Classification of chronic kidney disease 10 years on: what have we learnt in the Netherlands

Classification of chronic kidney disease 10 years on: what have we learnt in the Netherlands Dear Editor, With great interest we read the editorial ‘Classification of chronic kidney disease 10 years on: what have we learnt and what do we need to do now?’ (1). Based on our research in primary care in the Netherlands during the last 10 years, we can agree with the challenges that arise from this editorial: timely identification of chronic kidney disease (CKD) especially in patients at high risk for progressive CKD, facilitation of a patient-centred tailored pathway between primary and secondary care and last but not least patient involvement. We found that Dutch primary care shows important gaps in the quality of care in all aspects of CKD management. In a retrospective observational study in 47 primary practices, serving 207469 people, 9295 patients met the criteria for CKD resulting in a known prevalence of 5.7%, K\DOQI stage 1–2 accounted for 1.05% and stages 3–5 for 4.66% (2). In the Netherlands, the estimated community prevalence is 10.4% (3). For our data, this implies that 21% and 88% of expected CKD patients with K\DOQI stages 1–2 and 3–5, respectively, could have been ascertained in primary care. However, coding of a CKD diagnosis was much lower (32%) and identification of CKD is very important as it is associated with better care. Monitoring disease progression (43%), especially monitoring of albuminuria, was suboptimal. Blood pressure targets (<140/90 mmHg) were reached in 44% of the patients. Female sex was associated with lower quality of care. Comorbidity of diabetes appeared to be related to higher quality of care. In the Netherlands, patients with diabetes are treated in disease management programmes, and Dutch diabetes guidelines advise annual monitoring of renal function. Our findings suggest that embedding of CKD care in a support model and organization comparable with that for diabetes would stand the best change to improve quality of care. This should not be a single disease case model, but should support general practitioner (GP)-based CKD care and preferably be integrated in existing support models for care to prevent care-fragmentation. Subsequently, in a 14-month prospective observational cohort study, we followed the patients from the above-mentioned study in which consultation or referral to a nephrologist was advised according to Dutch Interdisciplinary guidelines: 2527 CKD patients fulfilled consultation criteria, 225 referral criteria (4). The adherence by GPs to the guideline recommendations was low. As a consequence, the vast majority of patients with CKD were only managed in primary care without nephrologist co-management. Patients without nephrologist co-managemant were less frequently assigned with a CKD diagnosis again underlining the importance of CKD identification. To improve CKD management in primary care, we introduced telenephrology, a web-based consultation system, between the GP and nephrologist (5). A cluster randomized trial was performed in the above-mentioned 47 practices between March 2011 and June 2012 (6). A total of 3004 patients with CKD were included. All practices participated in a CKD management course and were given an overview of their patients with CKD. There was no difference in referral rate between practices using telenephrology (intervention) and control practices not using telenephrology. The referral rate of only 2.3% in the intervention group and 3.0% in the control group was much lower than our expectations. Nevertheless, the majority of GPs had a positive opinion on telenephrology. A key benefit from the management course and overview of patients with CKD was a high increase in the number of patients that had CKD documented on the episode list of their Electronic Medical Record in a 16-month period. This documentation can be a notification for GPs to monitor patients and can be regarded as an indicator for awareness. Based on the unexpected poor CKD management in our studies, we started