The document summarizes a study conducted by the Renal Physicians Association (RPA) and Duke Center for Clinical Health Policy Research (DCCHPR) to test an Advanced Chronic Kidney Disease (CKD) Patient Management Toolkit in 10 nephrology practices across the US. The study aimed to evaluate the utility of the toolkit, assess care patterns and changes needed to improve care, and evaluate the impact on conforming to CKD guideline recommendations. The 10 sites were divided into two groups, with one group implementing the toolkit while the other served as a comparator. The study provided a unique opportunity to involve diverse practices and patients to understand challenges in CKD management and insights for the future.

1. LOOKING UNDER THE HOOD: Renal Physicians Association Field Test of the Advanced CKD Patient Management Toolkit Remy R. Coeytaux, MD, PhD March 22, 2009

2. Chapters of the Story 1. The Challenge 2. The Protagonists 3. The Plot 4. The Toolkit 5. The Study 6. Looking Under the Hood 7. Insights 8. The Future

3. The Challenge Epidemiology of advanced CKD Timely diagnosis Comorbidities and competing demands Co-management of patients across medical specialties Access to, and cost of, nephrology specialty care Imperfect/incomplete evidence to inform management decisions Practice variations Time and resource constraints Access to appropriate technology and tools Limitations of health information technology

4. The Protagonists Renal Physicians Association (RPA) Duke Center for Clinical Health Policy Research (DCCRP) 10 nephrology sites across the U.S. Patients with chronic kidney disease

5. The Plot (RPA-DCCHPR collaboration) 2000 RPA funds clinical practice guideline for advanced CKD 2003-2004 Advanced CKD Patient Management Toolkit developed and disseminated 2006 Toolkit pilot tested in 2 practices in North Carolina Revised toolkit issued 2008 Field test of 10 nephrology practices launched

6. The Plot Appropriate Patient Preparation for Renal Replacement Therapy CPG Multidisciplinary workgroup chaired by Kline Bolton, MD Report released in October, 2002 Patient population: adults with GFR < 30, not on dialysis 7 goals of care Optimal management of anemia Bone disease prevention and management Control of blood pressure Maintenance of adequate nutrition Management of lipid disorders Timing of RRT and vascular access Appropriate and timely patient education

7. The Toolkit

8. The Advanced CKD Toolkit Adaptable and Customizable Consider tools appropriate for the practice’s needs Select tool versions per individual preference Customize tools (e.g. change lab values, modify letters)

9. What Practical Approaches/Tools Can We Use? 3. Manage 2. Plan and communicate 1. Identify Education resources CKD classes Communication and reminder tools Diary Management tools Identification tools Patient tools Physician tools

10. Identification Tools CKD Identification and Action Plan (card and poster) GFR calculator (slide-rule, resources for calculations on Palm/hand-held PC device/Web sites) Chart stickers

11. Planning & Communication Tools Awareness Letter from nephrologist to referring physician Referring Physician Faxback Form Post-Consult Letter

12. Management Tools Management Flow Sheet Reminder Information on target levels Data repository for performance measurement Algorithms Anemia Hypertension Nutrition Dyslipidemia Bone disease Patient diary Initiates discussion Educational tool Patient-initiated physician reminder

13. The Study: Title Field Test of the Advanced CKD Patient Management Toolkit a.k.a. RPA 10-Site Toolkit Implementation Study

14. The Study: Investigators Duke Center for Clinical Health Policy Research Dale Singer, MHA (Executive Director, RPA) Amy Beckrich (Project Manager, RPA) William E Haley, MD (RPA Consultant) Renal Physicians Association (RPA) David Matchar, MD (Principal Investigator) Remy Coeytaux, MD, PhD (Acting Principal Investigator) Gregory Samsa, PhD (Biostatistician) Uptal Patel, MD (Nephrologist) Meenal Patwardhan, MD, MHSA (Consultant) Jameta Barlow, MPH (Project Manager) Julian Irvine (Project Coordinator)

