Groups 5 Focus Groups –26 PCCs Questions Questions –Barriers and Facilitators to following CKD guidelines –Barriers and Facilitators to CKD care –Ideal CKD Management Resources –Collaboration with subspecialists Thematic analysis Thematic analysis

8. CKD Management Barriers Clinician factors Clinician factors –External Multiple demands on time Multiple demands on time –Internal Lack of knowledge Lack of knowledge Patient factors Patient factors –Travel –Non-adherence to treatment regimen Systems issues Systems issues –Access to information –Lack of decision support systems

9. CKD Management Tool Based on patient centered medical home Based on patient centered medical home Components Components –CKD guideline checklist Based on NKF’s KDOQI guidelines Based on NKF’s KDOQI guidelines Individualized to patient Individualized to patient –Point of care educational modules Integrated into guideline checklist Integrated into guideline checklist –Electronic nephrology consultation –Patient information resources Human factors input for usability Human factors input for usability

14. Usability Testing If you build it will they come? If you build it will they come? Determine functions to test Determine functions to test –Develop scenarios –Develop testing scripts –3 user types Evaluate plan Evaluate plan –Think aloud interviews – thematic analysis –Questionnaires

15. Usability Testing Clip

16. Implementation 20 PCCs and their clinic support staff 20 PCCs and their clinic support staff 6 month trial using tool with stage 3 CKD patients 6 month trial using tool with stage 3 CKD patients Proof of concept Proof of concept Outcomes Outcomes –Changes in PCCs knowledge and self-efficacy –Guideline usage –Tool usage

17. Acknowledgements Funding Funding –UW ICTR Type 2 Translational Pilot Grant –UW Department of Medicine R&D Grant –Salary support ICTR Science Award 1KL2RR025012 WREN WREN –Paul Smith, MD; Mike Grasmick, PhD; Katie Pronschinske WiNHR WiNHR –Howard Bailey, MD; Laila Borokhim Industrial Engineering Industrial Engineering –Doug Wiegmann, PhD; Ashley Eggerman; Renaldo Blocker

18. KDOQI National Kidney Foundation Kidney Disease Outcomes Quality Initiative National Kidney Foundation Kidney Disease Outcomes Quality Initiative Evidence-based clinical practice guidelines for all stages of CKD Evidence-based clinical practice guidelines for all stages of CKD Since 1997 developed 13 guidelines Since 1997 developed 13 guidelines

19. Focus Group Characteristics Years in practice (M, SD, Range) 13.8 (8.9) (1-31) Gender (Male, %) 13 (50%) Specialty FM (#, %) 18 (69%) Practice location (#, %) R – 6 (24%) S – 7 (28%) U – 12 (48%)

20. CKD Management Barriers Patient factors Patient factors –Multiple physicians –Travel –Insurance Issues –Not adherent to treatment regimen Lack of understanding of CKD Lack of understanding of CKD

21. CKD Management Barriers Systems issues Systems issues –Access to information Can’t access information across systems Can’t access information across systems –No access to nephrologists –Lack of decision support systems –Not set up for CKD care Based on acute care model Based on acute care model Unable to monitor f/u Unable to monitor f/u