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Translating research findings of chronic kidney disease management to clinical practice: challenges and opportunities
Translating Research Findings of Chronic Kidney Disease Management to Clinical Practice: Challenges and Opportunities Lesley Ann Stevens and Adeera Levin Chronic Kidney disease (CKD) has been identified as a public health epidemic, fueled in part by improved outcomes of both diabetic and cardiac patient populations, as well as by the increasing recognition that it is possible to identify CKD at earlier stages. The estimated 8 to 10 million Americans that have CKD, with its concomitant morbidity and mortality, have the potential to overwhelm the current system of specialty practice medicine and health care resources. How can clinicians, clinician scientists, and health care administrators translate research findings into clinical practice in an effective manner to improve the care of this burgeoning patient group? The challenge of translating research into clinical care requires identification of that which we do and do not know, communication of knowledge between those who do and do not know, and efficient collection of information for systematic evaluation. This article will describe the challenges of translating current research findings into clinical practice. There is a need to identify the complexity of CKD disease processes and issues associated with delivery of care and to describe the difficulties in the dissemination of new knowledge to physicians. Because of the propensity of CKD to affect identifiable groups of patients, we will discuss the potential challenges of these strategies given the racial, ethnic, and cultural diversity in North America. A potential solution to these challenges is a new paradigm of “process-based medicine” that integrates clinical and basic science research findings with multidisciplinary and shared care models of health care delivery. In this context, attention to advances in information technology, the cognitive processes that underlie physician learning, and the findings of outcome research may ensure true integration of clinical research and clinical practice. © 2004 by the National Kidney Foundation, Inc. Index Words: Chronic kidney disease; translation of research into practice; health care system; comanagement; specialist care; informatics.
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n the past 2 decades, there has been a proliferation of evidence on which to base medical practice in general and kidney disease specifically. Despite this, the quality of care for many patient groups has not improved. In the majority of countries, regardless of the structure of the health care system, there is consistent evidence for poor quality of care and dissatisfaction among the population.1-4 The poor quality and dissatisfaction with care are not associated with the amount of money spent on health care. Despite the fact that the United States, as compared with Great Britain, Canada, Australia, and New Zealand, spends more than 40% more per capita on medical
From Tufts-New England Medical Center, Boston, MA, USA; and the University of British Columbia, Vancouver, Canada. Address correspondence to Adeera Levin, MD, FRCPC, St. Paul’s Hospital, University of British Columbia, Vancouver BC, Canada. E-mail: [email protected] © 2004 by the National Kidney Foundation, Inc. 1073-4449/04/1101-0009$30.00/0 doi:10.1053/j.arrt.2003.10.010
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care, it ranks 27th in infant mortality, 27th in life expectancy, and ranks poorly on issues related to care coordination, medical errors, overall rating of doctors, and the ability to have questions answered.1,5 Poor quality of care measures have also been observed for patients with chronic kidney disease (CKD) in the analysis of National Health and Nutrition Examination Survey (NHANES) III data. Although 75% of patients with elevated serum creatinine and blood pressure levels received treatment for blood pressure, only 11% reached recommended target levels of the Sixth Report of the Joint National Committee to slow the progression of kidney disease (130/85) and only 27% achieved satisfactory blood pressure levels of 140/90, target levels recommended for prevention of cardiovascular disease.6,7 In a recent publication of patients attending CKD clinics in Canada, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, medications proven to reduce progression of CKD, were prescribed at low rates, showing that even nephrologists are not nec-
Advances in Renal Replacement Therapy, Vol 11, No 1 (January), 2004: pp 66-75
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essarily implementing evidence-based care strategies in those with identified CKD.8 Treatment of anemia, a well-recognized and often symptomatic complication of CKD, is similarly suboptimal in those receiving care from nephrologists.9 Poor quality of delivered medical care in CKD is related to several factors including those specific to the disease entity itself and those factors that impact the translation of research in general.
CKD The recent Kidney Disease Quality Outcome Initiative (KDOQI) system for the definition, evaluation, and management of kidney disease describes a simple approach to a complex disease. The strengths of this system are that it allows for improved communication with researchers, health care providers, and patients and improves on previous definitions of CKD, which rested on the insensitive marker of serum creatinine. The KDOQI classification system defines CKD as the presence of kidney damage (laboratory or imaging) or an estimated glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2, for a period of greater than 3 months. The classification system presumes that the diagnosis of the etiology is made, and that treatment of the primary disease has been instituted, where applicable. Irrespective of the diverse etiologies, when progressive, kidney disease in the patterns of progressive loss of kidney function is similar. The high prevalence of CKD based on a reduction in estimated GFR has recently been shown from analyses of population health surveys.10 However, the numbers of persons who will progress to dialysis or to adverse events related to CKD has not yet been describe; thus, the importance of the estimated prevalence figures are not completely understood. Similarly, we do not understand the basis for the diversity of expression of disease within identified high-risk groups (eg, diabetes, hypertension, and blacks).10,11 This diversity is likely related to the presence of physical (increased intraarterial pressure, intraglomerular pressures, proteinuria) and metabolic factors (acidosis, abnormal mineral metabo-
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lism), which are differently expressed in individuals. Most of these effects are mediated through a number of complex inflammatory and cytokine processes that include upregulation of hormones and growth factors (eg, angiotension II, tumor growth factor , parathyroid hormone aldosterone) and cytokine release (interleukin-2, interleukin-6). The interaction of these physical and biological factors, genetics, and environment that causes disease expression remains a source of ongoing study. The unanswered questions are fruitful for research endeavors but may inadvertently limit implementation of strategies as clinicians may become paralyzed by the amount of uncertainty over an individual patient’s risk for progression. More than a decade of clinical evidence has shown that progression of CKD can be attenuated by a reduction of proteinuria and blood pressure and blockade of the renin-angiotensin system.12-15 Most of the studies to date have been in well-defined populations (ie, diabetes, late stages of CKD), thus limiting their generalizability, or have been smaller studies with intermediate endpoints with inconclusive findings, thus limiting the adoption of the findings. Clinical trials usually have rigorous protocols designed to increase patient and provider adherence; yet these protocols cannot be replicated in real life, which undermines their external validity. To date, there have been only limited large populationbased clinical studies that have included diverse clinical sites (academic and nonacademic) and have shown benefits of easily implemented treatments in reducing the rate of progression of CKD in a diverse patient group. If the challenge for the clinician was simply to delay the progression of kidney disease by treating hypertension and reducing proteinuria, the task might be simpler. Patients with CKD have a multiplicity of comorbid conditions or complications relating to their kidney dysfunction: anemia, mineral metabolism derangement, and nutritional and metabolic disturbances, in addition to concomitant disorders such as cardiovascular disease and or diabetes. Racial and ethnic groups who are at high risk for CKD (eg, blacks, Native populations) are also known to receive poorer quality
