Nynke Scherpbier-de Haan

Initial Implementation of a Web-Based Consultation Process for Patients With Chronic Kidney Disease

PURPOSE A Web-based consultation system (telenephrology) enables family physicians to consult a nephrologist about a patient with chronic kidney disease. Relevant data are exported from the patient’s electronic file to a protected digital environment from which advice can be formulated by the nephrologist. The primary purpose of this study was to assess the potential of telenephrology to reduce in-person referrals. METHODS In an observational, prospective study, we analyzed telenephrology consultations by 28 family practices and 5 nephrology departments in the Netherlands between May 2009 and August 2011. The primary outcome was the potential reduction of in-person referrals, measured as the difference between the number of intended referrals as stated by the family physician and the number of referrals requested by the nephrologist. The secondary outcome was the usability of the system, expressed as time invested, the implementation in daily work hours, and the response time. Furthermore, we evaluated the questions asked. RESULTS One hundred twenty-two new consultations were included in the study. In the absence of telenephrology, 43 patients (35.3%) would have been referred by their family physicians, whereas the nephrologist considered referral necessary in only 17 patients (13.9%) (P <.001). The family physician would have treated 79 patients in primary care. The nephrologist deemed referral necessary for 10 of these patients. Time investment per consultation amounted to less than 10 minutes. Consultations were mainly performed during office hours. Response time was 1.6 days (95% CI, 1.2–1.9 days). Most questions concerned estimated glomerular filtration rate, proteinuria, and blood pressure. CONCLUSION A Web-based consultation system might reduce the number of referrals and is usable. Telenephrology may contribute to an effective use of health facilities by allowing patients to be treated in primary care with remote support by a nephrologist.

Effect of shared care on blood pressure in patients with chronic kidney disease: a cluster randomised controlled trial

BACKGROUND Chronic kidney disease (CKD) is highly prevalent in patients with diabetes or hypertension in primary care. A shared care model could improve quality of care in these patients AIM To assess the effect of a shared care model in managing patients with CKD who also have diabetes or hypertension. Design and setting A cluster randomised controlled trial in nine general practices in The Netherlands. METHOD Five practices were allocated to the shared care model and four practices to usual care for 1 year. Primary outcome was the achievement of blood pressure targets (130/80 mmHg) and lowering of blood pressure in patients with diabetes mellitus or hypertension and an estimated glomerular filtration rate (eGFR)<60 ml/min/1.73 m(2). RESULTS Data of 90 intervention and 74 control patients could be analysed. Blood pressure in the intervention group decreased with 8.1 (95% CI = 4.8 to 11.3)/1.1 (95% CI = -1.0 to 3.2) compared to -0.2 (95% CI = -3.8 to 3.3)/-0.5 (95% CI = -2.9 to 1.8) in the control group. Use of lipid-lowering drugs, angiotensin-system inhibitors and vitamin D was higher in the intervention group than in the control group (73% versus 51%, 81% versus 64%, and 15% versus 1%, respectively, [P = 0.004, P = 0.01, and P = 0.002]). CONCLUSION A shared care model between GP, nurse practitioner and nephrologist is beneficial in reducing systolic blood pressure in patients with CKD in primary care.

