AstraZeneca - January 2023 - case study 4

Pan Leicester Integrated Chronic Kidney Disease (CKD) Transformation Project: A Quality Improvement Project to Identify CKD Patients In Primary Care Suitable for Virtual Management to Improve Patient Outcomes – AstraZeneca

Chronic kidney disease can result in progressive kidney damage leading to complete kidney failure and increased cardio-vascular and mortality risk. Early diagnosis and risk stratification are essential to define management in patients with significant risk. The Kidney Failure Risk Equation (KFRE) tool measures the 2- and 5-year percentage risk of reaching end stage renal disease (ESKD) for patients with CKD stage 3 to 55. NICE recommends referring adults with CKD for specialist assessment if they have a 5-year risk of needing RRT of greater than 5% measured using the KFRE.

There are almost 10,500 patients diagnosed with CKD (QoF) with a prevalence of 3.8% across East Leicestershire and Rutland CCG and almost 7,700 patients diagnosed with CKD with a prevalence of 2.3% across Leicester City CCG, however the prevalence is expected to be much higher than this.

Advice and Guidance (A&G) is a non-face-to-face activity delivered by consultant-led services and is a key part of the National Elective Care Recovery and Transformation Programme’s work. The NHS Long Term Plan includes a commitment to redesign outpatient services so that patients will be able to avoid up to a third of face-to-face outpatient appointments over the next five years. This will remove the need for up to thirty million outpatient visits a year: saving patients time and improving their experience.

This project looks to address some of these pressing issues set out above which will benefit patients. Based on data within County and City practice’s iCKD services can identify patients suitable for virtual management, reduce A&G queries, reduce formal referrals required and identify high-risk patients for expedited referral. In addition,

this will bring secondary care expertise into primary care to upskill clinical pharmacists for medication review and prescribing eligibility.

The aims and objectives of the project are:

Risk stratify the CKD population of Leicester City and County and subsequently improve clinical outcomes by bringing secondary care capability into primary care and implementing gold standard management.

1. Increase early identification of CKD patients suitable for virtual management.
2. Provide a community outreach service, enabling multidisciplinary team (MDT) at a PCN level, driving new models of care.
3. Improve the quality of care delivered to CKD patients by increasing the capability and confidence of primary care providers.

The program aims to improve key outcome measures from baseline over 18 months

• CKD education talk and description of iCKD project proposal delivered by NHS project leads, delivered to all participating PCNs
• Increased clinical review of CKD registers including risk factors of KFRE
• Identification of medication optimisation – utilisation of treatments proven to modify CV and renal end points (ACEi/ARB and SGLT2i) in line with societal and local guidelines
• Increased screening programme for all new registered patients to include urine ACR measurement and haematuria
• Appropriate referral to secondary care of patients most at risk of progression to ESRD. Reduction of A&G queries and inappropriate referrals including patients discharged after one clinic attendance

GB-49317 October 2023