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of care.16,17 Thus, CKD treatment strategies require a complex, multifaceted approach with attention to medical as well social, cultural, and psychological factors. Furthermore, CKD as a chronic disease requires longitudinal follow through; as such, there are no immediate returns for either the patient or the physician. The process of recurrent drug adjustment to achieve blood pressure and antiproteinuric targets and readjustments over time because of changing condition can be frustrating and demoralizing for patients and physicians. Unlike acute conditions or simpler diseases, the care of patients with CKD does require patience, and the impact of good care is the achievement of lack of progression and maintenance of good health. Given that most CKD patients, especially at earlier stages are asymptomatic, the maintenance of that state does not truly feel like an “outcome.” Barriers to Delivering Evidence-Based Care Failure to adopt evidence-based care strategies reflects the well-described difficulty of changing human behavior.18 How and under what conditions people modify behavior has been the focus of psychological, social, and medical research. Behavior is changed only after a cognitive and behavioral process that consists of discrete steps including acquisition of new knowledge, persuasion that the new behavior is preferable, decision to adopt the new behavior, implementation of the new behavior, and confirmation that new behavior is appropriate. Barriers may exist at one or more of these steps and are related to 3 major categories of factors: knowledge, attitude, and external/system factors. Identifying the barriers to change may allow the development of specific strategies, thus facilitating the implementation of evidence-based practice in medicine. Knowledge Lack of knowledge can either be related to a deficiency of evidence or to the lack of awareness or familiarity of physicians with the evidence base. Although the field of CKD requires significantly more investigation for full understanding, key messages about blood pressure targets, reduction of proteinuria, and treatment of comorbid conditions have been
ubiquitous for the last 5 to 10 years. Thus, these messages should be well known to nephrologists. However, as the emphasis shifts toward earlier recognition and identification of CKD, there is an increasing importance of non-nephrologist physicians (both primary care and specialist physicians) in the overall care for patients with CKD. The knowledge transfer rate in this group is likely to be slower than to a group of nephrology specialists. The key piece of information that must be acquired by these physicians is that the kidney function should be measured by reduction in GFR (ie, not serum creatinine) and that both GFR and markers of kidney damage (urine assessments and/or radiology) are necessary for the diagnosis. This is a novel, relatively complex concept and therefore may not be easily disseminated without explicit instruction. In the last 2 years, there have been increasing numbers of publications concerning CKD in general medical journals; however, the impact of written materials on changing behavior is usually minimal. Other methods for improving physician knowledge and behavior include academic detailing, audit and feedback, provider reminder systems, incentives, local opinion leaders, outreach visits, continuous quality improvement, clinical information systems, and computer decision support systems. However, each of these strategies has met with mixed success.19-21 Thus, knowledge dissemination continues to be a limiting factor in the implementation of the new CKD guidelines. Attitudes The attitude of physicians and of other decision makers as to the importance of CKD is also a key barrier to implementing appropriate care. Attitudes that constitute barriers include disagreement among specialty physicians on the significance of data or published studies; the lack of data on outcomes deemed important to the physician, patient, or system; the lack of motivation to implement care plans; or the lack of expected efficacy or outcome. Within the nephrology community currently, there is reluctance by some nephrologists for widespread adoption of the current classification system. The absence of data as to the benefits of treatment in earlier stages of
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CKD (ie, stages 2-3 GFR 60-90 mL/min/m2 with kidney damage or GFR ⬍ 60 mL/min/ 1.73 m2) and the potential consequences of labeling on patients’ overall quality of health has fueled the debate.22,23 Nephrologists may not use the proven treatment strategies for such patient groups and referring physicians may thus receive conflicting messages as to the necessity of early referral. This inconsistency may increase the difficulty for nonnephrologist physicians to learn about CKD and its management. External Barriers The external barriers to implementation include patient-specific factors, contradictory or noncomplimentary nature of existing guidelines or data, the economic and human resources and time required for care of chronic diseases, and the health care system itself. Patient factors. Patients are not homogenous beings to whom treatment strategies can be applied. They come with their own preferences, cultural and ethnic backgrounds, and socioeconomic resources. Each of these obviously has an impact on the physician’s abilities to implement treatments. Even within universal health care programs (such as exist in Canada, United Kingdom, and other European countries), the variability in treatment strategies is mitigated by patient belief systems and attitudes, not simply by access to economic resources.16 Because CKD is an asymptomatic disease, it is often difficult to motivate individuals to follow complex diet and drug treatment regimens, especially when these regimens are inconvenient and may have side effects. The impact of chronic disease on social/familial structure and function differs according to cultural and socioeconomic background. Family dynamics and roles may be adversely impacted by the diagnosis and treatment of a chronic disease. Specific populations: Ethnic and racial groups.
Certain racial and ethnic groups suffer from higher prevalence and more severe forms of chronic diseases, including CKD.11,24 Blacks have an overall death rate that is 1.6 times higher than that of the white US population.25 One in 4 blacks who reported that they had a chronic or serious illness did not have an
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ambulatory visit in the preceding year as compared with with 1 in 6 whites; blacks were less likely to be covered by any insurance, and blacks Americans had higher and increasing hospitalization rates than did whites in the period between 1991 through to 1998 for the diagnoses of angina, hypertension, diabetes, and congestive heart failure.26-28 The increased prevalence of CKD in blacks, natives, and other ethnic groups may be in part because of genetic factors; however, the poor quality of health care received in these groups has a significant impact on the poor outcomes. The influence of education and healthy lifestyle during formative years on long-term outcomes should not be underestimated. Rural/geographically isolated. Patients and physicians who reside in geographically isolated areas also pose significant challenges in terms of knowledge dissemination, access to implementation tools, or to resources themselves. The unique problems of more isolated communities are compounded by lack of critical mass of patient groups, and physician resources, which limit exposure, and thus familiarity. Nonalignment of Existing Guidelines Interestingly, current guidelines for diabetes mention the need for serial measurement of HbA1C and urine protein but not of kidney function.29,30 A recent analysis of NHANES III data showed that approximately 30% of patients with diabetes and impaired kidney function had no evidence of albumunuria or retinopathy.31 Guidelines for cardiovascular disease, hypertension, and dyslipidemia recognize CKD as a risk factor for these conditions but do not recommend serial measurement or follow-up of kidney function, other than as it pertains to complications of specific medication use.32 Although CKD groups are clear about the interlinking of diabetes, cardiovascular disease (CVD) and CKD, it is not as apparent from the cardiovascular and diabetes groups that they view CKD with similar importance. Thus, conflicting prioritization from different subspecialties may contribute to the confusion at the clinical implementation level.
