UH Population Health Mining Commonly Available Patient Data to Improve Care of Chronic Kidney Disease
November 03, 2022
UH Clinical Update | November 2022
By the time a patient is diagnosed with chronic kidney disease (CKD), the opportunity to prevent or delay some its most damaging effects has often passed.
Why it matters: “Most patients with CKD present with abrupt incident end-stage renal disease in acute care settings requiring urgent dialysis,” says Esther Thatcher, PhD, a nurse-scientist with UH Population Health, part of a UH team writing in the journal Population Health Management. “Unfortunately, most of these patients usually have missed many opportunities to diagnose disease and delay disease progression, have multiple complications, and often start dialysis with a central venous catheter, a major risk factor for mortality.”
A Better Way
At UH, the Population Health team and Division of Nephrology are taking a “big data” approach to try to short-circuit this process. They’re identifying UH patients through their glomerular filtration rate (eGFR) values on the common comprehensive metabolic panel who have CKD – but who don’t have a current documented diagnosis. Then they’re working with practices in the UH Primary Care Institute about the best way to proactively reach and treat these patients.
“Our goal is to proactively use population level data to detect patients who have signs of chronic kidney disease who may not have been diagnosed with it,” Dr. Thatcher says. “It is quite common for people in the U.S. who have chronic kidney disease to not be aware that they have it, and to not have a diagnosis for it. So we designed a patient registry that will detect patients who have both diagnosed chronic kidney disease and an unrecognized chronic kidney disease, where their lab values show that they do have chronic kidney disease but they haven't received it a diagnosis for it. We are then gathering more information about those patients to be able to proactively communicate with their primary care providers.”
Linkage to Primary Care
Communicating with UH primary care providers is of paramount importance in this project, Dr. Thatcher says.
“We want to make sure that the approach we take to engage patients and get them diagnosed is the one that's most acceptable both for patients and providers,” she says. “We're starting with the providers and talking with them, trying to find out their preferred approach. We believe that the relationship between the primary care provider and the patient needs to be strengthened through this process, so we really want to support the primary care providers’ communication directly to their patients.”
Results and Best Practices
So far, Dr. Thatcher says, this project has identified 2,200 patients with undiagnosed CKD in the UH Accountable Care Organization population. The project has also identified UH primary care practices that seem to have fewer cases of undiagnosed CKD than others – practices that can serve as a model for others.
“What we're doing right now is looking at the practices and providers who are doing really well with diagnosing their patients, and have very few unrecognized patients,” she says. “We can go to them and say, ‘You’re doing a great job? How are you doing that?’ With that information, we can spread those best practices to our other PCPs.”
Managing Other Chronic Conditions
Dr. Thatcher says UH Population Health is also taking a similar “big data” approach to identify ways to improve the quality of care for patients with four other common chronic conditions – diabetes, hypertension, COPD and congestive heart failure.
‘This project we're doing with the chronic kidney disease actually fits into a larger initiative in Population Health called the Systems of Excellence,” she says. “Across these different disease processes, there are similar opportunities to work with our population data to proactively find gaps in care and address them. We're also working to standardize and provide support for primary care providers. They’re the providers the patients know and trust, so they’re the key.”