Family Medicine Matters Blog

The OCFP Blog discusses current topics and invites members to share their perspectives and ideas, and engage in a dialogue.

The Ontario Renal Network and KidneyWise Toolkit Have Changed My Practice… I Think They’ll Change Yours Too

August 8, 2016

Before you read on, think about how you currently manage your patients who have or are at risk for chronic kidney disease (CKD). Who are you screening for CKD? How many of your CKD patients are on statins even if they don’t have diabetes or other cardiovascular disease (CVD) risks? If an eGFR comes back less than 60 mL/min, when do you repeat it? When do you refer for nephrology consultation? Do your early CKD patients know which medications to avoid when they are sick?

 

This blog can support you in a linking learning to practice for CPD credits. Have a look at the KidneyWise toolkit, think about your questions, consider implementing the tool and then reflect on your practice in a month or two.

 

Now, read on:

 

About a year ago, I saw the KidneyWise toolkit advertised on Twitter and pursued it. It has changed my practice and my thinking about identifying patients at risk for CKD and managing patients with the disease.

 

Up until that point, I did not really have a coherent approach to CKD. I didn’t have an approach to screening patients at highest risk for the disease, didn’t repeat testing of abnormal renal test results in a consistent way, and didn’t really have set criteria for referral. 

 

So how has the KidneyWise toolkit changed my practice?

  1. I am screening my hypertensive patients at risk for CKD more consistently, and repeating testing of abnormal results (i.e. eGFR < 60 mL/min and/or urine ACR > 3 mg/mmol) in a timely manner to confirm the diagnosis.
  2. I am paying more attention to intentionally screening for CKD in patients 60 to 75 years old with CVD.
    image of kidneywise tool screenshot evaluation of risk
  3. I have been much more attentive about statins in patients with CKD (previously, I was unaware of the recommendation about statins in CKD!)
    Image of KidneyWise Tool Screenshot of page on CKD Management
  4. I am using the “sick day medication” information now, which I did not do previously.
    image of kidneywise tool screenshot sickday medication list
  5. I am more consistent in my referrals to my specialist colleagues – not only in following the guidelines as to when to refer patients but also in providing full information by using the KidneyWise referral form.

 

The KidneyWise toolkit is available at www.kidneywise.ca.

 

There is also a great video on the approach to the management of CKD in primary care via the KidneyWise toolkit on the Ontario Renal Network website. I really encourage you to take 40 minutes and watch it. It’s a great bit of education!

 

Recognizing that the KidneyWise toolkit has changed what I do, I was curious about who was behind it and how it got started. I had an opportunity to have a conversation with Dr. Allan Grill, who is the Provincial Primary Care Lead at the Ontario Renal Network and one of the leads for this project. He works with a dedicated team at the Ontario Renal Network, including Dr. Scott Brimble, a staff nephrologist at St. Joseph’s Healthcare Hamilton and the Provincial Medical Lead for the Early Detection portfolio. Here is a summary of our conversation.

 

Q: Can you give us some background on the Ontario Renal Network?

 

Dr. Grill: In 2009, kidney care services in Ontario went to the Ontario Renal Network under the umbrella of CCO. The Ontario Renal Network has been able to leverage CCO's quality improvement and change management processes to do the kind of improvement work that will make a difference to patients with renal disease.

The Ontario Renal Plan II outlines how the Ontario Renal Network will work to support people with kidney disease. With respect to primary care, one of the main priorities of the Ontario Renal Network is the early identification and prevention of progression of CKD.

 

Q: Considering the many different chronic diseases competing for the time of a primary care provider, why should CKD be important to primary care providers?

 

Dr. Grill:  The reality is that the majority of patients diagnosed with CKD are at low risk of significant progression. Most of them can and should be managed and monitored in primary care. We know that for patients who have been diagnosed with or are at risk for CKD, early intervention can help prevent further progression to advanced stages, which will significantly impact overall patient outcomes. Therefore, this is an important opportunity for family physicians to embrace.

 

There is also a significant overlap between CKD and cardiovascular disease (CVD), and we, as family physicians, are already really good at managing the latter. Recognizing this correlation with CKD, we can apply our CVD risk assessment and management skills for this whole group of patients.

 

The KidneyWise toolkit highlights the opportunity for family physicians to provide excellent CKD care through early identification and renal protection interventions. We can also identify the need for early referral to nephrology services for patients who are at higher risk of progression to end-stage renal disease (ESRD). These individuals may ultimately require renal replacement therapy – either dialysis or kidney transplant – and will benefit from the lead time to prepare for it.

 

Q: I have used the KidneyWise toolkit and found it really helpful for clinical management of some of my patients. Was there a particular patient or issue for you that led to your involvement in developing this?

 

Dr. Grill: It was not so much one particular patient but rather a recognition of a significant gap in the way in which CKD was addressed in clinical practice guidelines. Most existing guidelines are not targeted at primary care, but rather seem to be written for nephrologists. The other important issue is timely access to care. There are some situations where patients at low risk of progression to advanced CKD are referred to nephrology instead of being initially managed by family physicians. By using the KidneyWise toolkit, providers can be empowered to manage these patients independently, which decreases the wait times for higher priority referrals. I also think that we need to continue to find ways to strengthen connections between nephrology and primary care. The Ontario Renal Network recently completed a successful CKD mentorship program for family physicians and continues to work on innovative ways to enhance renal care in the primary care setting.

