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PRACTICE: Brian J Lee and Ken Forbes The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease BMJ 2009; 339: b2395 [Full text]

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The role of specialists, information systems and an evidence-based approach in managing the health of populations with chronic illness

Michael E. Stuart, Sheri A. Strite, Principal and Managing Partner Delfini Group, LLC, Portland, OR 97212-1222   (10 July 2009)

The role of specialists, information systems and an evidence-based approach in managing the health of populations with chronic illness 10 July 2009
Michael E. Stuart, President and Medical Director, Delfini Group Clinical Asst Professor, UW School of Medicine Seattle, Washington 98115, Sheri A. Strite, Principal and Managing Partner Delfini Group, LLC, Portland, OR 97212-1222 Send response to journal: Re: The role of specialists, information systems and an evidence-based approach in managing the health of populations with chronic illness	Editor--The article by Brian J Lee and Ken Forbes [1] represents an important contribution to the evidence-based quality improvement (QI) literature. Lee and Forbes report success in the use of an evidence-based QI approach that can be used by other health care organisations and other groups to improve health care quality and outcomes for patients through improved implementation strategies. The implementation strategies utilised by the Kaiser Permanent CKD project team are consistent with what currently appear to be the most effective quality improvement strategies (likely to result in greater than a 10% absolute increase in improved care) [2]. The combination of leadership support, clinician-directed audit and feedback cycles, clinical decision support systems, specialty outreach programmes, chronic disease management programmes, continuing professional education based on interactive small-group case discussions, and patient-mediated clinician reminders were all used at Kaiser Permanente Hawaii to improve the medical management of CKD [3]. And importantly, the information upon which the guidelines were based was developed through a systematic approach to obtaining potentially relevant clinical trials and evaluating them through a rigorous critical appraisal approach[4]. An evidence-based process is not only important to provide patients with the best available care, but is also important for effective implementation of that care because information that is strongly supported by rigorously appraised evidence can increase trust by providing tags that clearly label information as being based on high quality evidence or expert opinion. Process information, decision support materials, documentation and tools used by Kaiser Permanente Hawaii are available here: www.delfini.org/Showcase_Project_NephrologyCPG.htm and http://www.delfini.org/delfiniTools.htm. In addition to using a rigorous evidence-based approach to create clinical recommendations, key features contributing to the improved medical management and possibly improved cost effectiveness of managing patients with chronic kidney disease (CKD) appear to be a combination of unsolicited, risk-driven nephrology consultations enabled by the innovative use of Kaiser Permanente’s electronic medical system not only to improve referrals to nephrology but also to provide evidence-based decision-support to generalists. The Kaiser Permanente electronic system includes not only registration, scheduling, billing, but also clinical information systems — both inpatient and outpatient, laboratory and X-ray information, pharmacy records, the ability to create annotations and messages for individualised care, as well as decision-support, alert and flagging features. Lee and Forbes emphasise that this system allows nephrologists to stratify CKD patients by risk category and provide electronic or real-time communications, resulting in ongoing, efficient management of low-risk patients in primary care using solicited and unsolicited consultations, mentoring and avoidance of inappropriate referrals. Thus, more complicated patients can be referred to nephrology and retraction of premature referrals of low risk patients by generalists can be easily accomplished after consulting with nephrologists. We would like to emphasise that Kaiser Permanente’s electronic medical system allows generalists rapid access to important evidence-based CKD decision-support and management information such as laboratory testing recommendations, specifics about the avoidance of nephrotoxic drugs, blood pressure management recommendations, recommendations for the use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers as well as many other guideline recommendations. We believe that part of the improved CKD management achieved at Kaiser Permanente Hawaii was achieved through the involvement of local stakeholders. 1. Lee BJ, Forbes K. The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease. BMJ 2009;339:b2395 2. Scott I. What are the most effective strategies for improving quality and safety of health care? Intern Med J. 2009 Jun;39(6):389-400. 3. Delfini project showcase: nephrology chronic kidney disease guideline project. Delfini Group, LLC 2007.www.delfini.org/Showcase_Project_NephrologyCPG.htm. 4. Evidence-based guideline development process information and critical appraisal materials used by Kaiser Permanente Hawaii are included among those found at http://www.delfini.org/delfiniTools.htm. Competing interests: None declared