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Resources In a constrained environment of both economic and human resources, the care of chronic asymptomatic disease is perceived to be expensive. Limited time leads to prioritization of those aspects of care that can be easily managed or more importantly shifts away from preventive strategies to treatment of seriously ill patients (ie, those requiring dialysis). It has been explicitly shown from a “business case” perspective how much cost savings can be accrued by slowing the progression of CKD and therefore prevention of ESRD.33 However, it is difficult for insurance companies or governments to appreciate the longterm gain associated with expensive investment in the infrastructure necessary to establish such preventative strategies. Considering all aspects of resource utilization and from a societal perspective, we and others would argue that if there are insufficient resources at the current time, without a prevention strategy, the resource shortage will only become worse.33
Solutions Learning Processes It is well known that behavior is difficult to change in all areas of human life. Medicine is no exception, particularly when the behavior change is based on new or complex ideas, as in CKD. Simple ideas with observable advantages over the old, which are consistent with previous ideas, values, and experiences, and which are presented by credible sources (eg, someone who is alike in cultural, personal, and social characteristics) will be more likely to be accepted.18,34 This in part explains the success of problem-based learning in continuing medical education, the importance of drawing analogies between CKD to more familiar paradigms (eg, CVD or diabetes), and the importance of selecting the right medium for presentation of the new information.35-38 Although a full discussion of the theoretical basis for adult learning and behavior change are beyond the scope of this article, attention to these processes is essential for effective translation of research into clinical practice.
Care Delivery Models Primary care and specialist and comanagement.
Primary care physicians (PCPs) and specialists each bring unique skills to patient management, and for many patients, it is important to incorporate both into the care plan. Health care systems with good primary care have better overall measures of health status as indicated by birth weight, postneonatal mortality, life expectancy, and with lower costs.39 However, higher rates of adherence to recommended treatments,40-43 and better outcomes are observed with specialist care.41,43-46 In situations in which comanagement has been instituted, improved care and outcomes have been noted.40,45,47 Shared care allows information from specialist to PCP to be shared in the sociocultural context of the individual case, thus improving the understanding of individual patient needs and perspectives. The specific configuration of the comanagement depends on the structure of the health care system, geographical location of the practice, and individual patient and physician needs. PCP care is likely to be sufficient with patients whose disease falls into the milder forms of the disease spectrum, whose complications from disease are not common, and if the condition itself is not one in which research findings are rapidly accumulating.48 PCPs who have a large practice of patients with chronic disease will require less input then those who have less experience, as has been shown with human immunodeficiency virus patients.49 In rural settings or where there is an under supply of nephrologists or other specialists, comanagement can be done not only with visits but also by telephone, e-mail, or other forms of electronic information transfer. Health care structure. Complex multifaceted disease processes require systematic approaches to care delivery. In the current era, in which there is a shortage of physicians, especially specialty physicians, the management of a large group of patients with a complex disease requires an organizational strategy that involves other members of the health care team. The paradigm of individual physicians being completely responsible for all aspects of care for their patients is no longer viable:
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shared care between physicians and other members of the health care team is an obvious solution to the lack of physician resources and to the demand for increased services that complex disease requires. Allied health care workers such as dietitians, pharmacists, and social workers are integral to providing excellent care for patients with CKD; indeed, full benefit of treatments required nutritional counseling, education, and medications. Other aspects of chronic care management that can be facilitated in this framework are self-management by patients, evidence-based decision support by physicians, case management, planned appointments, and routine blood work.50 Multidisciplinary care attempts to incorporate the unique medical, sociological, psychological, and cultural background of individuals together in the overall care plan. In addition, community involvement as equal partners in the development of an intervention program, culturally and linguistically appropriate materials, and cultural competence are all necessary elements for successful translation of research findings for patients in racial and ethnic groups.16,51,52 Diabetes clinics and clinics for other chronic conditions such as asthma and rheumatological diseases have been clearly shown to improve outcomes of patients.53-55 However, there have been few publications as to the value of such clinics in CKD. We have published the impact of a multidisciplinary care clinic on patient outcomes with specific reference to outcomes once dialysis has commenced,56-58 and others have shown that those referred early to nephrologists have better outcomes once on dialysis.59 However these publications have not attempted to show the impact of this approach on the progression of CKD. Information technology. The integration of complex information with routine clinical practice is central to translating research findings to clinical practice. Electronic medical records (EMR) allow for collation of all information relative to an individual patient, are visible to all members of the health care team (even at geographically distant sites), and also allow for the incorporation of patient and encounter specific prompts to ensure appro-
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priate care delivery/treatment prescription. These prompts are a form of problem-based learning and may improve acquisition of new information. Furthermore, EMR and other forms of electronic collation of information, permit ongoing data collection. Appropriate analysis of prospective data can potentially enhance understanding of the predictors of progression and response to treatments; this is particularly important in areas such as CKD in which the existing data are preliminary. The integration of information technology and clinical care will potentially help evaluate patient-specific evidence-based therapeutic strategies.
