1. 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

2. Outline Background Project Overview Objectives Implementation Examples
Questions

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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).

10. 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.

11. 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).

12. 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.

13. 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

14. 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

15. 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.

16. Impact of Implementation Strategies on Change Components
Priority
Change Capacity
Change Process Content
Performance Feedback
Academic Detailing
Practice Facilitation
Local Learning Collaboratives
IT Support

17. 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

18. 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

19. 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.

22. Example Process Flowchart

23. 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).

24. Questions?