Improving early identification and management of chronic kidney disease
Chronic Kidney Disease (CKD) is a growing problem in the UK. 15% of UK population over 35 have CKD, but only 2 in 10 people with the disease are currently diagnosed.
What was the aim of the project?
We collaborated with Imperial College Health Partners (ICHP), AstraZeneca, Imperial College Health Care NHS Trust Nephrology Department, and London Kidney Network on the NHS Insights Priorities Programme (NIPP), with the aim to improve the diagnosis and early management of chronic kidney disease in North West London. The project brought together primary and secondary care clinicians and patients to redesign the NWL renal care pathway.
What did we do?
In the discovery phase of the project, data was collected from interviews with patients at risk of CKD, patients diagnosed with CKD, primary and secondary care clinicians as well as population data analysis and an academic literature review to understand the largest challenges and opportunities in the existing NWL pathways. The findings of the review were used to facilitate workshop sessions to determine the next steps of the project.
How did we involve people?
We recruited, mentored and supported patient members to lead on six workshop sessions. Through these workshops, clinicians and patients co-designed pathway improvements together and these solutions were then tested in GP practices and with patients to get feedback.
What did we learn?
We applied the real-world data on health inequalities to investigate the needs of people with CKD and those at risk of CKD to inform the project. The results will highlight challenges and support changes to improve services in NWL.
Key findings:
Criteria for annual screening for CKD are not being fully utilised.
Test results indicative of CKD are not being coded for CKD and therefore patients are unlikely to be receiving optimised treatment for their condition.
What next?
We have developed CKD pathway which will be launched across Primary Care Networks (PCN) in NWL and evaluated with support from the Discover-NOW CKD data study, analysing the CKD population over the last 10 years.
What will the new primary care CKD Pathway look like?
The new pathway will:
Enhance mental and physical health of CKD patients by providing consistent dependable management of the disease.
Provide patients with the opportunity for collaborative management of their CKD through education
Support patient empowerment through education and structured management of CKD, enabling the patient to be more active and proactive by allowing them to collaborate with medical staff and take responsibility for their condition.
Increase access options (language, mode, and time of delivery) and personalised care
Direct primary care referral to existing and accessible CKD education options
Deliver a virtual patient-led education session supported by a CKD nurse which has been integrated into primary care pathways
Deliver educational materials around CKD testing including a one-page summary of CKD testing and diagnosis
Improve (through patient involvement) messaging sent to CKD patients when their annual testing is due
Include automated CKD clinical guidance and alerts on relevant primary care pathology results
Deliver enhanced primary care templates in diabetes, hypertension and CKD
Create primary care searches and recall of patients which identify those with unmet needs
Change guidance to make diagnosis, coding, and management more objective. This included removal of outdated adjustments of test results for ethnic minorities
WSIC & Discover-NOW dataset
With the Discover-NOW team and ICHP through our Information & Intelligence Theme we will be looking to improve the completeness and quality of the data to make it more useful for NHS activities as well as research.
Associated Research Theme
This news story is related to our NHS Insights Prioritisation Programme (NIPP) on Improving early identification and management of chronic kidney disease and in partnership with Northwest London's AHSN; Imperial College Health Partners.