Proposed Studies/Future Research: Integration CVD and kidney disease share many similarities both in disease expression, progression, and impact. Thus, the nephrology community may learn about implementation by examining implementation strategies that have been successful in changing CVD care. In the past 2 decades, there has been improvement in the understanding and treatment of CVD with a consequent decrease in morbidity and mortality. In part, this has been because of the recognition that a number of easily identifiable risk factors for CVD exist and that these factors have preferred and easily implemented treatment strategies (ie, lipid-lowering agents, aspirin, and antihypertensive control). Although certainly not complete, the success of the translation of these strategies in CVD has been because of a number of interlinked strategies including (1) a public health campaign fueled by good epidemiological data; (2) involvement of nonprofit organizations for patient focused education and treatment; (3) large population-based clinical studies, both observational and randomized60,61; and (4) the execution of interventional studies in the context of both tertiary and community based institutions allowing easier uptake of new therapies once approved.62 In the area of nephrology, we have only recently showed the large prevalence of disease by using population-based studies.10 A number of nonprofit patient-based organizations, most notably the National Kidney Foun-
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dation, have recently been involved in public campaigns (Kidney Evaluation Education Program, Kidney Disease Outcomes Quality Initiative). There have to date been no large population-based clinical studies that have involved both tertiary and community sites and that have shown a benefit to an easily implemented treatment in reducing the rate of progression of CKD. The current strategic initiatives are in keeping with previously successful CVD strategies and as such may well be as successful. The translation of research into clinical behavior requires this multipronged approach to the problem. A number of studies in various stages of development both in Canada and other countries will attempt to show the outcomes of patients using different approaches (Parfrey et al, unpublished data, 2003; A. Levin, unpublished data, 2003).63 Population-based studies are being designed such that CKD patients will be identified through laboratory systems, using estimates of GFR equations, with appropriate prompts to the ordering physicians as to the meaning and appropriate investigation of GFR abnormalities. These patients will be followed in the systematic manner for a period of time to determine changes in kidney function, other parameters, and outcomes. Some of these patients will naturally be referred to nephrologists and the impact of that referral can be followed. Concomitant with this opportunity for a natural history study, ongoing or planned large randomized control trials in diabetics and cardiac patients should be encouraged to enroll patients with different stages of CKD, as determined by estimated GFR. Furthermore, large randomized controlled trials of patients with all levels of CKD have been proposed to understand the impact of care delivery models and combinations of treatment strategies on patient outcomes. However, these studies will require at least 5 or 10 more years before outcomes can be shown, thus the need to search for some intermediate strategies. In the interim, examination of existing data sets, such as the recently completed Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), Atherosclerosis Risk in Communities (ARIC), African American Study of Kidney Disease and Hypertension (AASK), may
help to understand the implication of impaired kidney function, CVD, and diabetes and to show the safety and utility of specific treatment strategies in these patients. The coordination of clinicians, clinical epidemiologists, clinical trial participants, and health care administrators is important if vital information is to be gathered and analyzed in a timely manner such that the impact of various strategies can be evaluated.
Conclusions In this era of escalating information, costly technology, and an increasing prevalence of chronic complex diseases in an aging population, we must develop systems to translate research into delivery of quality clinical care. At present in nephrology, we have some knowledge of disease processes, and rudimentary knowledge about risk factors for progression, and how best to deliver care to those with a chronic disease. We find ourselves in a health care environment not suited to either the care of chronic conditions or prevention. We suggest that a new paradigm, “processbased medicine,” which incorporates evidence based medicine with multidisciplinary and shared care models of health care delivery is essential. It requires attention to advances in information technology, the cognitive processes that underlie physician learning, and the results of outcome research. Information technology should facilitate shared care models of care delivery for chronic conditions and allow opportunities to add new knowledge and deliver good care to complex patient groups. What can be done now in advance of major changes we suggested earlier? We need to educate medical students, health care professionals, and established physicians about CKD. These educational initiatives should be done in the context of cases or specific patients, especially for established practitioners, and should be simplified to make analogies to familiar concepts. The concept that CKD is a risk factor for CVD and thus needs to be managed (as does diabetes and dyslipidemia) should be more clearly articulated. Basic and clinical research in kidney disease has been enhanced by discoveries in vas-
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cular biology, diabetes, and cardiology. Much of the clinical research has been thwarted by lack of clear definition of CKD; thus, the development of the new staging system that defines and classifies kidney disease permits ongoing robust clinical trials. Incorporating this classification system into clinical practice of all physicians, by automatic laboratory reporting of estimates of GFR, will both raise awareness and improve communication between all medical professionals. Comanagement of CKD patients between different physicians and multidisciplinary teams and the coordinated investigation of treatments and treatment strategies by both clinicians and researchers will lead to improved outcomes for patients with CKD. Systematic evaluation of the impact on health care delivery systems, resources, and patient outcomes requires a new integrated paradigm of care and discovery.
