Primaris CKD Tips

March 3, 2011

Evaluate individuals with diabetes annually for kidney disease. This includes checking the albumin/creatinine ratio, blood pressure, and serum creatinine to estimate the GFR. For people with documented chronic kidney disease, base ongoing follow up on clinical circumstances such as blood pressure, kidney function, potassium level, and medication dose changes. Repeat the albumin/creatinine ratio or the protein/creatinine ratio every three months to monitor progression of kidney disease and response to therapy.

March 3, 2011

Diabetes is the leading cause of chronic kidney disease in the United States. Diabetic nephropathy occurs in 20-40% of people with diabetes. A routine urinalysis/dipstick for protein is not sensitive enough to detect microalbuminuria and is therefore not an appropriate test for early detection of diabetic kidney disease. The NKF recommends the albumin-to-creatinine ratio for people with diabetes. This calculation estimates the amount of protein excreted in the urine in one day. A ratio greater than 30 mg of albumin/1 gram of creatinine indicates that the kidneys are damaged.  Albumin excretion can vary from day to day and can be affected by uncontrolled blood pressure, high blood glucose, fever, urinary tract infection, hematuria, and strenuous physical activity.  Repeat a positive albumin/creatinine ratio in 3-6 months to confirm diagnosis.

Albumin/Creatinine Ratio Results

Once a person has an albumin/creatinine ratio of > 300 mg/g (macroalbuminuria), follow the urine protein excretion using the protein/creatinine ratio. The protein/creatinine ratio is measured from a random urine sample and can be used to follow progression of kidney disease and response to therapy.

January 10, 2011

Every year, it seems to get harder and harder to maintain or hopefully increase the efficiency and profit level for the practice.   Here's something to consider.  What do you do regarding your No Show patients?   They could actually be dubbed the "office silent killer".   The category of No Show patients, left unattended, can truly cost the practice, especially over the long haul.  Here are some ideas which you might want to consider for Every year, it seems to get harder and harder to maintain or hopefully increase the efficiency and profit level for the practice.   Here's something to consider.  What do you do regarding your No Show patients?   They could actually be dubbed the "office silent killer".   The category of No Show patients, left unattended, can truly cost the practice, especially over the long haul.  Here are some ideas which you might want to consider for your operation. 

First, you need a process to identify No Show patients which you can put in place, keep in place, and monitor on a monthly bases.  This will now start to identify those patients who are taking up valuable time slots, but not showing for their appointments.  Of course, there are always unexpected issues that arise; however, these should be the exception not the rule.  After awhile, you may find that the same people keep failing to show for their appointments.  These patients may need a little TLC to come to understand the importance of the visit and why it's important for them to keep their appointments.  Many patients simply state "they feel just fine" and they don't understand why they need to continue to come to the doctor.   Since the patient "feels fine", they simply don't take seriously the warnings the doctor continues to present to them.  Once again, these patients may need more education and dialog to get them on board with their care.  Many older patients still think they only need to see the doctor when they don't feel well.  Otherwise, they are just wasting their money.   Given the complexities of medicine, often the patient is lost as to the plan of care the doctor has for them.  

Secondly, the process needs to have a point person.  This is a person who can combine the weekly information and keep track of the progress.  In the beginning, as with most changes, it's hard to incorporate this process into the staff's daily routine.  Don't be discouraged if in the beginning it's a little hit and miss.  Keep reminding the staff to do their follow up and keep collecting their efforts.  It can help to have a standardized form.  Now you can start to see what your specific No Show rate is for each provider.  The No Show rate is computed by dividing the No Show patients by the number of patients scheduled to be seen that day for each provider.   By keeping track and having a numeric report you can chart your progress and help focus additional support to those patients who need the help.   It's possible you may find additional reasons for the No Shows, such as the patient has become dissatisfied and has gone to another provider, or a physician is consistently running late.   Of course as these and other conditions are discovered, steps will need to be taken to correct. 

Thirdly, the process needs to have a report which shows its progress by the month.  Now that you have a month's worth of statistics you can share it with your providers.  In addition, you can project the revenue loss.  Over time, this number should reduce, along with the revenue loss.  The success of your efforts can be reflected month by month.  At the end of the year, hopefully your efforts will be trending towards a reduction in your No Show patients, resulting in fuller, more productive days.  

If you would like some help in setting up a system which will work for your practice, please give me a call at the number below.  I have a turn-key process which can work for any practice.   Wishing you a great New Year!   For further information, please contact Linda Lesh at 314.374.6451.