 

Q: Can you briefly talk about the process you undertook to develop this toolkit? Were primary care providers consulted?

 

Dr. Grill: In 2012 the Ontario Renal Network conducted a needs assessment regarding primary care; 250 family physicians and nurse practitioners were consulted. We learned that primary care providers wanted to increase their knowledge about CKD via access to reference tools and decision aids that were evidence based and easy to use.

 

We used that feedback to put together the KidneyWise toolkit, which has three components: a clinical algorithm, an evidence-based information summary, and a standardized outpatient nephrology referral form.

 

We owe some of the work that we have done to the nephrology group at The Ottawa Hospital. We adapted the algorithm from a study they published looking at nephrology referral patterns – they wanted to ensure that their CKD guidelines supported the needs in primary care.

 

We used their existing clinical algorithm as a starting point, added some additional content and information, and made sure that we were aligned with other related guidelines, like the Kidney Disease Improving Global Outcomes (KDIGO) Canadian Cardiovascular Lipid Management in CKD guidelines.

 

We also applied some research on what makes tools effective – like ensuring that the steps of the algorithm are clear and practical, making the tool accessible through a web interface, and supporting it with an app that can be used at the point of care. We are also aware that the KidneyWise toolkit will have increased uptake when it is able to interface with electronic medical records, and we are currently exploring this option.

 

Q: Across the system, I think it is really important that we create win-win’s between family physicians and specialists. I can see how this is potentially very helpful for family docs. I am wondering what the feedback is from nephrologists.

 

Dr. Grill: Nephrologists from across Ontario and Canada vetted and endorsed the toolkit. We also sent it to family physicians and other primary care providers for feedback during its development.


The Ontario Renal Network has nephrology leads within 26 CKD programs, and 14 regional renal programs aligned with the LHINs. These programs have been very supportive of finding ways to increase access to consultation services and to increase education for family physicians regarding CKD management. We have plans to further this work on primary care engagement and dissemination of the KidneyWise toolkit.

 

Q: Do you know if any LHINs have implemented a central referral service for nephrology consults – like a 1-800 number to send the referrals to for triage? Is that a goal that was contemplated initially?

 

Dr. Grill: Some regional renal programs have centralized their referral intake from primary care. The Ontario Renal Network is looking at what is working well across the province, with the goal of making sure that all primary care providers have equitable access to nephrology services when required. Other successful innovative methods of referral, such as e-consults, have also been started, and we’ll be looking at ways to spread these initiatives.

 

 Q: Tell me about the goals of the KidneyWise toolkit and what impact it will have on Ontario if it is fully utilized?

 

Dr. Grill: Our hope is that three things will be accomplished as the toolkit is more widely adopted into practice: One, it will improve primary care providers’ recognition of which patients are at highest risk and should be screened for CKD. Two, primary care providers will know which investigations to order when working-up a patient for CKD and how to interpret the results. And three, it will empower primary care providers in the management of CKD, including appropriate referral to nephrology for patients identified as being at higher risk for progression to advanced disease.

 

Ultimately we want to ensure that all Ontarians with CKD achieve better health outcomes. We are in the process of creating a framework to measure these outcomes.

 

Q: Tell me about your hopes for the project as it moves forward. How will it grow or evolve from this point.

 

Dr. Grill: There are several things in the works. We are continuing to work with EMR vendors to make the toolkit more easily available for use in clinical practice. We have an upcoming project to develop educational resources for family physicians and pharmacists for medication management in patients with CKD to reduce their risk of acute kidney injury (AKI).  We see a real opportunity to provide resources that would support patients with self-management of their CKD, which would help them better manage their disease over the long term. We are also engaged in projects looking at referral access to nephrologists, as well as primary care CKD practice patterns and outcomes.

 

We are also actively monitoring the reach of this project. So far there have been 3,900 downloads of the KidneyWise app and many “hits” on the Ontario Renal Network website to use the web-based tool (www.kidneywise.ca). We continue to use multiple strategies for reaching primary care providers, including presentations at accredited medical conferences and social media (e.g., Twitter), and we are hopeful we’ll continue to attract more users moving forward.

 

Finally, I would like to acknowledge the ongoing hard work and dedication of several members of our team, including Monisha Bhatt, Ann Thomas and Frank Sijinardo. Dr. Brimble and I look forward to our continued working relationship with them.

 

Interested in using this information to access CME credits? Consider reviewing the information, giving it a try in practice and then reflecting on how it has changed your practice. You can do a linking learning to practice exercise here for CPD credits.

 

Dr. Allan Grill will be be presenting KidneyWise: A Primary Care Innovation for Chronic Kidney Disease Management at the OCFP’s ASA 2016 on Friday, Nov. 25. Click here to learn more.

 

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