Collaborative Use of KDOQI Guideline to Improve Chronic Kidney Disease Care

Chronic kidney disease (CKD) is a silent yet deadly disease affecting millions of people worldwide. It is the gradual loss of kidney function, measured and stratified by estimated glomerular filtration rate (eGFR); it is often secondary to chronic diseases such as diabetes, hypertension, or intrinsic kidney disease. Risk factors for CKD are common problems in primary care such as diabetes, hypertension, chronic use of NSAIDS, low socioeconomic status, older age and ethnic minority. The National Kidney Foundation (NKF) estimates one-half of people with at least one risk factor for CKD have the disease, but few even know it. Research shows that early detection and intervention can save lives and costs associated with disease progression. Use of the NKF Kidney Disease Outcomes Quality Initiative (KDOQI) evidence-based clinical guideline for evaluation, classification, and stratification of CKD has been shown to be effective in identifying the disease early and slowing complications and loss of kidney function by screening annually and intervening early, especially in the primary care setting. Patients at a free nurse managed health center in the southeastern US were not routinely screened for CKD. Subsequently, the disease was going unidentified in a population with known high incidence of diabetes, hypertension, and low socioeconomic status. An interprofessional team at the nurse managed health center consisting of NPs, social worker, technical support manager, nurses, medical assistants, and community resources director agreed to work collaboratively to initiate a pilot project using the KDOQI guideline. The purpose of the project was to implement a change in the way patients at risk for CKD were identified and subsequently managed. The team worked to develop a routine clinical order set based on the KDOQI guideline that would trigger the assessment for risk factors and markers of CKD in all patients scheduled for a routine visit. The project goals were to increase the identification of those with CKD, reduce risk and progression, and improve the management of those with CKD by modifying treatment plans such as improved B/P control and halting the use of NSAIDS. All patients scheduled for a routine visit during a two month interval were evaluated for inclusion in the pilot. Inclusion criterion was clinical evidence of CKD, exclusion criteria was no clinical evidence of disease. Clinical Indicators of eGFR, blood pressure, evidence of urine protein evaluation, use of NSAIDS and ICD-9 coding for CKD were selected by the team as the measures to evaluate how effectively the NP providers applied the KDOQI guideline. Of the 200 patients screened in two months, 56 were identified with evidence of CKD, of these, 22 enrolled in the pilot. The 22 patients were managed per the KDOI guided order set for a period of 5 months. Post intervention data showed ICD-9 coding increased from 0% to 80% and urinary protein checks increased from 59% to 90% which was an expected result of the intervention. Uncontrolled blood pressure decreased from 59% to 40% and use of NSAIDS decreased from 32% use to 5% which was also an expected result. The baseline mean eGFR (69.94 ml/min) increased to 76.23 ml/min which was an expected result related to the improvements in blood pressure control and reduced use of NSAIDS. Use of the KDOQI guideline successfully changed the way this nurse managed health center evaluated for risks and presence of CKD in the pilot population. “Our project has changed the way I practice; I use my GFR calculator everyday now and I think twice before I prescribe an NSAID” (anonymous NP provider). In order to sustain the change the order set was imbedded into the electronic medical record. In addition, steps to further ensure the quality of the practice change included periodic review of CKD outcomes, continued review of the literature for best practice enhancements, continuing education of all providers, and development of nephrology referral network.