15. The Study: Continuum of Activities 1) Evidence Report on Appropriate Patient Preparation for Renal Replacement Therapy McCrory D, et al. Evidence Report: Appropriate Patient Preparation for Renal Replacement Therapy. Rockville, MD, RPA, 2002. 2) Clinical practice guideline and performance measures (CPG and CPMs) RPA. The RPA Advanced CKD Patient Management Toolkit: Improving Management and Care of Advanced Chronic Kidney Disease Patients. Rockville, MD; 2004. 3) “Advanced CKD Patient Management Toolkit” Matchar D, et al. Facilitated Process Improvement: An approach to the seamless linkage between evidence and practice. American Journal of Kidney Diseases. 2006; 47(3): 528-538. Patwardhan MB et al. Opportunities for Improving Management of Advanced Chronic Kidney Disease. American Journal of Medical Quality. 2008; 23: 184-192 Patwardhan MB, et al. Advanced Chronic Kidney Disease Practice Patterns among Nephrologists and Non-Nephrologists: A Database Analysis. Clin.J. Am. Soc. Nephrol. 2007 2: 277-283. Patwardhan MB, et al. Non-nephrologist and nephrologist perspectives on implementing a chronic kidney disease guideline. 2007 Journal of Healthcare Quality. Web exclusives. Patwardhan MB, et al. Opportunities for improving management of advanced chronic kidney disease: current practice patterns. American Journal of Medical Quality. 2008. Vol. 23, No. 3, 184-192. Patwardhan MB, et al. Utility of the advanced chronic kidney disease patient management tools: case studies. American Journal of Medical Quality. 2008. Vol. 23, No. 2, 105-114. Pilot test of toolkit Utility of the Advanced Chronic Kidney Disease Patient Management Tools: Case Studies. Patwardhan et al. American College of Medical Quality, Vol. 23, No. 3, > 184-192 (2008) Field test of toolkit in 10, real-world practice settings

16. The Study: Specific Aims Evaluate the utility of the Advanced CKD Patient Management Toolkit Assess care patterns and changes in processes required to improve care 3. Evaluate the impact of the implementation exercise on improved conformance to guideline recommendations.

17. The Study: 10 Sites Nephrophiles, LLC, Santa Fe, NM Site champion: Robert Kossmann, MD Long Island Hypertension & Nephrology, Port Washington, NY Site champion: Teresa Alfano, NP-CNN Western New England Renal and Transplant Associates, Springfield, MA Site champion: Michael Germain, MD Renal Associates of Baton Rouge, Baton Rouge, LA Site champion: Jaimie Smith, BSW, RSW The Center for Kidney Care, Mt Laurel, NJ Site champion: Dan Strauch, MHA, CMPE Renal Medicine Associates, Albuquerque, NM Site champion: Elizabeth Evans, CNP Associates in Kidney Care, Des Moines, IA Site champion: TBD Indiana Medical Associates, Fort Wayne, IN Site champion: TBD Boise Kidney and Hypertension Institute, Meridian, ID Site champion: Kirsten Vanderhalf, BS CRC North Houston Nephrology, Houston, TX Site champions: Toni Ambrosy and Debbie McCarthy, LVN

18. The Study: Research Plan 10 nephrology sites across the country selected Randomly divided into two groups Group 2 serves as a comparator for Group 1 Level of conformance to guidelines will be measured 7 goals of care (anemia, HT, bone disease, nutrition, dyslipidemias, education, timing of RRT) Toolkit will be implemented Level of conformance to guidelines will be measured post implementation Change in conformance will be measured Sustainability of change will be assessed

19. Looking Under the Hood Unique opportunity: 10 nephrology practices Different patient populations; different regions in the U.S. Variety of tools and technology Shared goals Universal challenges Unique set of expertise & perspectives: RPA: interface of science, management, and policy DCCHPR: health policy; practice guideline implementation Practicing physicians: real-world issues

20. Insights (To be presented live)

21. The Future (To be presented live)

22. Thank you. Time for questions and discussion