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 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). This type of multi-component intervention to assist implementation in primary care practices is well supported. Used successfully in PBRN settings.

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. Performance Feedback is especially efficacious when base rates are low and the feedback is delivered intensively.

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. The relationships established by the facilitator with members of the practice appear to be critical to their success.

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: Baseline and after each project Wave: 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). 3 members are selected BY THE PRACTICE. 4/8 practices per PBRN selected for interview.

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. Secondary objectives: 1. Use a less intensive strategic diffusion strategy that builds on lessons learned by the early implementers help an addition 16 primary care practices implement the guidelines. 2. Evaluating the impact of implementation and diffusion strategies on the 3 components of practice change (priority for the change, overall change capacity, and change process context).

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 Practice Enrollment Form Completed by one person from each practice to provide information about overall practice characteristics. Change Process Capability Questionnaire (CPCQ) 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. CPCQ completed by all 3 (clinician, nurse, and manager).

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: Diagnosis of CKD Diagnosis of anemia Avoidance of unsafe medications (NSAIDS, metformin) Use of indicated medications (ACEI or ARB) Use of low dose aspirin Measurement of HgbA1c Measurement of Hgb BP < 130/80 HgbA1c < 7 LDL cholesterol < 100

Conceptual Framework for Implementation Intervention (Phase I) CHANGE PROCESS CAPABILITY 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 self-management support PRIORITY Strong desire for change Resource allocation Freedom from competing priorities 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 Change Capacity Change Process Content Performance Feedback Academic Detailing Practice Facilitation 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 Process flow map and team protocols triggered by low eGFR: Clarifying who will do what, when, and how Nurse standing orders allowing nurses to take care of certain tasks without clinician involvement: To get CKD on Problem List; To get appropriate labs ordered; To distribute patient education materials Reflexive lab testing: To get appropriate labs done without separate order or clinic visit EHR flags: To remind clinicians and nurses about certain tasks EHR template: To make sure all items have been addressed during visits Registry/panel management: To generate lists of patients who are behind on guideline recommended actions

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 Dehydration, etc. can cause a false positive (increase creatinine), therefore having 2+ GFRs <60 at least 3 months apart is necessary for diagnosis.

Example Process Flowchart

Proportion on Vitamin D3 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 1 mo. .11* 3 mo. .20** *p=.0322 **p=.0060 prtest d3_base==d3_june Pr(Z<z)=.0322 prtest d3_base==d3_aug Pr(Z<z)=.0060 Also the case for low-dose aspirin between Base and June (p=.0349).

Questions?