It is often called a ‘silent’ disease as symptoms are usually absent. Consequently, the condition can go undiagnosed, which is a problem because people with CKD are more likely to have cardiovascular problems, such as strokes or heart attacks. In addition, although the numbers progressing to severe CKD and requiring dialysis or transplant are small, the costs to the healthcare system are high. Early identification of CKD holds the promise of improving both long term cardiovascular and kidney outcomes and reducing costs.
One of the best ways of managing the progression of CKD – and reducing the likelihood of eventual kidney failure – is to control a person’s blood pressure (BP) within recommended limits. Optimal BP targets have been identified through research and are set out in national clinical guidelines. However, we know that a significant proportion of the population with CKD are undiagnosed and, as such, do not have regular contact with a General Practitioner (GP) to monitor and manage their BP.
This was the starting point for the study described in this paper. Using nationally available primary care data in the English National Health Service (NHS), we realised that the recorded level of CKD in Greater Manchester (a region in the North of England) was 3 to 4 percent lower than what would be expected. This suggested that there were a large number of people in the community with undiagnosed, and potentially poorly managed, CKD. Working within a recently formed academic-health service partnership known as the NIHR CLAHRC Greater Manchester (National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Greater Manchester), we developed, carried out and measured the effect of an improvement programme to identify and manage adults with CKD in primary care.
We worked with 30 General Practice teams over a period of two and a half years, using a combination of quality improvement methods and approaches, including joint learning events, data collection and feedback and support from facilitators, that is, individuals who had been trained to provide practical guidance and support during the project. We measured the level of improvement by collecting the number of patients with CKD on GP disease registers and the percentage of patients with CKD who had their BP managed within agreed levels.
Overall, an additional 1863 patients with CKD were identified, an increase of 1.2% in the recorded level of CKD. When we compared this figure with other practices at a local and national level, we found that the practices that had been involved in the quality improvement programme had identified 2 to 4 times more people with CKD over the same time period. BP management also improved with practices managing at least three-quarters of their CKD patients within nationally recommended targets by the end of their involvement in the project – better than at local practices that were not part of the project. Overall our findings suggest that this is a promising improvement intervention to identify and manage patients with CKD in primary care and one that could be tested further through a controlled evaluation study.
The improvement team from Dr KK Chan and Partners General Practice receiving their end of project award from Dr Donal O’Donoghue