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26. Blendon R, Aiken L, Freeman H, et al: Access to medical care for black and white Americans. A matter of continuing concern. JAMA 261:278-281, 1989 27. Blendon R, Scheck A, Donelan K, et al: How white and African Americans view their health and social problems. Different experiences, different expectations. JAMA 273:341-346, 1995 28. Davis SK, Liu Y, Gibbons GH: Disparities in trends of hospitalization for potentially preventable chronic conditions among African Americans during the 1990s: Implications and benchmarks. Am J Public Health 93:447-455, 2003 29. Molitch M, DeFronzo R, Franz M, et al: Diabetic nephropathy. Diabetes Care 26:S94-98, 2003 30. Association, CD. 1998 Clinical practice guidelines for the management of diabetes in Canada. CMAJ 159(S8), 1998 31. Kramer H, Nguyen Q, Curhan G, et al: Renal insufficiency in the absence of albuminuria and retinopathy among adults with type 2 diabetes mellitus. JAMA 289:3273-3277, 2003 32. Liu P, Arnold M, Blenekie I, et al: The 2002/3 CCS Consensus Conference Update for the Diagnosis and Management of Heart Failure. Available at: www. ccs.ca. Accessed July 2003 33. Trivedi H, Pang M, Campbell A, et al: Slowing the progression of chronic renal Failure: Economic benefits and patients perspectives. Am J Kidney Dis 39: 721-729, 2003 34. Robinson P, Purves I, Wilson R: Learning support for the consultation: information support and decision support should be placed in an educational framework. Med Educ 37:429-433, 2003 35. Davis D, O’Brien MA, Freemantle N, et al: Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 282:867-874, 1999 36. Pereles L, Lockyer J, Fidler H: Permanent small groups: Group dynamics, learning, and change. J Contin Educ Health Prof 22:205-213, 2002 37. Kiessling A, Henriksson P: Efficacy of case method learning in general practice for secondary prevention in patients with coronary artery disease: Randomised controlled study. BMJ 325:877-880, 2002 38. Owen P, Allery L, Harding K, et al: General practitioners’ continuing medical education within and outside their practice. BMJ 299:238-240, 1989 39. Starfield B, Shi L: Policy relevant determinants of health: an international perspective. Health Policy 60:201-218, 2002 40. Ayanian JZ, Guadagnoli E, McNeil BJ, et al: Treatment and outcomes of acute myocardial infarction among patients of cardiologists and generalist physicians. Arch Intern Med 157:2570-2576, 1997 41. Jollis JG, DeLong ER, Peterson ED, et al: Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med 335:18801887, 1996
42. Legorreta AP, Christian-Herman J, O’Connor RD, et al: Compliance with national asthma management guidelines and specialty care: A health maintenance organization experience. Arch Intern Med 158:457464, 1998 43. Solomon DH, Bates DW, Panush RS, et al: Costs, outcomes, and patient satisfaction by provider type for patients with rheumatic and musculoskeletal conditions: A critical review of the literature and proposed methodologic standards. Ann Intern Med 127: 52-60, 1997 44. Kitahata MM, Koepsell TD, Deyo RA, et al: Physicians’ experience with the acquired immunodeficiency syndrome as a factor in patients’ survival. N Engl J Med 334:701-706, 1996 45. Ayanian JZ, Landrum MB, Guadagnoli E, et al: Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction. N Engl J Med 347:1678-1686, 2002 46. Jong P, Gong Y, Liu P, et al: Care and outcomes of patients newly hospitalized for heart failure in the community treated by cardiologists compared with other specialists. Circulation 108:184-191, 2003 47. Katon W, Von Korff M, Lin E, et al: Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 273:1026-1031, 1995 48. Greenfield S: The next generation of research in provider optimization. J Gen Intern Med 14:516-517, 1999 49. Landon B, Wilson I, Cohn S, et al: Physician specialization and antiretroviral therapy for HIV. J Gen Intern Med 18:233-241, 2003 50. Bodenheimer T: Innovations in primary care in the United States. BMJ 326:796-799, 2003 51. Bigby J: The challenge of eliminating disparities in health. J Gen Intern Med 17:489-490, 2002 52. Potvin L, Cargo M, McComber A, et al: Implementing participatory intervention and research in communities: Lessons from the Kahnawake Schools Diabetes Prevention Project in Canada. Soc Sci Med 56:12951305, 2003 53. Gaede P, Vedel P, Parving H, et al: Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study. Lancet 353:617-622, 1999 54. Norris S, Nichols P, Caspersen C, et al: The effectiveness of disease and case management for people with diabetes: A systematic review. Am J Prev Med 2:1538, 2002 55. Vliet V, Breedveld F, Hazes J: The two-year follow-up of a randomized comparison of in-patient multidisciplinary team care and routine out-patient care for active rheumatoid arthritis. Br J Rheumatol 36:82-85, 1997 56. Curtis B, Ravani P, Malberti F, et al: CAN- IT impact, Canadian Italian Study of the Impact of Mutlidsiciplinary Clinics on dialysis outcomes. J Am Soc Nephrol (in press) 57. Levin A, Lewis M, Mortiboy P, et al: Multidisciplinary predialysis programs: Quantification and limitations
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of their impact on patient outcomes in two Canadian settings. Am J Kidney Dis 29:533-540, 1997 58. Levin A: Identification of patients and risk factors in chronic kidney disease—Evaluating risk factors and therapeutic strategies. Nephrol Dial Transplant 16:5760, 2001 (Suppl) 59. Jungers P, Massy ZA, Nguyen-Khoa T, et al: Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients. Nephrol Dial Transplant 16:2357-2364, 2001 60. The Multiple Risk Factor Intervention Trial Research Group: Mortality rates after 10.5 years for participants in the Multiple Risk Factor Intervention Trial. Find-
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ings related to a priori hypotheses of the trial. JAMA 263:1795-1801, 1990 61. Dawber T, Kannel W: The Framingham study. An epidemiological approach to coronary heart disease. Circulation 34:553-555, 1996 62. Yusuf S, Sleight P, Pogue J, et al: Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 342:145-153, 2000 63. British Columbia Guidelines and Protocols Advisory Committee, Identification, Evaluation and Management of Patients with Chronic Kidney Disease. Victoria, BC, Ministry of Health, 2003
I
n the past 2 decades, there has been a proliferation of evidence on which to base medical practice in general and kidney disease specifically. Despite this, the quality of care for many patient groups has not improved. In the majority of countries, regardless of the structure of the health care system, there is consistent evidence for poor quality of care and dissatisfaction among the population.1-4 The poor quality and dissatisfaction with care are not associated with the amount of money spent on health care. Despite the fact that the United States, as compared with Great Britain, Canada, Australia, and New Zealand, spends more than 40% more per capita on medical
From Tufts-New England Medical Center, Boston, MA, USA; and the University of British Columbia, Vancouver, Canada. Address correspondence to Adeera Levin, MD, FRCPC, St. Paul’s Hospital, University of British Columbia, Vancouver BC, Canada. E-mail: [email protected] © 2004 by the National Kidney Foundation, Inc. 1073-4449/04/1101-0009$30.00/0 doi:10.1053/j.arrt.2003.10.010
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care, it ranks 27th in infant mortality, 27th in life expectancy, and ranks poorly on issues related to care coordination, medical errors, overall rating of doctors, and the ability to have questions answered.1,5 Poor quality of care measures have also been observed for patients with chronic kidney disease (CKD) in the analysis of National Health and Nutrition Examination Survey (NHANES) III data. Although 75% of patients with elevated serum creatinine and blood pressure levels received treatment for blood pressure, only 11% reached recommended target levels of the Sixth Report of the Joint National Committee to slow the progression of kidney disease (130/85) and only 27% achieved satisfactory blood pressure levels of 140/90, target levels recommended for prevention of cardiovascular disease.6,7 In a recent publication of patients attending CKD clinics in Canada, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, medications proven to reduce progression of CKD, were prescribed at low rates, showing that even nephrologists are not nec-
Advances in Renal Replacement Therapy, Vol 11, No 1 (January), 2004: pp 66-75
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essarily implementing evidence-based care strategies in those with identified CKD.8 Treatment of anemia, a well-recognized and often symptomatic complication of CKD, is similarly suboptimal in those receiving care from nephrologists.9 Poor quality of delivered medical care in CKD is related to several factors including those specific to the disease entity itself and those factors that impact the translation of research in general.
