Example 1: Identifying and managing patients at risk of chronic disease exacerbation

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This is one of five examples from our report Making the case for quality improvement: lessons for NHS boards and leaders. Each example illustrates how quality improvement approaches are being used by teams and organisations in different parts of the NHS in England to improve care and value for money.

Early identification of patients at risk of developing end-stage kidney disease: Heart of England NHS Foundation Trust

What was the problem?

Around one in eight people will develop chronic kidney disease at some point in their lifetime (Kidney Care UK 2017). It is more common among older people and people with diabetes and hypertension. While most cases of chronic kidney disease are mild or moderate and can be managed at home or in primary care, around 60,000 people in the UK have end-stage kidney disease that requires ‘renal replacement therapy’ – usually dialysis or transplantation (Caskey et al 2015). As well as having a major impact on patients’ quality of life, treatments such as dialysis are expensive – the annual cost of dialysis per patient is around £25,000 (Kerr et al 2012). 

Preventing or delaying end-stage kidney disease depends on the early identification of patients whose kidney function is deteriorating. As symptoms related to kidney disease usually occur only when the disease is advanced, the main way of detecting declining kidney function is through a blood test (estimated glomerular filtration rate – eGFR). The Heart of England NHS Foundation Trust aimed to develop a surveillance system that would allow trained clinical laboratory staff to identify people at risk of end-stage kidney disease using existing laboratory data.

What did they do?

Starting in 2004, a kidney consultant at the trust used the nephrology department database to generate eGFR graphs of all the results from patients with diabetes who had had a new test in the previous week. Patients with declining kidney function were assessed for their need to be seen in the specialist clinic. This enabled the clinical team to identify patients at risk of end-stage kidney disease at an early point and instigate an appropriate course of treatment. 

Having seen the benefits from using the system among people with diabetes, the trust was awarded a grant by The Health Foundation in 2012 to extend the system to cover the entire population served by the trust’s pathology service. 

What impact has it had?

The trust’s eGFR surveillance system has been instrumental in enabling it to stabilise the number of patients having renal replacement therapy at a time when it is on the rise across the rest of the UK. UK Renal Registry data from 2012–14 shows a 4 per cent fall in the number of patients starting renal replacement therapy in the trust, compared with a national increase of 8 per cent. The system has also helped the trust to become the first (and so far only) one to achieve a late presentation rate – the proportion of patients presenting to a renal specialist less than 90 days before the start of their renal replacement therapy – of less than 5 per cent. In contrast, the average rate across England is 18 per cent and 12 English renal centres have a rate in excess of 20 per cent.

The success of the trust’s surveillance system has prompted the development of a new programme, ASSIST-CKD, aimed at spreading the approach across up to 20 UK pathology laboratories and their surrounding GP networks. 

ASSIST-CKD website.

Caskey F, Castledine C, Dawnay A, Farrington K, Fogarty D, Fraser S, Kumwenda M, MacPhee I, Sinha MD, Steenkamp R, Williams AJ (2015). 18th annual report of the Renal Association [online]. Renal Association website. Available at: www.renalreg.org/reports/2015-eighteenth-annual-report/ (accessed on 20 September 2017).

Gallagher H, Methven S, Casula A, Thomas N, Tomson CRV, Caskey FJ, Rose T, Walters SJ, Kennedy D, Dawnay A, Cassidy M, Fluck R, Rayner HC, Nation M (2017). ‘A programme to spread eGFR graph surveillance for the early identification, support and treatment of people with progressive chronic kidney disease (ASSIST-CKD): protocol for the stepped wedge implementation and evaluation of an intervention to reduce late presentation for renal replacement therapy’. BMC Nephrology, vol 18, p 131.

Kennedy DM, Chatha K, Rayner HC (2013). ‘Laboratory database population surveillance to improve detection of progressive chronic kidney disease’. Journal of Renal Care, vol 39, suppl 2, pp 23–9.

Kerr M, Bray B, Medcalf J, O’Donoghue DJ, Matthews B (2012). ‘Estimating the financial cost of chronic kidney disease to the NHS in England’. Nephrology Dialysis Transplantation, vol 27, suppl 3, pp iii73–80. Available at: www.ncbi.nlm.nih.gov/pubmed/22815543 (accessed on 20 September 2017).

Kidney Care UK (2017). Chronic kidney disease [online]. Kidney Care UK website.

Rayner HC, Baharani J, Dasgupta I, Suresh V, Temple RM, Thomas ME, Smith SA (2014).
Does community-wide chronic kidney disease management improve patient outcomes?’. Nephrology Dialysis Transplantation, vol 29, no 3, pp 644–9.

Rayner HC, Hollingworth L, Higgins R, Dodds S (2011). ‘Systematic kidney disease management in a population with diabetes mellitus: turning the tide of kidney failure’. BMJ Quality & Safety, vol 20, no 10, pp 903–10.
 
The Health Foundation (undated). ‘Identification of diabetes patients at risk of renal disease’. The Health Foundation website.

The Health Foundation (undated). ‘A programme to spread eGFR graph Surveillance for the early Identification, Support and Treatment of people with progressive Chronic Kidney Disease (ASSIST-CKD)’. The Health Foundation website.