qualitative research (focus groups) to explore GPs’ perspectives of management of early-stage CKD and the applicability of an existing national interdisciplinary guideline (7). A key finding was the abstractness of the CKD concept. The GPs expressed various perspectives about defining CKD and interpreting estimated glomerular filtration rates. Views about clinical relevance influenced the decision-making, although factual knowledge seems lacking. In the meantime, the Dutch Interdisciplinary guideline is revised and the findings of our qualitative study were an important starting point in the concept of this revision. The clinical concept of CKD is clarified: the high risk of cardiovascular morbidity, mortality, and deterioration to end-stage renal disease. The revised guideline supports a high level of primary care engagement to ensure patient-centred care and to creation of a tailored pathway between primary and secondary care. To explore the role of patient involvement, we started a qualitative study (interviews) in patients with CKD stage 3–5 treated in primary care (8). There is an enormous variety in thoughts about CKD and on the impact of CKD. In addition to the Editorial comments, we wish to emphasize that repeating the message about the consequences of CKD encourages a healthier lifestyle and makes patients realize how to influence CKD. Patients want tailored information. To deliver tailored information, there is a need for providers to be aware of patients’ perspectives about CKD first, not only at diagnosis, but also during treatment. We fully agree the challenges for future research. Clinical coding of patients with CKD needs to be improved, with less variation in practice. Identification of people who have progressive kidney disease is a top priority. As the author stated, the most important research priority, however, from a patient perspective, is the question whether self-management can increase patients’ skills and confidence in managing their condition and improve clinical outcomes in the longer term. We hope that our studies can contribute to these challenges. Declaration Funding: The Dutch Kidney Foundation funded the study. Conflict of interest: We have no conflict of interest. References 1. Thomas N. Classification of chronic kidney disease 10 years on: what have we learnt and what do we need to do now? Fam Pract 2018 Mar 13 [Epub ahead of print]. doi:10.1093/fampra/cmy015. 2. Van Gelder VA , Scherpbier-De Haan ND , De Grauw WJ et al. Quality of chronic kidney disease management in primary care: a retrospective study . Scand J Prim Health Care 2016 ; 34 : 73 – 80 . Google Scholar CrossRef Search ADS PubMed 3. de Zeeuw D , Hillege HL , de Jong PE . The kidney, a cardiovascular risk marker, and a new target for therapy . Kidney Int Suppl 2005 ; 98 : S25 – 9 . 4. van Dipten C , van Berkel S , van Gelder VA et al. Adherence to chronic kidney disease guidelines in primary care patients is associated with comorbidity . Fam Pract 2017 ; 34 : 459 – 66 . Google Scholar CrossRef Search ADS PubMed 5. Scherpbier-de Haan ND , van Gelder VA , Van Weel C et al. Initial implementation of a web-based consultation process for patients with chronic kidney disease . Ann Fam Med 2013 ; 11 : 151 – 6 . Google Scholar CrossRef Search ADS PubMed 6. van Gelder VA , Scherpbier-de Haan ND , van Berkel S et al. Web-based consultation between general practitioners and nephrologists: a cluster randomized controlled trial . Fam Pract 2017 ; 34 : 430 – 6 . Google Scholar CrossRef Search ADS PubMed 7. van Dipten C , van Berkel S , de Grauw WJC et al. General practitioners’ perspectives on management of early-stage chronic kidney disease: a focus group study . BMC Fam Pract 2018 April 17; in press. 8. van Dipten C , de Grauw WJC , Wetzels JFM et al. What patients with mild-to-moderate kidney disease know, think, and feel about their disease: an in-depth interview study . J Am Board Fam Med accepted 5 April 2018 © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Classification of chronic kidney disease 10 years on: what have we learnt in the Netherlands