November 3, 2010

It’s the current standard of care: Patients with diabetes and hypertension and/or microalbuminuria and blood pressure below 130/80 should be treated with a regimen including an ACEI or an ARB. This treatment aims to delay the onset and progression of nephropathy and reduce CVD risk ¹.

We can avoid missing treatment opportunities by understanding the reasons why physicians inconsistently prescribe these medications and why patients inconsistently adhere to them.

1. My patient refuses to take the medication.  There are many reasons people may not take the medications you prescribe. Spend some time finding out about your patient’s belief system; reinforce lifestyle modifications; maximize your practice’s customer service (provide easy access to the facility, reduce minimum waiting times, encourage an open and friendly office staff).  Work with other healthcare professionals to reinforce your treatment regimens.  Most health plans offer outreach to patients with chronic conditions and can provide additional support.
2. My patient’s ACEI makes her cough excessively.  If your patient claims she cannot tolerate an ACEI or an ARB, re-read the tip above before discontinuing. You may also consider switching to another medication in the class, or from an ACEI to an ARB (see the tips below), or vice versa. Always be sure to document any side effects in the patient’s medical record. 
3. ACEI/ARB drugs worsen serum creatinine/serum potassium.  Small and non-progressive increases in the serum creatinine concentration accompanying better blood pressure control do not reflect structural injury to the kidney. Rather, they reflect a favorable effect on renal hemodynamics and, in particular, a lowering of intraglomerular pressure.  Only consider discontinuing the drug if the rise in creatinine is greater than 30% or if repeat values show a progressive increase.  Do not forget to monitor the urine albumin/creatinine ratio and eGFR.  Then look for other causes, such as renal artery obstruction; an azotemic response to superimposed illness such as gastroenteritis or early sepsis; development or deterioration of a co-morbidity such as heart failure; or the effect of another drug such as NSAIDs.
   Mild hyperkalemia is not an indication for cessation of ACEI/ARB therapy.  When faced with a mild increase in potassium, before discontinuing the ACEI, consider reducing the dosage or halting other drugs the patient is taking. If the potassium is more than 5.6mEq/l despite precautions, then discontinue the ACEI or ARB or switch to another class of antihypertensive medication ².  Patients with a potassium level in the 5-6 range should be followed closely; consider a nephrology referral early for these patients.
4. My patient cannot afford the drug.  Suppose your patient coughs on his ACEI, cannot afford a more costly ARB and there are no other RAS-suppressing options.  Good news! In April, the FDA approved the first generic ARB and a combination drug losartan/hydrochlorothiazide.  Patents for two additional ARBs will expire in 2010, so be on the lookout for FDA approval of other ARB generics in the near future.   
5. I have several thousand patients in my panel, it is impossible to keep track of every single one.  If titrating drugs, combining drug regimens, or access to clinical guidelines is a challenge, use decision support systems such as flow charts and feedback reminders.  Physicians should periodically audit their own charts to assess patient adherence and treatment to goal for selected medical conditions (for example, diabetes) or clinical services (e.g., immunizations). 

If you do not have the resources to do your own medical record audit, Primaris offers free solutions.  We can help you and your staff with free tools and patient materials to help you improve care.  E-mail Anne Carpenter, Primaris’ CKD Lead Program Manager, at acarpenter@primaris.org if you would like assistance from the CKD team.

1 The American Diabetes Association [2010] "Standard of Medical Care in Diabetes" and National Kidney Foundatoin [2007] "KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease"

2 Palmer [2003], Nephrology Dialysis Transplantation, 18, 1973-1975

June 1, 2010

The National Kidney Foundation has provided an algorithm to determine why, when and how to screen diabetic patients for kidney disease using the urine microalbumin screening test.  Please share this with other providers in your practice and help us decrease the increase in chronic kidney disease in Missouri.

March 22, 2010

The National Kidney Foundation's Web site provides multidisciplinary patient care plans for physicians, nurses, dieticians, social workers, and dialysis technicians to help evaluate and treat patients with Chronic Kidney Disease.  It takes less than 30 seconds to enter the necessary data and get your action plan.  There are no names or personal information required, so no HIPAA issues.

http://www.kidney.org/professionals/KDOQI/cap.cfm

This link takes you to the homepage of the Multidisciplinary Clinical Action Plans; next click Online Version

Choose your discipline from the drop-down field

• Insert or calculate the patient’s GFR (calculator included).
• Indicate presence of kidney damage and comorbidities (Diabetes and HTN).
• Click ‘Create Care Plan’ to see discipline-specific care planning by stage of CKD.
• Click on ‘More Information’ to expand and collapse the section for clearer navigation.
• Links are provided to reference guidelines, tables, figures, further reading and resources and patient education materials.
• Printing the care plan is permissible under the terms listed.