CKD The recent Kidney Disease Quality Outcome Initiative (KDOQI) system for the definition, evaluation, and management of kidney disease describes a simple approach to a complex disease. The strengths of this system are that it allows for improved communication with researchers, health care providers, and patients and improves on previous definitions of CKD, which rested on the insensitive marker of serum creatinine. The KDOQI classification system defines CKD as the presence of kidney damage (laboratory or imaging) or an estimated glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2, for a period of greater than 3 months. The classification system presumes that the diagnosis of the etiology is made, and that treatment of the primary disease has been instituted, where applicable. Irrespective of the diverse etiologies, when progressive, kidney disease in the patterns of progressive loss of kidney function is similar. The high prevalence of CKD based on a reduction in estimated GFR has recently been shown from analyses of population health surveys.10 However, the numbers of persons who will progress to dialysis or to adverse events related to CKD has not yet been describe; thus, the importance of the estimated prevalence figures are not completely understood. Similarly, we do not understand the basis for the diversity of expression of disease within identified high-risk groups (eg, diabetes, hypertension, and blacks).10,11 This diversity is likely related to the presence of physical (increased intraarterial pressure, intraglomerular pressures, proteinuria) and metabolic factors (acidosis, abnormal mineral metabo-
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lism), which are differently expressed in individuals. Most of these effects are mediated through a number of complex inflammatory and cytokine processes that include upregulation of hormones and growth factors (eg, angiotension II, tumor growth factor , parathyroid hormone aldosterone) and cytokine release (interleukin-2, interleukin-6). The interaction of these physical and biological factors, genetics, and environment that causes disease expression remains a source of ongoing study. The unanswered questions are fruitful for research endeavors but may inadvertently limit implementation of strategies as clinicians may become paralyzed by the amount of uncertainty over an individual patient’s risk for progression. More than a decade of clinical evidence has shown that progression of CKD can be attenuated by a reduction of proteinuria and blood pressure and blockade of the renin-angiotensin system.12-15 Most of the studies to date have been in well-defined populations (ie, diabetes, late stages of CKD), thus limiting their generalizability, or have been smaller studies with intermediate endpoints with inconclusive findings, thus limiting the adoption of the findings. Clinical trials usually have rigorous protocols designed to increase patient and provider adherence; yet these protocols cannot be replicated in real life, which undermines their external validity. To date, there have been only limited large populationbased clinical studies that have included diverse clinical sites (academic and nonacademic) and have shown benefits of easily implemented treatments in reducing the rate of progression of CKD in a diverse patient group. If the challenge for the clinician was simply to delay the progression of kidney disease by treating hypertension and reducing proteinuria, the task might be simpler. Patients with CKD have a multiplicity of comorbid conditions or complications relating to their kidney dysfunction: anemia, mineral metabolism derangement, and nutritional and metabolic disturbances, in addition to concomitant disorders such as cardiovascular disease and or diabetes. Racial and ethnic groups who are at high risk for CKD (eg, blacks, Native populations) are also known to receive poorer quality
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of care.16,17 Thus, CKD treatment strategies require a complex, multifaceted approach with attention to medical as well social, cultural, and psychological factors. Furthermore, CKD as a chronic disease requires longitudinal follow through; as such, there are no immediate returns for either the patient or the physician. The process of recurrent drug adjustment to achieve blood pressure and antiproteinuric targets and readjustments over time because of changing condition can be frustrating and demoralizing for patients and physicians. Unlike acute conditions or simpler diseases, the care of patients with CKD does require patience, and the impact of good care is the achievement of lack of progression and maintenance of good health. Given that most CKD patients, especially at earlier stages are asymptomatic, the maintenance of that state does not truly feel like an “outcome.” Barriers to Delivering Evidence-Based Care Failure to adopt evidence-based care strategies reflects the well-described difficulty of changing human behavior.18 How and under what conditions people modify behavior has been the focus of psychological, social, and medical research. Behavior is changed only after a cognitive and behavioral process that consists of discrete steps including acquisition of new knowledge, persuasion that the new behavior is preferable, decision to adopt the new behavior, implementation of the new behavior, and confirmation that new behavior is appropriate. Barriers may exist at one or more of these steps and are related to 3 major categories of factors: knowledge, attitude, and external/system factors. Identifying the barriers to change may allow the development of specific strategies, thus facilitating the implementation of evidence-based practice in medicine. Knowledge Lack of knowledge can either be related to a deficiency of evidence or to the lack of awareness or familiarity of physicians with the evidence base. Although the field of CKD requires significantly more investigation for full understanding, key messages about blood pressure targets, reduction of proteinuria, and treatment of comorbid conditions have been
ubiquitous for the last 5 to 10 years. Thus, these messages should be well known to nephrologists. However, as the emphasis shifts toward earlier recognition and identification of CKD, there is an increasing importance of non-nephrologist physicians (both primary care and specialist physicians) in the overall care for patients with CKD. The knowledge transfer rate in this group is likely to be slower than to a group of nephrology specialists. The key piece of information that must be acquired by these physicians is that the kidney function should be measured by reduction in GFR (ie, not serum creatinine) and that both GFR and markers of kidney damage (urine assessments and/or radiology) are necessary for the diagnosis. This is a novel, relatively complex concept and therefore may not be easily disseminated without explicit instruction. In the last 2 years, there have been increasing numbers of publications concerning CKD in general medical journals; however, the impact of written materials on changing behavior is usually minimal. Other methods for improving physician knowledge and behavior include academic detailing, audit and feedback, provider reminder systems, incentives, local opinion leaders, outreach visits, continuous quality improvement, clinical information systems, and computer decision support systems. However, each of these strategies has met with mixed success.19-21 Thus, knowledge dissemination continues to be a limiting factor in the implementation of the new CKD guidelines. Attitudes The attitude of physicians and of other decision makers as to the importance of CKD is also a key barrier to implementing appropriate care. Attitudes that constitute barriers include disagreement among specialty physicians on the significance of data or published studies; the lack of data on outcomes deemed important to the physician, patient, or system; the lack of motivation to implement care plans; or the lack of expected efficacy or outcome. Within the nephrology community currently, there is reluctance by some nephrologists for widespread adoption of the current classification system. The absence of data as to the benefits of treatment in earlier stages of
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CKD (ie, stages 2-3 GFR 60-90 mL/min/m2 with kidney damage or GFR ⬍ 60 mL/min/ 1.73 m2) and the potential consequences of labeling on patients’ overall quality of health has fueled the debate.22,23 Nephrologists may not use the proven treatment strategies for such patient groups and referring physicians may thus receive conflicting messages as to the necessity of early referral. This inconsistency may increase the difficulty for nonnephrologist physicians to learn about CKD and its management. External Barriers The external barriers to implementation include patient-specific factors, contradictory or noncomplimentary nature of existing guidelines or data, the economic and human resources and time required for care of chronic diseases, and the health care system itself. Patient factors. Patients are not homogenous beings to whom treatment strategies can be applied. They come with their own preferences, cultural and ethnic backgrounds, and socioeconomic resources. Each of these obviously has an impact on the physician’s abilities to implement treatments. Even within universal health care programs (such as exist in Canada, United Kingdom, and other European countries), the variability in treatment strategies is mitigated by patient belief systems and attitudes, not simply by access to economic resources.16 Because CKD is an asymptomatic disease, it is often difficult to motivate individuals to follow complex diet and drug treatment regimens, especially when these regimens are inconvenient and may have side effects. The impact of chronic disease on social/familial structure and function differs according to cultural and socioeconomic background. Family dynamics and roles may be adversely impacted by the diagnosis and treatment of a chronic disease. Specific populations: Ethnic and racial groups.
