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The scheme of distribution and collection of questionnaires.

The scheme of distribution and collection of questionnaires.

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Much of chronic disease is managed in primary care and chronic kidney disease (CKD) is a recent addition. We are conducting a cluster randomised study of quality improvement interventions in CKD (QICKD) - Clinical Trials Registration: ISRCTN56023731. CKD registers have a lower than expected prevalence and an initial focus group study suggested vari...

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... 8 Barriers that hinder effective CKD care in primary care settings include lack of awareness and understanding of guidelines for risk stratification and management of CKD, confusion regarding appropriate referral criteria and timing, and lack of confidence in managing CKD. 9 Additionally, PCPs have limited time to manage complex visit agendas. 10,11 The advent of electronic health records (EHRs) has propelled an interest in using electronic decision supports to improve care. ...
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Rationale & objective: Most adults with chronic kidney disease (CKD) in the U.S. are cared for by primary care providers (PCP). We evaluated the feasibility and preliminary effectiveness of an electronic clinical decision support system (eCDSS) within the electronic health record (EHR) with or without pharmacist follow-up to improve management of CKD in primary care. Study design: Pragmatic, cluster randomized trial SETTING & PARTICIPANTS: 524 adults with confirmed eGFRCr 30-59 mL/min/1.73m2 cared for by 80 PCPs at the University of California San Francisco. EHR data were used for patient identification, intervention deployment, and outcomes ascertainment. Interventions: Each PCP's eligible patients were randomized as a group into one of three treatment arms: 1) usual care, 2) eCDSS: testing of creatinine, cystatin C and urinary albumin-to-creatinine ratio with individually tailored guidance for PCPs on blood pressure, potassium and proteinuria management, cardiovascular risk-reduction, and patient education, or 3) eCDSS plus pharmacist counseling (eCDSS-PLUS). Outcomes: Primary clinical outcome was change in blood pressure over 12 months. Secondary outcomes were PCP awareness of CKD as well as use of ACEi/ARB and statin. Results: All 80 eligible PCPs participated. Mean patient age was 70, 47% were non-white, mean eGFRcr was 56 +/-0.6 mL/min/1.73m2. Among patients receiving eCDSS with or without pharmacist counseling (n=336), 178 (53%) completed labs and 138 (41%) had labs followed by a PCP visit with eCDSS deployment. eCDSS was opened by the PCP for 102 (74%) patients, with at least one suggested order signed for 83 of these 102 (81%). Changes in systolic blood pressure were -2.1 ± 1.5 mmHg with usual care, -2.8 ± 1.8 with eCDSS and -1.1 ± 1.1 with eCDSS-PLUS (p=0.69). PCP awareness of CKD was 16% with usual care, 26% with eCDSS, and 32% for eCDSS -PLUS (p=0.09). In as-treated analyses, PCP awareness of CKD was significantly greater with eCDSS and eCDSS-PLUS (73% and 69%) vs. usual care (47%), p<0.01. Limitations: Recruitment of smaller than intended sample size, and limited uptake of the testing component of the intervention. Conclusions: While we were unable to demonstrate the effectiveness of eCDSS to lower blood pressure, and uptake of the eCDSS was limited by low testing rates, eCDSS utilization was high once labs were available and was associated with higher PCP awareness of CKD.
... 4,5 Randomized controlled trials have shown that controlling blood pressure, 6 reducing proteinuria using angiotensin-converting enzyme (ACE) inhibitors or angiotensinogen receptor blockers (ARBs), 7-9 and improving glycemic control in people with diabetes 10,11 can delay CKD decline and reduce the morbidity and mortality associated with CKD. 12 However, many people with CKD are not receiving the benefit of these findings. There are a number of possible reasons for this, including low levels of CKD awareness among both providers and patients, [13][14][15] low confidence among primary care clinicians for delivering CKD care, 16 and low empowerment of patients to live healthy lifestyles, adhere to medication regimens, and avoid nephrotoxic insults. 17,18 The Chronic Care Model provides a framework for delivering high-quality chronic disease care and can be incorporated into a Patient-Centered Medical Home. ...