A pharmacy medication alert system based on renal function in older patients

BACKGROUND Delayed antibiotic prescribing is promoted as a strategy to reduce antibiotic consumption, but its use and its effect on antibiotic consumption in routine care is poorly described. AIM To quantify delayed antibiotic prescribing in adults presenting in primary care with acute cough/lower respiratory tract infection (LRTI), duration of advised delay, consumption of delayed antibiotics, and factors associated with consumption. DESIGN AND SETTING Prospective observational cohort in general practices in 14 primary care networks in 13 European countries. METHOD GPs recorded clinical features and antibiotic prescribing for adults presenting with an acute infective illness with cough as the dominant symptom. Patients recorded their consumption of antibiotics from any source during the 28-day follow up. RESULTS Two hundred and ten (6.3%) of 3368 patients with usable consultation data were prescribed delayed antibiotics. The median recommended delay period was 3 days. Seventy-five (44.4%) of the 169 with consumption data consumed the antibiotic course and a further 18 (10.7%) took another antibiotic during the study period. 50 (29.6%) started their delayed course on the day of prescription. Clinician diagnosis of upper respiratory tract/viral infection and clinicians perception of patients wanting antibiotics were associated with less consumption of the delayed prescription. Patients wanting antibiotics was associated with greater consumption. CONCLUSION Delayed antibiotic prescribing was used infrequently for adults presenting in general practice with acute cough/LRTI. When used, the effect on antibiotic consumption was less than found in most trials. There are opportunities for standardising the intervention and promoting wider uptake.BACKGROUND Patients with diabetes or cardiovascular disease are at risk of reduced renal function and frequently use drugs that interact with renal function. GPs monitor renal function in these patients. Computerised prescription systems produce alerts in patients labelled as having chronic kidney disease, but alerts are often ignored. If pharmacists use a pharmacy medication alert system (PMAS) based on renal function, they can provide the GP with therapeutic advice to optimise the medication. The extent of this advice and the feasibility in the clinical context are unknown. AIM To assess the therapeutic advice formulated by pharmacists with help of a PMAS based on the renal function of patients aged ≥70 years with diabetes or cardiovascular disease. DESIGN AND SETTING Observational study in primary health care in the Netherlands. METHOD GPs provided pharmacists with the renal function of older patients with diabetes or cardiovascular disease who were using target drugs, that is, drugs requiring therapeutic advice in patients with reduced renal function. With the help of a PMAS, pharmacists assessed the actual medication. The GP weighed the advice in relation to the clinical context of the individual patient. RESULTS Six hundred and fifty patients were prescribed 1333 target drugs. Pharmacists formulated 143 therapeutic recommendations (11% of target drugs) concerning 89 patients (13.7% of study population). In 71 recommendations in 52 patients (8.0% of study population), the GP agreed immediately. CONCLUSION The use of a PMAS resulted in therapeutic advice in 11% of the target drugs. After weighing the clinical context, the GP agreed with half of the advice.

Quality of chronic kidney disease management in primary care: a retrospective study

Abstract Background: Early detection and appropriate management of chronic kidney disease (CKD) in primary care are essential to reduce morbidity and mortality. Aim: To assess the quality of care (QoC) of CKD in primary healthcare in relation to patient and practice characteristics in order to tailor improvement strategies. Design and setting: Retrospective study using data between 2008 and 2011 from 47 general practices (207 469 patients of whom 162 562 were adults). Method: CKD management of patients under the care of their general practitioner (GP) was qualified using indicators derived from the Dutch interdisciplinary CKD guideline for primary care and nephrology and included (1) monitoring of renal function, albuminuria, blood pressure, and glucose, (2) monitoring of metabolic parameters, and alongside the guideline: (3) recognition of CKD. The outcome indicator was (4) achieving blood pressure targets. Multilevel logistic regression analysis was applied to identify associated patient and practice characteristics. Results: Kidney function or albuminuria data were available for 59 728 adult patients; 9288 patients had CKD, of whom 8794 were under GP care. Monitoring of disease progression was complete in 42% of CKD patients, monitoring of metabolic parameters in 2%, and blood pressure target was reached in 43.1%. GPs documented CKD in 31.4% of CKD patients. High QoC was strongly associated with diabetes, and to a lesser extent with hypertension and male sex. Conclusion: Room for improvement was found in all aspects of CKD management. As QoC was higher in patients who received structured diabetes care, future CKD care may profit from more structured primary care management, e.g. according to the chronic care model. Key points Quality of care for chronic kidney disease patients in primary care can be improved. In comparison with guideline advice, adequate monitoring of disease progression was observed in 42%, of metabolic parameters in 2%, correct recognition of impaired renal function in 31%, and reaching blood pressure targets in 43% of chronic kidney disease patients. Quality of care was higher in patients with diabetes. Chronic kidney disease management may be improved by developing strategies similar to diabetes care.

Chronische nierschade: een zorg voor de eerste lijn

Chronische nierschade komt steeds meer voor door de vergrijzing en de toename van diabetes en hoge bloeddruk. Je kunt enorme gezondheidswinst boeken als je chronische nierschade adequaat behandelt. Niet alleen vanwege de chronische nierschade zelf, maar ook vanwege de hart- en vaatziekten die ermee samenhangen. Een groot deel van de zorg kan plaatsvinden in de eerste lijn door de praktijkondersteuner. Dit artikel behandelt uitgebreid de diagnostiek van chronische nierschade, en het vervolg indien een patiënt chronische nierschade blijkt te hebben. Bovendien is er aandacht voor de organisatie van de zorg en de taken van de verschillende professies die bij de patiënt betrokken zijn, zoals de praktijkondersteuner, de praktijkassistent en de nefroloog.

