The role of the kidneys is to remove waste products and extra fluid from the bloodstream. They also help control blood pressure and stimulate the production of red blood cells. In the case of patients with chronic kidney disease, waste products remain in their blood and they can be prone to anaemia, cardiovascular disease, renal failure and ultimately death.
However, there are many things that GPs and patients can do to slow down the process.
This project aims to help GPs better identify and manage patients with the condition. “Chronic kidney disease is a clinical problem that’s been around for years,” project clinical lead Dr Simon de Lusignan says. “What’s new is that we now have is a much more effective way of flagging up patients whose kidney function is declining, called estimated glomerular filtration rate. In addition, a new quality target for people with chronic kidney disease was introduced with the Qualities and Outcomes Framework last year.”
Once the patients have been identified, the next step is to control their blood pressure, which slows the rate of decline of kidney function. “This could delay when people might need to go onto dialysis or transplantation,” Simon explains. “In the case of elderly patients, it can delay decline in their kidney function until this ceases to be their top health problem. This means they never actually need to go on to suffer the symptoms of kidney failure and avoid the need for dialysis and transplantation.”
Part of the problem is the way chronic kidney disease is perceived by GPs, which is partly down to the 'disease' label. "Broadly half of women over 75 and half of men over 85 have this condition and calling it chronic kidney disease is a bit of an unhelpful label," Simon explains. "What we’re trying to promote is the idea that chronic kidney disease is really a vascular risk factor, just like having raised cholesterol."
"We want primary healthcare teams or professionals to respond to someone with chronic kidney disease in the way they currently do with diabetes," he continues. "They check the patient's blood pressure and cholesterol levels and discourage them from smoking. It’s exactly the same messages with chronic kidney disease."
“Other things GPs can do include looking at the medication patients are on to see if they are taking anything that impairs kidney function but isn’t essential for their care; and also checking men for signs of prostate disease,” Simon adds.
To tackle the problem, the team are looking at three different quality improvement techniques. These techniques will be run in separate practices, while a fourth practice will be measured without any intervention to provide a baseline comparison.
Firstly, a patient empowerment programme will try to increase patients’ understanding of the disease and its implications for their lifestyle. Secondly, audit based education will be used to feed back data to groups of practices about their quality of care, with a local clinical champion presenting comparative data in an educational context. Thirdly, the team will work with a practice looking to offer new ways of looking after people with chronic kidney disease.
“To try and ensure the findings can be generalised, we’re planning to run this in eight areas: four in the North of England and four in the South,” Simon says. “We’ll also try to pair up inner city and suburban practices, so that we get a mixture of types of practices in each intervention.”
“The problem is linking cause and effect when you do this, which is one of the big challenges in quality improvement research,” he continues. “We’re planning to address this by collecting data at multiple points and looking to link changes to the dates of interventions. We'll also compare the results from different practices and work with a smaller group on the issues around involvement in quality improvement from the patient's and health professional's perspective."
If the project is successful, the team hopes to interest Primary Care Trust commissioning teams in their findings. “If the lessons for this are going to be shared, then the critical people are commissioners in the eight different areas this study will cover,” Simon explains. “The biggest challenge is getting the methodology right so we can ascribe change to interventions in a way that will convince the commissioners that these are the strands of quality improvement that are really worth embedding in the NHS in the medium to long term.”
Lead organisations: St George’s University of London and Kidney Research UK
Partners: Renal Association, Royal College of General Practitioners
Contacts
St George's: Simon de Lusignan
Kidney Research: Michael Nation
10 April 2007