Chronic Kidney Disease A Team-Based Quality Improvement Project Implementing The EMR

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Melinda Miles
6 years ago
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1 Chronic Kidney Disease Team-Based Quality Improvement Project Implementing The EMR

2 Participants ttending Physician: John Malaty, MD Resident Physician Investigators: John George, MD David Kramer, DO Dale Taylor, MD Study Coordinators: Paulette Blanc, MPH lyson Listhaus, MPH

3 Other Participants Sapna min, MD Loumarie Colon, MD Jeffrey Costain, MD njalee Dave, MD George Eldayrie, MD Sally Hinman, MD Kim Lynch, MSHI Jessica Prince, MD Keiran Shute, MD Jacob Szereszewski, MD nd of course all of our wonderful nursing and front office staff!

4 None Disclosures

5 Learning Objectives fter attending this session, you will be able to: Perform a practical, team-based QI project in your own residency program or practice More effectively utilize technology to automate processes to efficiently manage chronic diseases by improving adherence to guidelines Discuss the national guidelines for chronic kidney disease (CKD) management

6 Why QI? Why EMR? Why Team-Based? It is important to: use quality markers and national guidelines to improve patient care integrate technology into practice and utilize your EMR to improve patient care work as a team to evaluate and manage patients manage an efficient and effective healthcare team

7 Why CKD? Stage 3 or 4 CKD affects 8.05% of the US population, as measured from Patients with CKD have increased morbidity and a two-fold risk of all-cause mortality Patients with CKD have decreased quality of life and increased cost of care Patients don t complain of CKD during visits

Roles of the Healthcare Team Residents and Faculty Researched CKD national guidelines and recommendations Kidney Disease Outcomes Quality Initiative

Staff of care with the ability to reproduce data from smartlists Patient Generated Front Care!

8 Roles of the Healthcare Team Residents and Faculty Researched CKD national guidelines and recommendations Kidney Disease Outcomes Quality Initiative (KDOQI), Joint National Committee (JNC8), merican College of Physicians (CP) Improved Created an EMR template addressing pertinent aspects Epic IT Staff of care with the ability to reproduce data from smartlists Patient Generated Front Care! daily reports of clinic patients to identify those with depressed egfrs Office Staff Nursing Staff Flagged encounter forms of those with depressed egfrs Residents and Faculty Used the template and collected data

9 QI ims Primary im: chieve BP < 140/90 in Stage III-IV CKD patients Secondary ims: Identify and stage patients with CKD Optimize DM management Reduce SCVD risk with statin therapy Improve renal protection with CE-I/RB therapy Vaccinate against influenza

10 Our EPIC Template.CKD CKD definition: abnormalities of kidney structure or function present for >3 months with health implications or egfr < 60 ml/min/1.73m 2 for >3 months.

11 Our EPIC Template

12 Our EPIC Template GFR Category / Stage of CKD egfr Stage I 90 Stage II 60 Stage III 30 Stage IV 15 Stage V < 15

target blood pressure for patients with CKD without albuminuria is

13 Our EPIC Template JNC8 Recommendation: target blood pressure for patients with CKD is < 140/90 mmhg for all ages KDOQI Recommendation: target blood pressure for patients with CKD without albuminuria is 140/90 mmhg and for patients with CKD and albumin excretion 30mg/24hr is 130/80 mmhg

target acceptable for those with limited

14 Our EPIC Template KDOQI Recommendation: target Hb1c for patients with CKD is ~7% to prevent or delay microvascular complications of diabetes mellitus (higher target acceptable for those with limited life expectancy, comorbid conditions, or risk of hypoglycemia)

15 Our EPIC Template KDOQI Recommendation: statin therapy is recommended for patients with CKD who are not treated with dialysis in the setting of DM, CD, TI/CV, SCVD 10-year risk >7.5%, or age 50