Certain racial and ethnic groups suffer from higher prevalence and more severe forms of chronic diseases, including CKD.11,24 Blacks have an overall death rate that is 1.6 times higher than that of the white US population.25 One in 4 blacks who reported that they had a chronic or serious illness did not have an
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ambulatory visit in the preceding year as compared with with 1 in 6 whites; blacks were less likely to be covered by any insurance, and blacks Americans had higher and increasing hospitalization rates than did whites in the period between 1991 through to 1998 for the diagnoses of angina, hypertension, diabetes, and congestive heart failure.26-28 The increased prevalence of CKD in blacks, natives, and other ethnic groups may be in part because of genetic factors; however, the poor quality of health care received in these groups has a significant impact on the poor outcomes. The influence of education and healthy lifestyle during formative years on long-term outcomes should not be underestimated. Rural/geographically isolated. Patients and physicians who reside in geographically isolated areas also pose significant challenges in terms of knowledge dissemination, access to implementation tools, or to resources themselves. The unique problems of more isolated communities are compounded by lack of critical mass of patient groups, and physician resources, which limit exposure, and thus familiarity. Nonalignment of Existing Guidelines Interestingly, current guidelines for diabetes mention the need for serial measurement of HbA1C and urine protein but not of kidney function.29,30 A recent analysis of NHANES III data showed that approximately 30% of patients with diabetes and impaired kidney function had no evidence of albumunuria or retinopathy.31 Guidelines for cardiovascular disease, hypertension, and dyslipidemia recognize CKD as a risk factor for these conditions but do not recommend serial measurement or follow-up of kidney function, other than as it pertains to complications of specific medication use.32 Although CKD groups are clear about the interlinking of diabetes, cardiovascular disease (CVD) and CKD, it is not as apparent from the cardiovascular and diabetes groups that they view CKD with similar importance. Thus, conflicting prioritization from different subspecialties may contribute to the confusion at the clinical implementation level.
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Resources In a constrained environment of both economic and human resources, the care of chronic asymptomatic disease is perceived to be expensive. Limited time leads to prioritization of those aspects of care that can be easily managed or more importantly shifts away from preventive strategies to treatment of seriously ill patients (ie, those requiring dialysis). It has been explicitly shown from a “business case” perspective how much cost savings can be accrued by slowing the progression of CKD and therefore prevention of ESRD.33 However, it is difficult for insurance companies or governments to appreciate the longterm gain associated with expensive investment in the infrastructure necessary to establish such preventative strategies. Considering all aspects of resource utilization and from a societal perspective, we and others would argue that if there are insufficient resources at the current time, without a prevention strategy, the resource shortage will only become worse.33
Solutions Learning Processes It is well known that behavior is difficult to change in all areas of human life. Medicine is no exception, particularly when the behavior change is based on new or complex ideas, as in CKD. Simple ideas with observable advantages over the old, which are consistent with previous ideas, values, and experiences, and which are presented by credible sources (eg, someone who is alike in cultural, personal, and social characteristics) will be more likely to be accepted.18,34 This in part explains the success of problem-based learning in continuing medical education, the importance of drawing analogies between CKD to more familiar paradigms (eg, CVD or diabetes), and the importance of selecting the right medium for presentation of the new information.35-38 Although a full discussion of the theoretical basis for adult learning and behavior change are beyond the scope of this article, attention to these processes is essential for effective translation of research into clinical practice.
Care Delivery Models Primary care and specialist and comanagement.
Primary care physicians (PCPs) and specialists each bring unique skills to patient management, and for many patients, it is important to incorporate both into the care plan. Health care systems with good primary care have better overall measures of health status as indicated by birth weight, postneonatal mortality, life expectancy, and with lower costs.39 However, higher rates of adherence to recommended treatments,40-43 and better outcomes are observed with specialist care.41,43-46 In situations in which comanagement has been instituted, improved care and outcomes have been noted.40,45,47 Shared care allows information from specialist to PCP to be shared in the sociocultural context of the individual case, thus improving the understanding of individual patient needs and perspectives. The specific configuration of the comanagement depends on the structure of the health care system, geographical location of the practice, and individual patient and physician needs. PCP care is likely to be sufficient with patients whose disease falls into the milder forms of the disease spectrum, whose complications from disease are not common, and if the condition itself is not one in which research findings are rapidly accumulating.48 PCPs who have a large practice of patients with chronic disease will require less input then those who have less experience, as has been shown with human immunodeficiency virus patients.49 In rural settings or where there is an under supply of nephrologists or other specialists, comanagement can be done not only with visits but also by telephone, e-mail, or other forms of electronic information transfer. Health care structure. Complex multifaceted disease processes require systematic approaches to care delivery. In the current era, in which there is a shortage of physicians, especially specialty physicians, the management of a large group of patients with a complex disease requires an organizational strategy that involves other members of the health care team. The paradigm of individual physicians being completely responsible for all aspects of care for their patients is no longer viable:
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shared care between physicians and other members of the health care team is an obvious solution to the lack of physician resources and to the demand for increased services that complex disease requires. Allied health care workers such as dietitians, pharmacists, and social workers are integral to providing excellent care for patients with CKD; indeed, full benefit of treatments required nutritional counseling, education, and medications. Other aspects of chronic care management that can be facilitated in this framework are self-management by patients, evidence-based decision support by physicians, case management, planned appointments, and routine blood work.50 Multidisciplinary care attempts to incorporate the unique medical, sociological, psychological, and cultural background of individuals together in the overall care plan. In addition, community involvement as equal partners in the development of an intervention program, culturally and linguistically appropriate materials, and cultural competence are all necessary elements for successful translation of research findings for patients in racial and ethnic groups.16,51,52 Diabetes clinics and clinics for other chronic conditions such as asthma and rheumatological diseases have been clearly shown to improve outcomes of patients.53-55 However, there have been few publications as to the value of such clinics in CKD. We have published the impact of a multidisciplinary care clinic on patient outcomes with specific reference to outcomes once dialysis has commenced,56-58 and others have shown that those referred early to nephrologists have better outcomes once on dialysis.59 However these publications have not attempted to show the impact of this approach on the progression of CKD. Information technology. The integration of complex information with routine clinical practice is central to translating research findings to clinical practice. Electronic medical records (EMR) allow for collation of all information relative to an individual patient, are visible to all members of the health care team (even at geographically distant sites), and also allow for the incorporation of patient and encounter specific prompts to ensure appro-
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priate care delivery/treatment prescription. These prompts are a form of problem-based learning and may improve acquisition of new information. Furthermore, EMR and other forms of electronic collation of information, permit ongoing data collection. Appropriate analysis of prospective data can potentially enhance understanding of the predictors of progression and response to treatments; this is particularly important in areas such as CKD in which the existing data are preliminary. The integration of information technology and clinical care will potentially help evaluate patient-specific evidence-based therapeutic strategies.
