A collaborative involving 19 general practices from four PCTs across Greater Manchester working to improve care for patients with chronic kidney disease. Practices aimed to identify undiagnosed patients and ensure that at least 75% of patients on registers were treated to the NICE recommended blood pressure targets. In 12 months 1,324 patients were identified and 74% of the patients on registers were treated to BP targets.
CLAHRC for Greater Manchester
Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?
We aimed to halve the gap between expected and recorded prevalence of chronic kidney disease (CKD) and ensure patients were being well managed as marked by achievement of NICE recommended blood pressure targets in at least 75% of registered patients. NICE recommends that patients with proteinuria have blood pressure managed to within 120-129/80mmHg and patients without proteinuria have blood pressure managed to within 120-139/90mmHg. We wanted to identify undiagnosed patients and improve management of CKD in order to improve patients' care and reduce the risk of them suffering cardiovascular events or requiring renal replacement therapy. We used the NICE blood pressure targets in our aim as they demonstrate best practice care and in differentiating between patients with proteinuria and those without, raise awareness of the increased risk to patients with proteinuria. We wanted to provide staff in general practice with increased confidence in the management of CKD and in appropriate criteria for referrals to secondary care. We also wanted to give practice staff the skills to improve care in other disease areas and encourage shared learning between practices.
Research findings and QOF data from Greater Manchester had suggested a gap between the ascertained local prevalence and expected national average prevalence of CKD of around 2%, equating to around 41,000 undetected cases of CKD in Greater Manchester. This was seen as an important area to address as CKD is a significant risk indicator for other vascular diseases such as stroke and diabetes. The same data also demonstrated that of those diagnosed, some 30% were not receiving the full complement of care necessary to optimally manage the disease, such as monitoring and, where appropriate, lowering their blood pressure or testing them for proteinuria. We estimated that in addition to improving patient care, this work would significantly reduce costs in the form of reduced overall referrals to secondary care, reduced cardiovascular events and reduced demand for renal replacement therapies such as dialysis or transplantation.
Nineteen practices from four Greater Manchester PCTs, ranging in size, prevalence and locality were selected to participate in a 12 month improvement collaborative, based on the US Institute for Healthcare Improvement's 'Breakthrough Series' model. Over the 12 months, three learning sessions and a concluding summit event were held. The learning sessions utilised a mixed approach to shared learning by way of case study presentations from practices, didactic sessions from secondary care experts, motivational speakers, presentation of data and improvements, interactive group exercises and opportunities to ask each other questions around the improvement work. In between these collaborative events were action periods where an improvement team at each practice used PDSA (Plan, Do, Study, Act) cycles to test changes and apply improvements in practice. Each team was typically made up of a lead GP, a practice nurse and a practice manager, to reflect the multi-professional nature of the changes to be made and the need for effective teamwork to make improvements. Improvement teams were facilitated by two Knowledge Transfer Associates (KTAs), who proposed ideas to identify patients and improve management of CKD. KTAs were assigned to specific PCTs and made regular site visits to individual practices within these PCTs. This regular contact helped to build relationships and keep a focus on the improvement aims through discussing the monthly data reports and sharing useful lessons from other practices within the same or other PCTs. Practices were also supported by the CLAHRC CKD team which included a Consultant in Kidney Medicine and an expert in change management from the University of Manchester. The project incurred costs in providing facilitation support to practices, running workshops and providing funds for practices that allowed them to backfill the time they spent working on the improvement project.
Data was collected monthly, recording the number of patients on the CKD register, the number tested for proteinuria, the number whose proteinuria test result was recorded as positive or negative, and the number of patients whose blood pressure was within the target range. A Service Improvement and Information Analyst created practice level feedback reports and collaborative level dashboard reports clustered by PCT area. These allowed practices to track their progress individually and against peers and address any perceived weaknesses. Overall, the 19 collaborative practices identified 1,324 patients over the 12 months, equating to 92% of the aim set (n=1,441 patients). An overall recorded improvement from 34% to 74% of patients on CKD registers being managed to NICE blood pressure targets was observed. This is equivalent to up to 1,800 patients receiving more appropriate management of their blood pressure, specific to their individual needs. Additionally, the data showed that only 23% of registered CKD patients had been tested for proteinuria in October 2009. By August 2010 this had improved to 78%. There are cost savings associated with this work in the form of reducing referrals and preventing cardiovascular events. Preliminary analysis shows a significant decrease in referrals from a sample of practices in the collaborative - 15 fewer referrals were made in Q1 2009/10 compared to 34 in the same period the previous year, which was a 44% decrease. Additionally, calculations based on a similar project in 2007 suggest that this project will have prevented 1.06 heart attacks, 0.23 strokes, 11 dialysis years and 2.4 deaths in the next five years. Further research needs to be done on outcomes for patients and cost containment benefits that early identification and management of CKD patients can achieve by delaying or preventing progression into secondary care or leading to another vascular event but current projections suggest that the savings could be significant.
The improvement collaborative has been largely successful in achieving the aims that were set. However, the difference in the levels of achievement made by each practice highlights the complex and context-sensitive nature of achieving evidence-based improvements in practice. It was notable that the shared learning element of the collaborative seemed to be effective and that the practices genuinely learned improvement techniques from one another. The collaborative demonstrated that small PDSA cycles can be used as an effective tool within the primary care setting to facilitate effective changes and educate improvement teams around CKD. By testing the effect of change in their practice environment, teams can measure the benefits that the change brings before deciding how to implement that change as a common and sustained process. A common theme that emerged from the collaborative was a knowledge gap at practice level around accurate data extraction and at times this problem hindered the progress of the project in achieving its aims. The CLAHRC began the collaborative with four main drivers within a framework defined by an Expert Faculty. These were information, staff education, leadership and patient involvement. However, the latter two did not fit in with the improvements that practices were focusing on and were under-represented during the collaborative. With that in mind the CLAHRC team revised the project framework based on experience and evidence from the collaborative. The four drivers are now more practically orientated around the improvements required to fulfil the project objectives and are as follows; creating a foundation for improvement, identification of CKD patients, optimal management of those identified and sustaining the changes long-term.
Knowledge Transfer Associate
CLAHRC for Greater Manchester
Is the example industry-sponsored in any way?