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Rationale & Objective Sustainable interventions that enhance chronic kidney disease (CKD) management are not often studied in safety-net primary care, in which populations bear a disproportionate burden of disease and experience translational gaps between research and practice. We tested the feasibility of implementing and the impact of 2 technology-enhanced interventions designed to enhance CKD care delivery. Study Design A 2×2 randomized controlled pilot trial. Setting & Participants Primary care provider teams (n = 6) and 137 patients with CKD aged 18 to 75 years from 2 safety-net primary care clinics, 2013 to 2015. Interventions Primary care provider teams were randomly assigned to access a CKD registry with point-of-care notifications and quarterly feedback or a usual-care registry for 12 months. Patients within provider teams were randomly assigned to participate in a CKD self-management support program or usual care for 12 months. Outcomes We examined recruitment, randomization, and participation in each intervention. We also examined the impact of each intervention and their combination on change in systolic blood pressure (SBP), albuminuria, and patient self-reported behavioral measures after 12 months. Results Among potentially eligible patients identified using the electronic health record, 24% were eligible for study participation, of whom 35% (n = 137) were enrolled. Mean age was 55 years, 41% were non–English speaking, and 93% were of racial/ethnic minority. Mean baseline estimated glomerular filtration rate was 70.5 (SD = 30.3) mL/min/1.73 m²; mean baseline SBP was 131 (SD = 21.8) mm Hg. Nearly 90% of clinicians reported that the CKD registry influenced their CKD management. More than 95% of patients randomly assigned to CKD self-management support engaged regularly with the intervention. Estimated changes in SBP over 1 year were nonstatistically different in each of the 3 intervention groups compared with usual care: (usual care: 0.5 [95% CI, −5.2 to 6.3] mm Hg; CKD registry only: −5.4 [95% CI, −12.2 to 1.4] mm Hg; CKD self-management support only: −6.4 [95% CI, −13.7 to 1.0] mm Hg; and CKD registry plus CKD self-management support: −0.5 [−5.5 to 4.5] mm Hg), though differences were larger among those with baseline SBPs > 140/90 mm Hg. Decreases in albuminuria were similarly nonstatistically different in each of the intervention groups compared with usual care. No differences were observed in patient self-reported behaviors. Limitations Single health system. Conclusions Patient and provider interventions to improve CKD care are feasible to implement in low-income settings with promising results among those with uncontrolled blood pressure. Funding National Institute of Diabetes and Digestive and Kidney Diseases. Trial Registration ClinicalTrials.gov, number: NCT01530958.
... 3 Although randomized controlled trials have shown that controlling blood pressure (BP) and reducing proteinuria with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) can delay CKD decline and progression to end-stage renal disease (ESRD) and decrease CKD-associated morbidity and mortality, 4-7 many individuals with CKD are not receiving these evidence-based treatments. 8 The failure to implement these best practices may be related to providers' poor CKD awareness 9,10 and limited confidence among primary care providers (PCPs) in delivering CKD care 11 in the context of inefficient health care systems that rely on overburdened providers to deliver chronic disease care to complex patients. ...