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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0263-2136
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10.1093/fampra/cmy036
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Abstract

Dear Editor, With great interest we read the editorial ‘Classification of chronic kidney disease 10 years on: what have we learnt and what do we need to do now?’ (1). Based on our research in primary care in the Netherlands during the last 10 years, we can agree with the challenges that arise from this editorial: timely identification of chronic kidney disease (CKD) especially in patients at high risk for progressive CKD, facilitation of a patient-centred tailored pathway between primary and secondary care and last but not least patient involvement. We found that Dutch primary care shows important gaps in the quality of care in all aspects of CKD management. In a retrospective observational study in 47 primary practices, serving 207469 people, 9295 patients met the criteria for CKD resulting in a known prevalence of 5.7%, K\DOQI stage 1–2 accounted for 1.05% and stages 3–5 for 4.66% (2). In the Netherlands, the estimated community prevalence is 10.4% (3). For our data, this implies that 21% and 88% of expected CKD patients with K\DOQI stages 1–2 and 3–5, respectively, could have been ascertained in primary care. However, coding of a CKD diagnosis was much lower (32%) and identification of CKD is very important as it is associated with better care. Monitoring disease progression (43%), especially monitoring of albuminuria, was suboptimal. Blood pressure targets (<140/90 mmHg) were reached in 44% of the patients. Female sex was associated with lower quality of care. Comorbidity of diabetes appeared to be related to higher quality of care. In the Netherlands, patients with diabetes are treated in disease management programmes, and Dutch diabetes guidelines advise annual monitoring of renal function. Our findings suggest that embedding of CKD care in a support model and organization comparable with that for diabetes would stand the best change to improve quality of care. This should not be a single disease case model, but should support general practitioner (GP)-based CKD care and preferably be integrated in existing support models for care to prevent care-fragmentation. Subsequently, in a 14-month prospective observational cohort study, we followed the patients from the above-mentioned study in which consultation or referral to a nephrologist was advised according to Dutch Interdisciplinary guidelines: 2527 CKD patients fulfilled consultation criteria, 225 referral criteria (4). The adherence by GPs to the guideline recommendations was low. As a consequence, the vast majority of patients with CKD were only managed in primary care without nephrologist co-management. Patients without nephrologist co-managemant were less frequently assigned with a CKD diagnosis again underlining the importance of CKD identification. To improve CKD management in primary care, we introduced telenephrology, a web-based consultation system, between the GP and nephrologist (5). A cluster randomized trial was performed in the above-mentioned 47 practices between March 2011 and June 2012 (6). A total of 3004 patients with CKD were included. All practices participated in a CKD management course and were given an overview of their patients with CKD. There was no difference in referral rate between practices using telenephrology (intervention) and control practices not using telenephrology. The referral rate of only 2.3% in the intervention group and 3.0% in the control group was much lower than our expectations. Nevertheless, the majority of GPs had a positive opinion on telenephrology. A key benefit from the management course and overview of patients with CKD was a high increase in the number of patients that had CKD documented on the episode list of their Electronic Medical Record in a 16-month period. This documentation can be a notification for GPs to monitor patients and can be regarded as an indicator for awareness. Based on the unexpected poor CKD management in our studies, we started qualitative research (focus groups) to explore GPs’ perspectives of management of early-stage CKD and the applicability of an existing national interdisciplinary guideline (7). A key finding was the abstractness of the CKD concept. The GPs expressed various perspectives about defining CKD and interpreting estimated glomerular filtration rates. Views about clinical relevance influenced the decision-making, although factual knowledge seems lacking. In the meantime, the Dutch Interdisciplinary guideline is revised and the findings of our qualitative study were an important starting point in the concept of this revision. The clinical concept of CKD is clarified: the high risk of cardiovascular morbidity, mortality, and deterioration to end-stage renal disease. The revised guideline supports a high level of primary care engagement to ensure patient-centred care and to creation of a tailored pathway between primary and secondary care. To explore the role of patient involvement, we started a qualitative study (interviews) in patients with CKD stage 3–5 treated in primary care (8). There is an enormous variety in thoughts about CKD and on the impact of CKD. In addition to the Editorial comments, we wish to emphasize that repeating the message about the consequences of CKD encourages a healthier lifestyle and makes patients realize how to influence CKD. Patients want tailored information. To deliver tailored information, there is a need for providers to be aware of patients’ perspectives about CKD first, not only at diagnosis, but also during treatment. We fully agree the challenges for future research. Clinical coding of patients with CKD needs to be improved, with less variation in practice. Identification of people who have progressive kidney disease is a top priority. As the author stated, the most important research priority, however, from a patient perspective, is the question whether self-management can increase patients’ skills and confidence in managing their condition and improve clinical outcomes in the longer term. We hope that our studies can contribute to these challenges. Declaration Funding: The Dutch Kidney Foundation funded the study. Conflict of interest: We have no conflict of interest. References 1. Thomas N. Classification of chronic kidney disease 10 years on: what have we learnt and what do we need to do now? Fam Pract 2018 Mar 13 [Epub ahead of print]. doi:10.1093/fampra/cmy015. 2. Van Gelder VA , Scherpbier-De Haan ND , De Grauw WJ et al. Quality of chronic kidney disease management in primary care: a retrospective study . Scand J Prim Health Care 2016 ; 34 : 73 – 80 . Google Scholar CrossRef Search ADS PubMed 3. de Zeeuw D , Hillege HL , de Jong PE . The kidney, a cardiovascular risk marker, and a new target for therapy . Kidney Int Suppl 2005 ; 98 : S25 – 9 . 4. van Dipten C , van Berkel S , van Gelder VA et al. Adherence to chronic kidney disease guidelines in primary care patients is associated with comorbidity . Fam Pract 2017 ; 34 : 459 – 66 . Google Scholar CrossRef Search ADS PubMed 5. Scherpbier-de Haan ND , van Gelder VA , Van Weel C et al. Initial implementation of a web-based consultation process for patients with chronic kidney disease . Ann Fam Med 2013 ; 11 : 151 – 6 . Google Scholar CrossRef Search ADS PubMed 6. van Gelder VA , Scherpbier-de Haan ND , van Berkel S et al. Web-based consultation between general practitioners and nephrologists: a cluster randomized controlled trial . Fam Pract 2017 ; 34 : 430 – 6 . Google Scholar CrossRef Search ADS PubMed 7. van Dipten C , van Berkel S , de Grauw WJC et al. General practitioners’ perspectives on management of early-stage chronic kidney disease: a focus group study . BMC Fam Pract 2018 April 17; in press. 8. van Dipten C , de Grauw WJC , Wetzels JFM et al. What patients with mild-to-moderate kidney disease know, think, and feel about their disease: an in-depth interview study . J Am Board Fam Med accepted 5 April 2018 © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Family PracticeOxford University Press

Published: May 17, 2018

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