Primary Care Providers and Chronic Kidney Disease
Primary Care Providers (PCPs) are essential gatekeepers for chronic kidney disease (CKD), to which diabetes mellitus and hypertension, commonly addressed in the office setting, are the largest contributors. Therefore, there is a need for PCPs to keep these risk factors tightly controlled and screen these patients for signs of early CKD.
Monica Cades, DNP, CRNP, practicing with LVPG Family and Internal Medicine, was compelled by learning CKD is often missed during the PCP office visit. “Once identified, we’re all pretty good at ‘this is what you do,’” says Monica. “But there is a lack of information on how to identify it.” While this gap can adversely affect patients’ health and quality of life – leading to increasing morbidity and possible mortality – it also contributes to the high cost of health care.
The annual Medicare expense for a patient with CKD in stage 2 is about $1,700, while stage 4 can cost $12,700, and it continues to rise as the disease progresses. Medicare spends billions of dollars for care related to end-stage renal disease.
Monica took the challenge in the form of a Quality Improvement (QI) Project, offered as part of LVPHO’s Achieving Clinical Excellence® (ACE) program. Her intention was to identify and riskstratify CKD in patients with hypertension and diabetes in a primary care practice, who showed a decreased glomerular filtration rate (GFR) and/or micro-albumin. Identifying and Staging Chronic Kidney Disease in Patients with Hypertension and Diabetes in Primary Care through Pre-Visit Planning began in June 2017. Her first step was performing a needs assessment with patients in her own practice having both hypertension and diabetes. She found:
- 113 patients met the criteria for CKD diagnosis (37.9%)
- 75 patients had diagnosis pre-implementation (66.4%)
- 38 patients did not have diagnosis pre-implementation (33.6%)
With this data in hand, she and her multidisciplinary team, which included clinicians, Populytics’ data analysts, and population health leaders, implemented a new procedure that begins with the medical assistant (MA) in the office. The MA assigned to pre-visit planning reviews provider schedules and calls patients who have any outstanding orders related to CKD testing. The MA then reviews labs completed over the past three months, looking for GFR and micro-albumin, and records this information for the provider on a pre-visit planning form developed by the QI team. The provider sees the patient and, if CKD is an appropriate diagnosis, updates the EMR accordingly. The provider checks “Nephrology Referral” if needed, and updates the problem list with the appropriate ICD 10 code.
“The 50-79 age group is our biggest opportunity,” says Monica, who notes that if a patient’s GFR falls to less than 60, this is an alert for the provider to look further into the data. “These people are already in the system, so the data is available. We found about 95 percent of those that met criteria for CKD were diagnosed with CKD after using our pre-planning tool.”
Here are the results:
- 107 out of 113 patients had CKD diagnosis as of December 31, 2017 (94.7%)
- 6 out of 113 patients did not have CKD diagnosis as of December 31, 2017 (5.3%)
- 6 remaining patients did not have a scheduled follow up appointment as of December 31, 2017.
Monica is also looking into creating a laminated card for providers, containing CKD identification information that everyone can keep handy in their offices.
To learn more about the ACE Quality Improvement Project program, contact Wayne Stephens at firstname.lastname@example.org