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Background: Many individuals with chronic kidney disease (CKD) do not receive guideline-concordant care. We examined the impact of a team-based primary care CKD registry on clinical measures and processes of care among patients with CKD cared for in a public safety-net health care delivery system. Study design: Pragmatic trial of a CKD registry versus a usual-care registry for 1 year. Setting & participants: Primary care providers (PCPs) and their patients with CKD in a safety-net primary care setting in San Francisco. Intervention: The CKD registry identified at point of care all patients with CKD, those with blood pressure (BP)>140/90mmHg, those without angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) prescription, and those without albuminuria quantification in the past year. It also provided quarterly feedback pertinent to these metrics to promote "outreach" to patients with CKD. The usual-care registry provided point-of-care cancer screening and immunization data. Outcomes: Changes in systolic BP at 12 months (primary outcome), proportion of patients with BP control, prescription of ACE inhibitors/ARBs, quantification of albuminuria, severity of albuminuria, and estimated glomerular filtration rate. Results: The patient population (n=746) had a mean age of 56.7±12.1 (standard deviation) years, was 53% women, and was diverse (8% non-Hispanic white, 35.7% black, 24.5% Hispanic, and 24.4% Asian). Randomization to the CKD registry (30 PCPs, 285 patients) versus the usual-care registry (49 PCPs, 461 patients) was associated with 2-fold greater odds of ACE inhibitor/ARB prescription (adjusted OR, 2.25; 95% CI, 1.45-3.49) and albuminuria quantification (adjusted OR, 2.44; 95% CI, 1.38-4.29) during the 1-year study period. Randomization to the CKD registry was not associated with changes in systolic BP, proportion of patients with uncontrolled BP, or degree of albuminuria or estimated glomerular filtration rate. Limitations: Potential misclassification of CKD; missing baseline medication data; limited to study of a public safety-net health care system. Conclusions: A team-based safety-net primary care CKD registry did not improve BP parameters, but led to greater albuminuria quantification and more ACE inhibitor/ARB prescriptions after 1 year. Adoption of team-based CKD registries may represent an important step in translating evidence into practice for CKD management.
... We hypothesized that the NHANES question had low sensitivity but high specificity and that other questions were more sensitive. We also hypothesized that CKD awareness would be lower than awareness of hypertension, diabetes, and hyperlipidemia because of low awareness of, and confidence managing CKD among primary care providers (PCPs) compared with other chronic diseases (6,7). ...
Article
Background and objectives: Awareness of CKD is necessary for patient engagement and adherence to medical regimens. Having an accurate tool to assess awareness is important. Use of the National Health and Nutrition Examination Survey (NHANES) CKD awareness question "Have you ever been told by a doctor or other health professional that you had weak or failing kidneys (excluding kidney stones, bladder infections, or incontinence)?" produces surprisingly low measures of CKD awareness. We sought to compare the sensitivity and specificity of different questions ascertaining awareness of CKD and other health conditions. Design, setting, participants, & measurements: Between August of 2011 and August of 2014, an in-person questionnaire was administered to 220 adults with CKD, diabetes, hypertension, or hyperlipidemia who received primary care in a public health care delivery system to ascertain awareness of each condition. CKD awareness was measured using the NHANES question, and other questions, asking if patients knew about their "kidney disease", "protein in the urine", "kidney problem", or "kidney damage." Demographic data were self-reported; health literacy was measured. The sensitivity and specificity of each question was calculated using the medical record as the gold standard. Results: In this diverse population (9.6% white, 40.6% black, 36.5% Hispanic, 12.3% Asian), the mean age was 58 years, 30% had a non-English language preference, and 45% had low health literacy. Eighty percent of participants had CKD, with a mean eGFR of 47.2 ml/min per 1.73 m(2). The sensitivities of each CKD awareness question were: 26.4% for "kidney damage", 27.7% for "kidney disease", 33.2% for "weak or failing kidneys", 39.8% for "protein in the urine", and 40.1% for "kidney problem." Specificities ranged from 82.2% to 97.6%. The best two-question combination yielded a sensitivity of 53.1% and a specificity of 83.3%. This was lower than awareness of hypertension (90.1%) or diabetes (91.8%). Conclusions: CKD awareness is low compared with other chronic diseases regardless of how it is ascertained. Nevertheless, more sensitive questions to ascertain CKD awareness suggest current under-ascertainment.
... CKD appeared to be a distinct diagnosis where practitioners were reluctant to use it as a 'label' , with many being unsure of the benefits of disclosing the diagnosis, for fear of causing unintended anxiety [42]. Confidence in managing CKD was lower than for hypertension and diabetes, with practitioners harbouring doubts as to the significance of clinical guideline targets, such as blood pressure [15,32,43]. Hence, successful sense-making was more challenging than with many other chronic diseases. ...
