Patients firstBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4010 (Published 01 October 2009) Cite this as: BMJ 2009;339:b4010
- Trish Groves, deputy editor, BMJ
Statins are recommended for the secondary prevention of cardiovascular disease in all patients with chronic kidney disease. But the case for statins in primary prevention is much less certain, as Andrew Connor and Charlie Tomson point out, and doctors should come clean with patients about this uncertainty (doi:10.1136/bmj.b2949). The direction of causality between chronic kidney disease and cardiovascular disease remains unknown, many risk scores exclude patients with kidney disease, and cofactors such as malnutrition and inflammation may exacerbate the risk. Until the ongoing Study of Heart and Renal Protection (SHARP) reports, there’s too little evidence to extrapolate the known benefits of lipid lowering in the general population to patients with severe chronic kidney disease.
Another pitfall when managing patients with chronic kidney disease is failure to seek specialist help until it’s too late. In a quality improvement report nephrologist Brian Lee and analyst Ken Forbes describe how they tackled this challenge (doi:10.1136/bmj.b2395). Using a new computing algorithm they built a concise profile for every patient with chronic kidney disease, which was updated and stratified each month using personalised risk data from Kaiser Permanente Hawaii’s integrated clinical information system. At first this approach allowed nephrologists to offer their generalist colleagues tailored advice on managing each high risk patient, but those doctors already felt too overwhelmed with work and information to respond. Undaunted, the nephrologists offered to intervene when prompted by patients’ risk profiles, rather than by traditional referrals, and this idea went down much better. Over the next few years the specialists saw the right people, got fewer and more appropriate referrals, and used the released time and resources to support the generalists’ management of less seriously ill patients. The percentage of patients who started haemodialysis as outpatients nearly doubled. The paper reports a before and after study in just one US state and one condition, but we published it because it’s a good, practical example of using information technology and a bit of lateral thinking to integrate care and direct resources towards patients’ needs and better clinical outcomes.
Such integration is hard to achieve on a large scale, and has proved elusive in the UK despite fairly good clinical information systems in primary and secondary care and a prolonged, expensive plan to develop a NHS National Programme for Information Technology in England. This summer the Conservative party called for the programme to be scrapped in favour of more local systems, after publication of a report that the party commissioned from the IT Policy Review Group. Michael Cross disagrees with the Conservatives’ interpretation of that review and warns against short term populist interventions to dismantle the national programme (doi:10.1136/bmj.b3647). In any case, he says, the review actually supported much of the current plan. One thing he and the politicians do agree on, however, is that the technology must be refocused around the needs of patients, to save it from becoming just “a tool to extract data from the NHS.”
Cite this as: BMJ 2009;339:b4010