title: Improving the identification and management of chronic kidney disease in primary care: lessons from a staged improvement collaborative.
abstract: OBJECTIVE
  Undiagnosed chronic kidney disease (CKD) contributes to a high cost and care burden in secondary care. Uptake of evidence-based guidelines in primary care is inconsistent, resulting in variation in the detection and management of CKD.
  
  
  METHODS
  Routinely collected general practice data in one UK region suggested a CKD prevalence of 4.1%, compared with an estimated national prevalence of 8.5%. Of patients on CKD registers, ∼ 30% were estimated to have suboptimal management according to Public Health Observatory analyses.
  
  
  METHODS
  An evidence-based framework for implementation was developed. This informed the design of an improvement collaborative to work with a sample of 30 general practices.
  
  
  METHODS
  A two-phase collaborative was implemented between September 2009 and March 2012. Key elements of the intervention included learning events, improvement targets, Plan-Do-Study-Act cycles, benchmarking of audit data, facilitator support and staff time reimbursement.
  
  
  RESULTS
  Outcomes were evaluated against two indicators: number of patients with CKD on practice registers; percentage of patients achieving evidence-based blood pressure (BP) targets, as a marker for CKD care. In Phase 1, recorded prevalence of CKD in collaborative practices increased ∼ 2-fold more than that in comparator local practices; in Phase 2, this increased to 4-fold, indicating improved case identification. Management of BP according to guideline recommendations also improved.
  
  
  CONCLUSIONS
  An improvement collaborative with tailored facilitation support appears to promote the uptake of evidence-based guidance on the identification and management of CKD in primary care. A controlled evaluation study is needed to rigorously evaluate the impact of this promising improvement intervention.
authors.affiliation: Manchester Business School, University of Manchester, Booth Street West, Manchester M15 6PB, UK School of Nursing, University of Adelaide, Eleanor Harrald Building, Frome Road, Adelaide SA5005, Australia.
authors.forename: Gill
authors.initials: G
authors.lastname: Harvey
authors.affiliation: School of Social Sciences, University of Manchester, Arthur Lewis Building, Oxford Road, Manchester M13 9PL, UK Department for Science, Technology, Engineering and Public Policy (UCL STEaPP), University College London, 36-38 Fitzroy Square (2nd Floor), London W1T 6EY, UK.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Oliver
authors.affiliation: NIHR CLAHRC for Greater Manchester, 3rd Floor, Mayo Building, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK.
authors.forename: John
authors.initials: J
authors.lastname: Humphreys
authors.affiliation: NIHR CLAHRC for Greater Manchester, 3rd Floor, Mayo Building, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK.
authors.forename: Katy
authors.initials: K
authors.lastname: Rothwell
authors.affiliation: Renal Department, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK.
authors.forename: Janet
authors.initials: J
authors.lastname: Hegarty
mesh_terms: D019985:Benchmarking; D001794:Blood Pressure; D019468:Disease Management; D019983:Guideline Adherence; D006801:Humans; D007349:Insurance, Health, Reimbursement; D017410:Practice Guidelines as Topic; D015995:Prevalence; D011320:Primary Health Care / Q000458:organization & administration*; D015397:Program Evaluation; D058996:Quality Improvement / Q000458:organization & administration*; D051436:Renal Insufficiency, Chronic / Q000628:therapy*
keywords: chronic kidney disease; evidence-based guidance; implementation; improvement collaborative; primary care