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Background Chronic kidney disease (CKD) is common and a significant marker of morbidity and mortality. Its management in primary care is essential for maintenance of cardiovascular health, avoidance of acute kidney injury (AKI) and delay in progression to end-stage renal disease. Although many guidelines and interventions have been established, there is global evidence of an implementation gap, including variable identification rates and low patient communication and awareness. The objective of this study is to understand the factors enabling and constraining the implementation of CKD interventions in primary care. MethodsA rapid realist review was conducted that involved a primary literature search of three databases to identify existing CKD interventions in primary care between the years 2000 and 2014. A secondary search was performed as an iterative process and included bibliographic and grey literature searches of reference lists, authors and research groups. A systematic approach to data extraction using Normalisation Process Theory (NPT) illuminated key mechanisms and contextual factors that affected implementation. ResultsOur primary search returned 710 articles that were narrowed down to 18 relevant CKD interventions in primary care. Our findings suggested that effective management of resources (encompassing many types) was a significant contextual factor enabling or constraining the functioning of mechanisms. Three key intervention features were identified from the many that contributed to successful implementation. Firstly, it was important to frame CKD interventions appropriately, such as within the context of cardiovascular health and diabetes. This enabled buy-in and facilitated an understanding of the significance of CKD and the need for intervention. Secondly, interventions that were compatible with existing practices or patients’ everyday lives were readily accepted. In contrast, new systems that could not be integrated were abandoned as they were viewed as inconvenient, generating more work. Thirdly, ownership of the feedback process allowed users to make individualised improvements to the intervention to suit their needs. Conclusions Our rapid realist review identified mechanisms that need to be considered in order to optimise the implementation of interventions to improve the management of CKD in primary care. Further research into the factors that enable prolonged sustainability and cost-effectiveness is required for efficient resource utilisation.
... This was carried out to test whether QI might be secondary to improving confidence, knowledge and competence in managing CKD. 17 We identified four practices, two from each active study arm for in-depth process evaluation using focus groups. ...
... 28 New P4P guidelines are not always immediately accepted and embraced by practices, and low practitioner confidence in management of CKD ( particularly high-risk patients, such as those with proteinuria) provides a plausible explanation as to why they might have a negative effect on target attainment, even where P4P is in place. 17 There may be a gradual, underlying diffusion of knowledge and management of CKD. 29 There appeared a greater acceptance among healthcare professionals of CKD as a relevant diagnosis, compared with previous studies, 23 but this may simply be due to the length of time that has now elapsed since the introduction of P4P (2006) and NICE guidance (2008, table 1). ...
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Objectives This study is a process evaluation of the Quality Improvement in Chronic Kidney Disease (QICKD) study, comparing audit-based education (ABE) and sending clinical guidelines and prompts (G&P) with usual practice, in improving systolic blood pressure control in primary care. This evaluation aimed to explore how far clinical staff in participating practices were aware of the intervention, and why change in practice might have taken place. Setting 4 primary care practices in England: 2 received ABE, and 2 G&P. We purposively selected 1 northern/southern/city and rural practice from each study arm (from a larger pool of 132 practices as part of the QICKD trial). Participants The 4 study practices were purposively sampled, and focus groups conducted with staff from each. All staff members were invited to attend. Interventions Focus groups in each of 4 practices, at the mid-study point and at the end. 4 additional trial practices not originally selected for in-depth process evaluation took part in end of trial focus groups, to a total of 12 focus groups. These were recorded, transcribed and analysed using the framework approach. Results 5 themes emerged: (1) involvement in the study made participants more positive about the CKD register; (2) clinicians did not always explain to patients that they had CKD; (3) while practitioners improved their monitoring of CKD, many were sceptical that it improved care and were more motivated by pay-for-performance measures; (4) the impact of study interventions on practice was generally positive, particularly the interaction with specialists, included in ABE; (5) the study stimulated ideas for future clinical practice. Conclusions Improving quality in CKD is complex. Lack of awareness of clinical guidelines and scepticism about their validity are barriers to change. While pay-for-performance incentives are the main driver for change, quality improvement interventions can have a complementary influence.