Impact on cardiovascular risk follow-up from a shift to the CKD-EPI formula for eGFR reporting: a cross-sectional population-based primary care study

Objective To assess the impact on cardiovascular risk factor management in primary care by the introduction of chronic kidney disease epidemiological collaboration (CKD-EPI) for estimated-glomerular filtration rate (eGFR) reporting. Design and setting Cross-sectional study of routine healthcare provision in 47 primary care practices in The Netherlands with Modification of Diet and Renal Disease Study eGFR reporting. Methods eGFR values were recalculated using CKD-EPI in patients with available creatine tests. Patients reclassified from CKD stage 3a to CKD stage 2 eGFR range were compared to those who remained in stage 3a for differences in demographic variables, blood pressure, comorbidity, medication usage and laboratory results. Results Among the 60 673 adult patients (37% of adult population) with creatine values, applying the CKD-EPI equation resulted in a 16% net reduction in patients with CKD stage 3 or worse. Patients reclassified from stage 3a to 2 had lower systolic blood pressure (139.7 vs 143.3 mm Hg p<0.0001), higher diastolic blood pressure (81.5 vs 78.4 mm Hg p<0.0001) and higher cholesterol (5.4 vs 5.1 mmol/L p<0.0001) compared to those who remained in stage 3a. Of those reclassified out of a CKD diagnosis 463 (32%) had no comorbidities that would qualify for annual CVD risk factor assessment and 20 (12% of those with sufficient data) had a EuroSCORE CVD risk >20% within 10 years. Conclusions Use of the CKD-EPI equation will result in many patients being removed from CKD registers and the associated follow-up. Current risk factor assessment in this group may be lacking from routine data and some patients within this group are at an increased risk for cardiovascular events.

General practitioners’ perspectives on management of early-stage chronic kidney disease: a focus group study

BackgroundGuideline adherence in chronic kidney disease management is low, despite guideline implementation initiatives. Knowing general practitioners’ (GPs’) perspectives of management of early-stage chronic kidney disease (CKD) and the applicability of the national interdisciplinary guideline could support strategies to improve quality of care.MethodQualitative focus group study with 27 GPs in the Netherlands. Three analysts open-coded and comparatively analysed the data. Mind-mapping sessions were performed after data-saturation.ResultsFive themes emerged: defining CKD, knowledge and awareness, patient-physician interaction, organisation of CKD care and value of the guideline. A key finding was the abstractness of the CKD concept. The GPs expressed various perspectives about defining CKD and interpreting estimated glomerular filtration rates. Views about clinical relevance influenced the decision-making, although factual knowledge seems lacking. Striving to inform well enough without creating anxiety and to explain suitably for the intellectual ability of the patient caused tension in the patient-physician interaction. Integration with cardiovascular disease-management programmes was mentioned as a way of implementing CKD care in the future. The guideline was perceived as a rough guide rather than a leading document.ConclusionCKD is perceived as an abstract rather than a clinical concept. Abstractness plays a role in all formulated themes. Management of CKD patients in primary care is complex and is influenced by physician-bound considerations related to individual knowledge and perception of the importance of CKD. Strategies are needed to improve GPs’ understanding of the concept of CKD by education, a holistic approach to guidelines, and integration of CKD care into cardiovascular programmes.Trial registrationNot applicable.

Communities of practice: A means to support occupational therapists’ continuing professional development. A literature review

BACKGROUND This literature review investigates what research reports about the contribution that communities of practice (CoPs) can make in the continuing professional development (CPD) of qualified occupational therapists. METHODS Academic databases (CINAHL, MEDLINE and ERIC) were searched and articles were included based on pre-determined criteria. Five articles were included in the review. RESULTS The CoPs in the reviewed articles provided opportunities for knowledge sharing, knowledge translation, reflection on action and learning through boundary crossing. The presence of professionals with diverse perspectives was an important ingredient that facilitated CPD. CONCLUSION Research into the use of CoPs in occupational therapy is sparse. CoPs could provide a CPD forum for occupational therapists whether online or face to face. Practitioners are encouraged to participate in CoPs. Further research into the use of CoPs is recommended.

European Interprofessional Education Network Conference, Nijmegen, the Netherlands: Bridging education and practice

Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands; Department of Nursing, Faculty of Healthcare, Zuyd University of Applied Sciences, Maastricht, the Netherlands; Department of Family Medicine, Maastricht University, Maastricht, the Netherlands; Research Centre for Public Affairs, Faculty of Health, HAN University of Applied Sciences, Nijmegen, the Netherlands

Community of practice: leren dicht bij huis

SamenvattingScherpbier-de Haan ND. Community of practice: leren dicht bij huis. Huisarts Wet 2017;60(11):584-5. Huisartsen zullen steeds vaker samenwerken met andere professies binnen de eerste lijn. De kunst is om de kansen te zien en te benutten door een lerend team te vormen: een community of practice.