A collaborative project between AstraZeneca, Imperial College Health Partners, North West London Applied Research Collaborative (ARC), Imperial College Health Care Nephrology Department, and London Kidney Network (LKN) is seeking to support Primary Care teams to implement a series of small changes to their CKD pathways, which, when coordinated across the whole patient pathway, have a large overall impact on treatment and management of the disease.
The project, which focused on the early identification and management of Chronic Kidney Disease (CKD) as per NICE guidance, sought to find small changes that could be made to existing pathways to would support increased diagnosis of the disease in primary care specifically. Through extensive engagement with patients – both those diagnosed and those at risk – and primary and secondary care clinicians, four pathway innovations were selected to be taken forward to a testing phase, where health economic evaluations and analysis of population health data using the North West London (NWL) Discover data were used to ascertain both the financial efficiency and improvement in patient outcomes.
Discover is the depersonalised dataset of over 2.5million NWL residents who are registered with a NWL GP. Owing to the fact CKD is most prevalent in non-Caucasian citizens and also has links to social deprivation, there is a very large population suffering with the disease in NWL, which supported the recruitment of patients to the project team.
The engagement phase, which saw 21 patients and 19 clinicians come together to identify barriers to early diagnosis and management and co-design solutions to be taken forward to the testing phase. Allowing patients into the design phase of projects supports true co-design of service improvements and not only puts patients at the heart of transformation but encourages better self-management in those involved.
The recommendations from patients and clinicians were then taken forward for health economic evaluation, which used NWL data to validate both the patient impact and financial efficiency of the pathway changes. From this, the project team were able to make evidence-based recommendations on how to increase earlier diagnosis of the disease, with a view to reducing the number of adverse events for patients with CKD later in the pathway.
The project made the following incremental pathway changes, the cumulative effect of which was shown to streamline pathways, improve coding and enhance the patient experience. This should ultimately improve patient outcomes in the long term:
- Pathology results CKD guidance for primary care
- Early-stage CKD education options for primary care and patients to access
- CKD screening support for patients
- Enhanced primary care templates in Diabetes, hypertension and CKD
- CKD search and recall process for primary care
- Training and implementation package for primary care
Read more about this project on our Improving Identification and Management of CKD resource page. Or contact Matthew Wyatt for more information.