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Review of current practice in multidisciplinary CKD clinics in
Canada
Adeera Levin MD FRCPC Director BC Provincial Renal Agency
Professor of Medicine UBC Chair: Knowledge User Group CANN-NET
Co-Chair: Steven Soroka CAnadian KidNey KNowledge TraNslation & GEneration NeTwork
Members of the Knowledge User Group Name Institutional Affiliation
Chair: Adeera Levin University of British Columbia, Vancouver, BC
Vice-Chair: Steven Soroka Dalhousie University, Halifax, NS
Braden Manns University of Calgary, Calgary, AB
Andrey Cybulsky McGill University, Montreal, QC
Nairne Scott Douglas University of Calgary, Calgary, AB
Kailash Jindal University of Alberta, Edmonton, AB
Nadine Valk The Kidney Foundation of Canada
Andrew Steele Lakeridge Health, Oshawa, ON
Cheryl Harding CANA (Canadian Association of Nephrology Administrators)
Selina Allu University of Calgary, Calgary, AB
Sarah Gil University of Calgary, Calgary, AB
Understanding variations in care • Patients with chronic kidney disease (CKD) have variable outcomes
• Time to dialysis or death • Trajectories of progression • Accumulation of burden of disease over time
• Patients with CKD do not always receive care consistent with guidelines:
• complexities in CKD condition • variation in CKD management practice
• Resources, attitudes and philosophies, • lack of randomized trial data to inform care, • lack of access to and methods by which to disseminate best practice.
Continuum of Care and Multiple points for education and influencing decision making
CKD care Delay of progression Treatment of co-morbidities Education
Self management ( diet, medication etc) RRT choices
Preparation for RRT Transition to RRT
Variability in multiple domains may impact outcomes
Biology of clinical condition (CKD) and timing and severity of inter-current events
Structure and function of CKD clinics + Access to information or programs
Desired outcomes
The Context: CANN-NET and CKD Survey • CANN-NET priorities via consultative and iterative process:
• Understanding variations in : • Timing of dialysis initiation and • Appropriate use of home based therapies
These outcomes are likely impacted by upstream activities in CKD clinics ..therefore
• Survey of CKD Multidisciplinary Clinics: • Improved understanding of current care practices ( form) • Contact list to enable the establishment of a national network CKD clinics for future activities • Link CKD clinic structure and function with outcomes
CANN-NET CKD Survey Methodology 2 KT brokers established an up-to-date network of contacts for CKD clinics June 2012
1. Identify nursing, administrative or medical leads (or most relevant contact) to identify all renal programs across Canada (by email or phone).
2. Developed list of contact information for local nursing and medical leads and/or clinic managers for all multidisciplinary CKD clinics across Canada
3. Data collection • Semi-structured, open-ended questions • Confidential and non identified • General information on existing CKD clinic structure
• available resources, • model or care, • education resources, • use of clinical pathways, etc.
Preliminary Findings: April 2013
• 51 interviews conducted • 41 clinics
• 24 Western Canada, • 6 in Ontario, • 5 in Québec, and • 6 in the Atlantic Provinces
• 5 interviews were with medical leads (physicians).
13
3
4
4
6
5
1
4
1
Variability in number of patients to Nephrologists per clinic
Median = 150 patients per nephrologist
*Larger bubbles = more pt/nephrologists
Variability in number of patients to nurses Median = 230 patients per nurse
Variability in number of patients to dietitians Median = 175 patients per dietitian
Variabiliyt in number of patients to pharmacists Median = 175 patients per pharmacist
Variability in patients to social worker Median = 600 patients per social worker
Not all clinics work within programs which offer a full suite of dialysis options
% 0.00
20.00 %
40.00 %
60.00 %
80.00 %
% 100.00
In center HD
PD Thrice weekly
Home HD
Home Nocturnal
HD
In - center Nocturnal
HD
Daily in center HD
Self - care (in center) HD
Variability in models of care within CKD clinics • Nurse + MD constant (59%)
• Primary MD and variable Nurse (19%)
• Variable Nurse and MD (12%)
• Variable MD and same nurse (10%)
Same primary nephrologist &
same nurse
59 %
Different nephrologist &
same nurse
10 %
Same primary nephrologist & different nurse
19 %
Different nephrologist & different nurse
12 %
Details re: functioning of CKD Clinics: Variation persists 1. Referral criteria to CKD clinic
Referral criteria? 83% eGFR cut off as part of the criteria? 50% 2. Management of patients nearing dialysis initiation Policy whereby all patients assessed for home dialysis 68% All patients offered dialysis modality education? 100% 3 Dialysis modality education During clinics visits or through educational materials 32% Group dialysis modality education (or combination) 68% 4 Decision to initiate dialysis made with with regular multidisciplinary team meetings 46%
5. Dedicated dialysis modality coordinator? * (overt role description) 27%
Targets are in use for home dialysis therapies to variable degrees
Centers are aware of home dialysis target
30/41
73%
Target is based on prevalent patients
23/30
77%
Target is based on incident* patients
0/30
------ Both 7/30 23%
•Appropriate to target incidence (not prevalent) as output for CKD clinics…
•Difficult to achieve or better ‘prevalence’ targets as the ‘feeder’ group
What is and is not working*: recurrent themes
Needs/ Areas for improvement: 1. More staff (nurses, nephrologists, experts,
clerical staff, etc) 2. More space 3. More/improved/standardized teaching or
educational aids 4. Better CKD clinic processes
flow of patient referral, decrease wait times, offer telehealth, offer clinical pathway, timely insertion of catheters, etc)
5. Consistent support of home therapies, more dialysis options, support for dialysis for patients in rural communities
Working well: Initiatives and Processes 1. New initiatives around conservative care 2. Development of In-house teaching and educational tools
specific to population/clinic 3. Outreach for early CKD detection 4. The “buddy system” : dedicated nurse assigned to pt working
with the nephrologists= greater interaction with the pt /trust t. 5. A nurse-led telehealth clinic in a remote area
allows pts to stay in their communities; but followed by the MDC team
6. Patient support groups 7. Team of UC and administrative staff playing role in clinic
activities. 8. Inclusion of CKD patients in QI project teams
* Rank ordered themes
Information not yet captured
• Number of clinics with ‘full compliment’ of • RN, Dietician, Pharmacist, Social worker
• Number of clinics with other allied health professionals:
• OT, PT, Psychologist
• Relationship of CKD structure/operations to patient outcomes
Future directions:
• Complete CKD clinic survey and finalize report • include all CKD clinics across Canada
• Link CKD clinic structure/ function to outcomes • Identify best practices
• Longer term goals: Forming a National CKD Clinic Network
• Provide information about new clinical practice guidelines • Foster communication re: barriers faced by end-users face in Guideline
implementation • Foster solutions to address barriers and help with application and uptake of new
guidelines • Foster best clinical care
Thank you
• CKD Clinic staff participating
• Selina Allu and Sarah Gil ( KT brokers CANN-NET)