Proposed Studies/Future Research: Integration CVD and kidney disease share many similarities both in disease expression, progression, and impact. Thus, the nephrology community may learn about implementation by examining implementation strategies that have been successful in changing CVD care. In the past 2 decades, there has been improvement in the understanding and treatment of CVD with a consequent decrease in morbidity and mortality. In part, this has been because of the recognition that a number of easily identifiable risk factors for CVD exist and that these factors have preferred and easily implemented treatment strategies (ie, lipid-lowering agents, aspirin, and antihypertensive control). Although certainly not complete, the success of the translation of these strategies in CVD has been because of a number of interlinked strategies including (1) a public health campaign fueled by good epidemiological data; (2) involvement of nonprofit organizations for patient focused education and treatment; (3) large population-based clinical studies, both observational and randomized60,61; and (4) the execution of interventional studies in the context of both tertiary and community based institutions allowing easier uptake of new therapies once approved.62 In the area of nephrology, we have only recently showed the large prevalence of disease by using population-based studies.10 A number of nonprofit patient-based organizations, most notably the National Kidney Foun-
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dation, have recently been involved in public campaigns (Kidney Evaluation Education Program, Kidney Disease Outcomes Quality Initiative). There have to date been no large population-based clinical studies that have involved both tertiary and community sites and that have shown a benefit to an easily implemented treatment in reducing the rate of progression of CKD. The current strategic initiatives are in keeping with previously successful CVD strategies and as such may well be as successful. The translation of research into clinical behavior requires this multipronged approach to the problem. A number of studies in various stages of development both in Canada and other countries will attempt to show the outcomes of patients using different approaches (Parfrey et al, unpublished data, 2003; A. Levin, unpublished data, 2003).63 Population-based studies are being designed such that CKD patients will be identified through laboratory systems, using estimates of GFR equations, with appropriate prompts to the ordering physicians as to the meaning and appropriate investigation of GFR abnormalities. These patients will be followed in the systematic manner for a period of time to determine changes in kidney function, other parameters, and outcomes. Some of these patients will naturally be referred to nephrologists and the impact of that referral can be followed. Concomitant with this opportunity for a natural history study, ongoing or planned large randomized control trials in diabetics and cardiac patients should be encouraged to enroll patients with different stages of CKD, as determined by estimated GFR. Furthermore, large randomized controlled trials of patients with all levels of CKD have been proposed to understand the impact of care delivery models and combinations of treatment strategies on patient outcomes. However, these studies will require at least 5 or 10 more years before outcomes can be shown, thus the need to search for some intermediate strategies. In the interim, examination of existing data sets, such as the recently completed Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), Atherosclerosis Risk in Communities (ARIC), African American Study of Kidney Disease and Hypertension (AASK), may
help to understand the implication of impaired kidney function, CVD, and diabetes and to show the safety and utility of specific treatment strategies in these patients. The coordination of clinicians, clinical epidemiologists, clinical trial participants, and health care administrators is important if vital information is to be gathered and analyzed in a timely manner such that the impact of various strategies can be evaluated.
Conclusions In this era of escalating information, costly technology, and an increasing prevalence of chronic complex diseases in an aging population, we must develop systems to translate research into delivery of quality clinical care. At present in nephrology, we have some knowledge of disease processes, and rudimentary knowledge about risk factors for progression, and how best to deliver care to those with a chronic disease. We find ourselves in a health care environment not suited to either the care of chronic conditions or prevention. We suggest that a new paradigm, “processbased medicine,” which incorporates evidence based medicine with multidisciplinary and shared care models of health care delivery is essential. It requires attention to advances in information technology, the cognitive processes that underlie physician learning, and the results of outcome research. Information technology should facilitate shared care models of care delivery for chronic conditions and allow opportunities to add new knowledge and deliver good care to complex patient groups. What can be done now in advance of major changes we suggested earlier? We need to educate medical students, health care professionals, and established physicians about CKD. These educational initiatives should be done in the context of cases or specific patients, especially for established practitioners, and should be simplified to make analogies to familiar concepts. The concept that CKD is a risk factor for CVD and thus needs to be managed (as does diabetes and dyslipidemia) should be more clearly articulated. Basic and clinical research in kidney disease has been enhanced by discoveries in vas-
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cular biology, diabetes, and cardiology. Much of the clinical research has been thwarted by lack of clear definition of CKD; thus, the development of the new staging system that defines and classifies kidney disease permits ongoing robust clinical trials. Incorporating this classification system into clinical practice of all physicians, by automatic laboratory reporting of estimates of GFR, will both raise awareness and improve communication between all medical professionals. Comanagement of CKD patients between different physicians and multidisciplinary teams and the coordinated investigation of treatments and treatment strategies by both clinicians and researchers will lead to improved outcomes for patients with CKD. Systematic evaluation of the impact on health care delivery systems, resources, and patient outcomes requires a new integrated paradigm of care and discovery.
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