Intended for healthcare professionals

Rapid response to:

Practice Quality Improvement Report

The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease

BMJ 2009; 339 doi: (Published 08 July 2009) Cite this as: BMJ 2009;339:b2395

Rapid Response:

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: and

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

4. Evidence-based guideline development process
information and critical appraisal materials used by Kaiser
Permanente Hawaii are included among those found at

Competing interests:
None declared

Competing interests: No competing interests

10 July 2009
Michael E. Stuart
President and Medical Director, Delfini Group Clinical Asst Professor, UW School of Medicine
Sheri A. Strite, Principal and Managing Partner Delfini Group, LLC, Portland, OR 97212-1222
Seattle, Washington 98115