Review of current practice in multidisciplinary CKD clinics in

Canada

Adeera Levin MD FRCPC Director BC Provincial Renal Agency

Professor of Medicine UBC Chair: Knowledge User Group CANN-NET

Co-Chair: Steven Soroka CAnadian KidNey KNowledge TraNslation & GEneration NeTwork

Members of the Knowledge User Group Name Institutional Affiliation

Chair: Adeera Levin University of British Columbia, Vancouver, BC

Vice-Chair: Steven Soroka Dalhousie University, Halifax, NS

Braden Manns University of Calgary, Calgary, AB

Andrey Cybulsky McGill University, Montreal, QC

Nairne Scott Douglas University of Calgary, Calgary, AB

Kailash Jindal University of Alberta, Edmonton, AB

Nadine Valk The Kidney Foundation of Canada

Andrew Steele Lakeridge Health, Oshawa, ON

Cheryl Harding CANA (Canadian Association of Nephrology Administrators)

Selina Allu University of Calgary, Calgary, AB

Sarah Gil University of Calgary, Calgary, AB

Understanding variations in care • Patients with chronic kidney disease (CKD) have variable outcomes

• Time to dialysis or death • Trajectories of progression • Accumulation of burden of disease over time

• Patients with CKD do not always receive care consistent with guidelines:

• complexities in CKD condition • variation in CKD management practice

• Resources, attitudes and philosophies, • lack of randomized trial data to inform care, • lack of access to and methods by which to disseminate best practice.

Continuum of Care and Multiple points for education and influencing decision making

CKD care Delay of progression Treatment of co-morbidities Education

Self management ( diet, medication etc) RRT choices

Preparation for RRT Transition to RRT

Variability in multiple domains may impact outcomes

Biology of clinical condition (CKD) and timing and severity of inter-current events

Structure and function of CKD clinics + Access to information or programs

Desired outcomes

The Context: CANN-NET and CKD Survey • CANN-NET priorities via consultative and iterative process:

• Understanding variations in : • Timing of dialysis initiation and • Appropriate use of home based therapies

These outcomes are likely impacted by upstream activities in CKD clinics ..therefore

• Survey of CKD Multidisciplinary Clinics: • Improved understanding of current care practices ( form) • Contact list to enable the establishment of a national network CKD clinics for future activities • Link CKD clinic structure and function with outcomes

CANN-NET CKD Survey Methodology 2 KT brokers established an up-to-date network of contacts for CKD clinics June 2012

1. Identify nursing, administrative or medical leads (or most relevant contact) to identify all renal programs across Canada (by email or phone).

2. Developed list of contact information for local nursing and medical leads and/or clinic managers for all multidisciplinary CKD clinics across Canada

3. Data collection • Semi-structured, open-ended questions • Confidential and non identified • General information on existing CKD clinic structure

• available resources, • model or care, • education resources, • use of clinical pathways, etc.

Preliminary Findings: April 2013

• 51 interviews conducted • 41 clinics

• 24 Western Canada, • 6 in Ontario, • 5 in Québec, and • 6 in the Atlantic Provinces

• 5 interviews were with medical leads (physicians).

13

3

4

4

6

5

1

4

1

Variability in number of patients to Nephrologists per clinic

Median = 150 patients per nephrologist

*Larger bubbles = more pt/nephrologists

Variability in number of patients to nurses Median = 230 patients per nurse

Variability in number of patients to dietitians Median = 175 patients per dietitian

Variabiliyt in number of patients to pharmacists Median = 175 patients per pharmacist

Variability in patients to social worker Median = 600 patients per social worker

Not all clinics work within programs which offer a full suite of dialysis options

% 0.00

20.00 %

40.00 %

60.00 %

80.00 %

% 100.00

In center HD

PD Thrice weekly

Home HD

Home Nocturnal

HD

In - center Nocturnal

HD

Daily in center HD

Self - care (in center) HD

Variability in models of care within CKD clinics • Nurse + MD constant (59%)

• Primary MD and variable Nurse (19%)

• Variable Nurse and MD (12%)

• Variable MD and same nurse (10%)

Same primary nephrologist &

same nurse

59 %

Different nephrologist &

same nurse

10 %

Same primary nephrologist & different nurse

19 %

Different nephrologist & different nurse

12 %

Details re: functioning of CKD Clinics: Variation persists 1. Referral criteria to CKD clinic

Referral criteria? 83% eGFR cut off as part of the criteria? 50% 2. Management of patients nearing dialysis initiation Policy whereby all patients assessed for home dialysis 68% All patients offered dialysis modality education? 100% 3 Dialysis modality education During clinics visits or through educational materials 32% Group dialysis modality education (or combination) 68% 4 Decision to initiate dialysis made with with regular multidisciplinary team meetings 46%

5. Dedicated dialysis modality coordinator? * (overt role description) 27%

Targets are in use for home dialysis therapies to variable degrees

Centers are aware of home dialysis target

30/41

73%

Target is based on prevalent patients

23/30

77%

Target is based on incident* patients

0/30

------ Both 7/30 23%

•Appropriate to target incidence (not prevalent) as output for CKD clinics…

•Difficult to achieve or better ‘prevalence’ targets as the ‘feeder’ group

What is and is not working*: recurrent themes

Needs/ Areas for improvement: 1. More staff (nurses, nephrologists, experts,

clerical staff, etc) 2. More space 3. More/improved/standardized teaching or

educational aids 4. Better CKD clinic processes

flow of patient referral, decrease wait times, offer telehealth, offer clinical pathway, timely insertion of catheters, etc)

5. Consistent support of home therapies, more dialysis options, support for dialysis for patients in rural communities

Working well: Initiatives and Processes 1. New initiatives around conservative care 2. Development of In-house teaching and educational tools

specific to population/clinic 3. Outreach for early CKD detection 4. The “buddy system” : dedicated nurse assigned to pt working

with the nephrologists= greater interaction with the pt /trust t. 5. A nurse-led telehealth clinic in a remote area

allows pts to stay in their communities; but followed by the MDC team

6. Patient support groups 7. Team of UC and administrative staff playing role in clinic

activities. 8. Inclusion of CKD patients in QI project teams

* Rank ordered themes

Information not yet captured

• Number of clinics with ‘full compliment’ of • RN, Dietician, Pharmacist, Social worker

• Number of clinics with other allied health professionals:

• OT, PT, Psychologist

• Relationship of CKD structure/operations to patient outcomes

Future directions:

• Complete CKD clinic survey and finalize report • include all CKD clinics across Canada

• Link CKD clinic structure/ function to outcomes • Identify best practices

• Longer term goals: Forming a National CKD Clinic Network

• Provide information about new clinical practice guidelines • Foster communication re: barriers faced by end-users face in Guideline

implementation • Foster solutions to address barriers and help with application and uptake of new

guidelines • Foster best clinical care

Thank you

• CKD Clinic staff participating

• Selina Allu and Sarah Gil ( KT brokers CANN-NET)