Setting up a Successful CKD/Pre-ESRD Care System

The following example was submitted by Brian Lee, MD (Renal Population Management, Kaiser Permanente Hawaii Region), and Nancy Ikeda (Renal Clinic Supervisor):
 

Briefly, I work as a nephrologist at Kaiser Permanente, Hawaii Region. We have about 100 new starts every year, around 75% of whom are diabetic. In the first half of 2006, 10/55 HD (18.2%) starts in the first half used an AVF, 40/55 used a catheter. In the second half, 17/37 (45.9%) starts were with an AVF compared to 19/37 with a catheter. There were also 7 PD starts and one preemptive transplant in 2006.
 

There are two initiatives used to improve our performance. The first is the Renal Population Management System, which I designed and programmed. I screen all un-referred patients in our population for high-risk chronic kidney disease. To determine high risk, I use a model I developed for internal use that considers both GFR and proteinuria, and this predicts outcomes much more accurately than CKD staging alone. On a regular basis, I use our EMR (KP Healthconnect, which is essentially Epiccare) to review each high-risk patient, to see if he/she would be appropriate for referral. If so, I contact the PCP to advise referring the patient. In the last two and a half years we have generated around 200 referrals, many of whom have reached ESRD. PCPs satisfaction with this is high. Our late referral rates (referral less than 4 months and less than 1 year prior to ESRD) have been cut in half, and are much lower than any rates that have been published. Fewer than 30% of patients reaching ESRD have seen a nephrologist for less than one year.
 

The second is the Multidisciplinary Team (MDT) initiated and overseen by my colleague, Dr. Randy Chen. At least monthly, a list of all patients with GFR<20 and their dialysis preparation status is generated. There is a nurse assigned to this team, and she is given a report each week of this population, with their GFR score and last and next nephrologist appointments. The nurse checks to see that patients are coming in for their appointments with nephrologists, that they have referrals to the kidney and choices classes offered, and that the nephrologists refers them to a vascular surgeon, as deemed appropriate. The nurse calls patients to encourage them to come in to see the doctors and come to classes, and schedules appointments to vascular surgeons. The patients are reviewed by the nephrologists, and, as necessary, steps are taken to ensure that they are appropriately on track for an AVF. For example, a nephrologist might be queried about referral timing, and a slowly maturing fistula might need to go back to the surgeon. Patients who are non-compliant are discussed by the MDT in weekly meetings. We still have problems with noncompliant patients who do not want to go on dialysis until they find themselves in a health crisis. We are working on ways to reduce this problem.
 

So briefly, we make sure that patients at risk see a nephrologist at least a year prior to dialysis, and once they’re being followed, make sure that they are able to obtain a working fistula in time for dialysis.
 

Of course I am proud to be associated with a great group of nephrologists, vascular surgeons and staff, who make these improvements possible. Ours is a team effort.