... Although randomized controlled trials have demonstrated that measures such as blood pressure control [8], reduction of proteinuria with angiotensin converting enzyme inhibitors (ACEi) or angiotensinogen receptor blockers (ARB) [9][10][11], and glycemic control among persons with diabetes [12,13], can delay CKD decline and decrease CKD-associated morbidity and mortality [14], many individuals with CKD are not benefiting from these scientific advances. Lack of translation may be due to low levels of CKD awareness among providers and patients [15][16][17]; low self-efficacy among primary care providers for delivery of CKD care [18], particularly in an inefficient health care system with overburdened providers that deliver chronic disease care; and poor patient empowerment to participate in healthy lifestyles, adhere to medication regimens, and avoid nephrotoxic insults [19,20]. ...
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Background: Chronic kidney disease (CKD) is common and is associated with excess mortality and morbidity. Better management could slow progression of disease, prevent metabolic complications, and reduce cardiovascular outcomes. Low patient awareness of CKD and ineffective patient-provider communication can impede such efforts. We developed provider and patient-directed interventions that harness health information technology to enhance provider recognition of CKD and delivery of guideline concordant care and augment patient understanding and engagement in CKD care. Methods/design: We report the design and protocol of the Kidney Awareness Registry and Education (KARE) Study, a 2x2 factorial randomized controlled trial that examines the impact of a multi-level intervention on health outcomes among low-income English, Spanish and Cantonese-speaking patients with CKD in a safety net system. The intervention includes: (1) implementation of a primary care electronic CKD registry that notifies practice teams of patients' CKD status and employs a patient profile and quarterly feedback to encourage provision of guideline-concordant care at point-of-care and via outreach; and (2) a language-concordant, culturally-sensitive self-management support program that consists of automated telephone modules, provision of low-literacy written patient-educational materials and telephone health coaching. The primary outcomes of the trial are changes in systolic blood pressure (BP) and the proportion of patients with BP control (≤140/90 mmHg) after one year. Secondary outcomes include patient understanding of CKD, participation in healthy behaviors, and practice team delivery of guideline-concordant CKD care. Discussion: Results from the KARE study will provide data on the feasibility, effectiveness, and acceptability of technology-based interventions that support primary care efforts at improving health outcomes among vulnerable patients with CKD. Trial registration: ClinicalTrials.gov, number: NCT01530958.
... Cardiovascular diseases remain the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD), especially with diabetes mellitus. [20,21] The prevalence of cardiovascular death in CKD patients, especially in those on dialysis therapy is 10-20 times greater than the age, gender, and race-matched general population. [22,23] Some studies have demonstrated that atherosclerosis could induce an increase of the arterial IMT and arterial stiffening, and eventually lead to luminal obstruction with consequent ischemic events, such as myocardial infarction and stroke. ...
