Shared learning database

Type and Title of Submission


Reducing the variability of management of kidney disease in primary care using a care bundle approach


The aim of the project was to improve quality and reduce the variability in care of people with kidney disease (CKD) in primary care. The approach used a group of simple, well-defined, evidence-based quality improvement interventions (based on NICE guidance CG73), called a care bundle. We have implemented the care bundle for CKD in 26 GP Practices in England and Wales.

Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

CG73 - Chronic kidney disease

Is the submission industry-sponsored in any way?


Description of submission

Aims and objectives

The overall aim of the project was to improve the management of people with kidney disease in primary care, using a Quality Improvement (QI) intervention called a care bundle. A care bundle is a group of simple, well-defined, evidence-based quality improvement interventions that have yielded excellent results both in terms of the improved reliability of delivered care and better clinical outcomes. Our care bundle for kidney disease is based on NICE guidance CG73 (2008).


Chronic kidney disease (CKD) is common affecting about 6-8% of the population (de Lusignan 2009). It is an important risk factor for both end-stage renal disease and for cardiovascular disease (CVD. CKD is frequently unrecognised since it causes no symptoms in the early stages. However, it often exists together with other conditions, for example, hypertension, CVD and diabetes, and those at risk of CKD can be readily identified in the general population by screening questionnaires and the diagnosis confirmed or refuted with simple blood and urine tests in primary care. Early identification of CKD in primary care is highly beneficial since there is evidence that treatment can prevent or delay the progression of CKD, reduce or prevent the development of complications and reduce the risk of CVD Data from the Quality and Outcomes Framework indicate the presence of widespread variation, within and between PCTs, in the identification and treatment of kidney disease in primary care (NHS Information Centre). In many cases the recorded prevalence of CKD within a practice (i.e. patients on the CKD Register) has been less than 50% of that expected from national data. Some of this under-ascertainment is because people have not been tested; however there are also large numbers with CKD (on the basis of existing test results) who are not recognised and coded as such. Our team identified opportunities for improving knowledge of CKD management, increasing the number of people identified with CKD, increasing the number of people achieving NICE targets for blood pressure, improving the efficiency of testing and recall for people with CKD and other conditions such as diabetes and improving the way in which people with kidney disease are encouraged to self-manage.


A CKD-specific care bundle was developed by the study investigators and patients in collaboration with an expert group and piloted in a single practice in 2008-2009. The Care Bundle has four components: A. Ask the patient if they wish to participate in the self-management programme B. Measure and document proteinuria and prescribe medication if significant proteinuria present C. Document Blood Pressure and treat if hypertension present D. Document cardio-vascular risk GP Practices were recruited either via a renal network, through personal connection or via a local Primary Care Research Network (PCRN). The study team (comprising patients and renal practitioners) provided training for each Practice, helped with implementation, collated results and organised monthly teleconferences to review progress. There were some barriers to implementation including conflict with other time-consuming activities such as flu-jabs. Practices were given small backfill costs by the local PCRN.

Results and evaluation

The study finishes in September 2012. Progress in each participating Practice has been monitored monthly by: a) Practice-level outcome measures submitted to the study team including recorded prevalence of CKD (ie % of practice population on CKD register)and proportion of patients on the CKD Register treated according to NICE guidance on BP control. At baseline results show Practices were recording wide variation in prevalence as 4.8% +/- 2.2%. This shows that prevalence recording is variable although greater than mean recorded prevalence in SHAs (2.6-5.2%) in 2010-2011. We have worked with Practices to improve their reported CKD prevalence, especially if <3% at baseline. Baseline data also showed BP<130 mmHg in people with Diabetes Mellitus on their CKD Register 57.1% +/- 23.6% BP<140 mmHg in people who do not have Diabetes Mellitus on their CKD Register 71.8% +/- 22.4% meaning that NICE targets for people with CKD are less frequently achieved in people at higher risk of progressive CKD (those with diabetes and/or proteinuria). b) Each aspect of the care bundle was studied separately as individual process measures. Results show that the number of patients with CKD per month (up to December 2011) who had the QI intervention applied has ranged from 1-33 (mean 5.96 SD 7.88). The aim is to achieve 100% reliability in delivering the Care Bundle each month, where 100% means that all aspects of the Care Bundle have been applied at one time. More than 2 months' care bundle data have already been returned by 13 Practices and more 3 months care bundle data by 3 Practices. Baseline reliability was 0-100% although 100% reliability was only achieved in Practices seeing <5 patients. Overall reliability (all bundle components applied at the same time) of 100% has now been achieved in 10 Practices. By January 2012, 250 patients had taken up the offer of self-management and patient feedback so far has been very positive.

Key learning points

The intervention is on the surface extremely simple, a care bundle for the management of people with CKD based on NICE guidance to be applied in a primary care setting in the UK. However we have learnt that the following: - It is worth investing in good training in CKD management and this is valued by Practices and patients - Self-management training delivered by patients is crucial - There are competing interests in primary care when implementing a QI programme so flu-jab season is best to be avoided - QI works best when there is a QI champion in each Practice but who has support of colleagues - Outside facilitation for QI projects is beneficial - Help is sometimes needed to search IT systems to identify people with CKD - Careful consideration is needed when explaining CKD to patients

Contact Details

Name:Dr Nicola Thomas
Job Title:Project Co-ordinator ENABLE study
Organisation:Kidney Research UK
Address:Nene Hall Lynch Wood Park
Postcode:PE2 6FZ
Phone:07958 708347


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This page was last updated: 27 January 2012

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.