Kidney Week

Abstract: FR-PO255

Improving Patient and System Outcomes Through Integrated Care for CKD

Session Information

• CKD: Clinical, Outcomes, Trials - II
  October 26, 2018 | Location: Exhibit Hall, San Diego Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: CKD (Non-Dialysis)

• 1902 CKD (Non-Dialysis): Clinical, Outcomes, and Trials

Authors

• Beaulieu, Monica C., St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada

Monica C. Beaulieu,

• Canney, Mark, University of British Columbia, North Vancouver, British Columbia, Canada

Mark Canney,

• Induruwage, Dilshani, BC Provincial Renal Agency , Vancouver, British Columbia, Canada

Dilshani Induruwage,

• Levin, Adeera, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada

Adeera Levin,

Group or Team Name

• BC Kidney Care Committee

Background

In British Columbia Canada, patients with Chronic Kidney Disease not on dialysis (CKD-ND) are cared for by interprofessional kidney care clinics (KCC’s) using an integrated chronic disease model of care within a system which includes decision support and clinical pathways, a single information system, feedback and audit systems, process and outcomes measures, provincial education of health care providers, policy makers, and patients, and dedicated patient focused funding. The BC-KCC’s are integrated into a larger province wide renal network, with accountability for patient and system outcomes.

Methods

We describe the impact of a series of initiatives in KCC’s to standardize education and support decision making and access for home- based therapies (HBT), conservative care (CC) and pre-emptive transplantation (Tx) over time. Initiatives were introduced sequentially, using change management and adult education principles, with materials developed by a diverse group of health care professionals and supported administratively with provincial dissemination.

Results

In March 2018, the cohort has 10,979 pts; mean age 71, median GFR 33 ml/min/1.73m2 at registration; 54% are male, 50% DM and 43% have CVD. 1285 new pts and 1017 pts exited KCC. Table 1 describes the 6 monthly prevalence of key outcomes over time. Documented treatment decisions for those with GFR <20 have increased slightly, as has formal symptom assessments, and numbers of pts choosing and starting on HBT and following conservative care pathways.

Conclusion

An integrated approach based on fundamentals of chronic care models has led to improved patient outcomes systemwide in BC.