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Background: Hepcidin, as a regulator of body iron stores, has been recently discovered to play a critical role in the pathogenesis of anemia of chronic disease. Atherosclerotic cardiovascular disease is the most common complication and the leading cause of death in chronic hemodialysis (CHD) patients. In the current study, we aimed to explore the relationship between serum hepcidin and uremic accelerated atherosclerosis (UAAS) in CHD patients with diabetic nephropathy (CHD/DN). Methods: A total of 78 CHD/DN and 86 chronic hemodialyzed nondiabetic patients with chronic glomerulonephritis (CHD/non-DN) were recruited in this study. The level of serum hepcidin-25 was specifically measured by liquid chromatography-tandem mass spectrometry. Serum levels of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were measured by enzyme-linked immunosorbent assay. Results: High serum level of hepcidin-25 was seen in CHD patients. Serum hepcidin-25 in CHD/DN was significantly higher than that in CHD/non-DN patients. Serum hepcidin-25 was positively correlated with ferritin, high-sensitivity C-reactive protein (hs-CRP), TNF-α, and IL-6 in CHD/DN patients. CHD/DN patients exhibited higher common carotid artery intima media thickness (CCA-IMT), hs-CRP, and hepcidin-25 levels than that in CHD/non-DN patients. Moreover, in CHD/DN patients, CCA-IMT was positively correlated with serum hepcidin, hs-CRP, and low-density lipoprotein-cholesterol. On multiple regression analysis, serum hepcidin and hs-CRP level exhibited independent association with IMT in CHD/DN patients. Conclusions: These findings suggest possible linkage between iron metabolism and hepcidin modulation abnormalities that may contribute to the development of UAAS in CHD/DN patients.
... Further, a recent study of the use of laboratory prompts shows that they alone are not sufficient to raise the standard of care [30]. However, there are some pointers from educational research and from other disease areas that level of knowledge [31,32] and confidence is associated with improved practice; however most of these articles are descriptive rather than trial-based. A literature search on questionnaires and reliability revealed very few articles associated with confidence; though a city-based collaborative which also included education and better use of technology appears to have improved care [33]. ...
Article
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In the UK, chronic disease, including chronic kidney disease (CKD) is largely managed in primary care. We developed a tool to assess practitioner confidence and knowledge in managing CKD compared to other chronic diseases. This questionnaire was part of a cluster randomised quality improvement interventions in chronic kidney disease (QICKD; ISRCTN56023731). The questionnaire was developed by family physicians, primary care nurses, academics and renal specialists. We conducted three focus groups (n = 7, 6, and 8) to refine the questionnaire using groups of general practitioners, practice nurses and trainees in general practice. We used paper based versions to develop the questionnaire and online surveys to test it. Practitioners in a group of volunteer, trial practices received the questionnaire twice. We measured its reliability using Cohen’s Kappa (K). The practitioners in the focus groups reached a consensus as to the key elements to include in the instrument. We achieved a 73.1% (n = 57/78) initial response rate for our questionnaire; of these 57, 54 completed the questionnaire a second time. Family physicians made up the largest single group of respondents (47.4%, n = 27). Initial response showed more female (64.9%, n = 37) than male (35.1%, n = 20) respondents. The reliability results from retesting showed that there was moderate agreement (k > 0.4) on all questions; with many showing substantial agreement (k > 0.6). There was substantial agreement in the questions about loop diuretics (k = 0.608, CI 0.432-0.784, p < 0.001), confidence in managing hypertension (k = 0.628, 95%CI 0.452-0.804, p < 0.001), diastolic blood pressure treatment thresholds in CKD (k = 0.608, 95%CI 0.436-0.780, p < 0.001) and the rate of decline of eGFR that would prompt referral (k = 0.764, 95%CI 0.603-0.925, p < 0.001). The QICKD-CCQ is a reliable instrument for measuring confidence and knowledge among primary care practitioners on CKD management in the context of UK primary care.
... Questionnaire items and the theoretical basis for the questionnaire were identifi ed from literature review and corroborated by expert opinion. [7][8][9][10][11][12][13] The questions were a mixture of pre-coded, single, multiple choice, rank-order and likert-type questions. A draft questionnaire was prepared and circulated among the investigators who brainstormed the current issues in CKD management. ...
... The GPs in Singapore are less confi dent in managing CKD. Only half of the general practitioners were confi dent of managing CKD stage 1, 1 in 3 GPs were confi dent of managing CKD stage 2 and only 1 in 8 GPs were confi dent of managing CKD stage 3. Studies 11,12,14 elsewhere also showed a knowledge gap in CKD management among the general practitioners. However, low practitioner confi dence Don't see that many patients. ...