Recommendation: screening for proteinuria

16 Our EPIC Template KDOQI Recommendation: CE-I/RB therapy is recommended for patients with CKD who have urine albumin excretion > 300mg/24 hrs or have diabetes mellitus CP Recommendation: screening for proteinuria should not be performed in those already on CE-I/RB therapy

17 Our EPIC Template KDOQI Recommendation: influenza vaccination is recommended for all patients with CKD unless otherwise contraindicated

18 QI Review Primary im was met: Improvement of BP in CKD patients was noted Secondary ims: More patients with CKD have been identified More patients on statin therapy to reduce SCVD risk More patients needing CE-I/RB therapy identified DM control has not improved but those needing Hb1c measurement are better identified Flu vaccine rates have not improved but those needing vaccination are better identified

19 D Primary im: BP < 140/ , 21% T 11, 48% 12, 52% 62, 79% P-value = t Goal (BP < 140/90) t Goal (BP < 140/90) Not at Goal (BP 140/90) Not at Goal (BP 140/90)

20 D T Identification of CKD 70 CKD on Problem List CKD NOT on Problem List 20, 26% 2015 Stage of CKD 58, 74% II III IV V

21 D Statin Therapy , 22% 18, 78% 6, 8% , 92% T P-value = KDOQI guidelines for statin therapy changed and simplified after data collection Evaluated Lipids? lready On Statin LDL <100, TG <150 LDL >100, dd Statin Statin LDL >100, TG >150 No Lipid Panel 2015 Statin Therapy? Yes, On Statin No, dded Statin No, Statin Refused No, Contraindication No, ddress Statin Later

22 D CE-I/RB Therapy 1, 4% , 13% 4, 18% 2015 T 18, 78% 2014 On CE/RB? On CE-I/RB CE-I/RB dded Contraindicated 3, 4% 14, 18% 11, 14% 2015 Microalbuminuria? On CE-I/RB lb:cr < 30, Did not check 40, 51% lb:cr > 30, Not on therapy lb:cr to be ordered in future, Not on therapy lb:cr ordered, Not on therapy

23 D CE-I/RB Therapy , 6% T On CE-I/RB 15, 94% Not on therapy

24 D T Diabetes Control 1, 4% , 24% 22, 96% 2015 X 59, 76% P-value = Hb1c < 7 Hb1c < 7 Hb1C 7- ddressed Hb1C 7- ddressed Hb1C 7-Higher Goal Hb1C 7-Higher Goal Hb1c not checked Hb1c not checked

25 D T Influenza Vaccination 1, 4% , 27% 22, 96% 2015 X 57, 73% P-value = Flu Vaccine Received Flu Vaccine Received Flu Vaccine Refused Flu Vaccine Refused Flu Vaccine Contraindicated Flu Vaccine Contraindicated ddress Flu Vaccine Later ddress Flu Vaccine Later

References National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification and Stratification. m J Kidney Dis 39:S1-S266,2002 (suppl 1).

org/professionals/guidelines/guidelines_commentaries James P, Oparil S, Carter B, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in dults (JNC8). JM.

26 References National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification and Stratification. m J Kidney Dis 39:S1-S266,2002 (suppl 1). Including all Updates and Commentaries published by The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) which can be found at: James P, Oparil S, Carter B, et al Evidence-Based Guideline for the Management of High Blood Pressure in dults (JNC8). JM. 2014;311(5): doi: /jama Qaseem, Hopkins RH, Sweet, DE, et al. Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease: Clinical Practice Guideline From the merican College of Physicians. nn Intern Med. 2013;159(12): doi: / Coresh J, Selvin E, Stevens L, et al. Prevalence of chronic kidney disease in the United States. JM. 2007;298(17): Selvin E, Manzi J, Stevens L, et al. Calibration of serum creatinine in the National Health and Nutrition Examination Surveys (NHNES) , m J Kidney Dis. 2007;50(6):

27 Questions / Discussions

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