CKD Screening and Management in the Veterans Health Administration: The Impact of System Organization and an Innovative Electronic Record

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At the beginning of this decade, Healthy People 2010 issued a series of objectives to “reduce the incidence, morbidity, mortality and health care costs of chronic kidney disease.” A necessary feature of any program to reduce the burden of kidney disease in the US population must include mechanisms to screen populations at risk and institute early the aspects of management, such as control of blood pressure, management of diabetes, and, in patients with advanced chronic kidney disease (CKD), preparation for dialysis therapy and proper vascular access management, that can retard CKD progression and improve long-term outcome. The Department of Veterans Affairs and the Veterans Health Administration is a broad-based national health care system that is almost uniquely situated to address these issues and has developed a number of effective approaches using evidence-based clinical practice guidelines, performance measures, innovative use of a robust electronic medical record system, and system oversight during the past decade. In this report, we describe the application of this systems approach to the prevention of CKD in veterans through the treatment of risk factors, identification of CKD in veterans, and oversight of predialysis and dialysis care. The lessons learned and applicability to the private sector are discussed.

Section snippets

Features of the VHA

The VHA is the largest integrated health care system in the United States, caring for 5.3 million patients in 155 medical centers, 881 clinics, 207 readjustment counseling centers, and 135 nursing homes.8 Until the early 1990s, the system had multiple incentives for inefficiency, including hospital funding based on occupancy and costs. However, starting in 1995, the VHA underwent a wide process of reengineering, changing what had been primarily an inpatient subspecialty-based system into a

Practice Guidelines and Performance Measures

Diabetes is the leading cause of ESRD,2 and as emphasized in the Healthy People 2010 objectives,7 detection of early diabetic nephropathy and intensive management of diabetes are measures that significantly impact the progress and outcome of CKD. The number and percentage of veterans with diabetes has increased markedly from about 561,000 (20%) in 2000 to about 1,300,000 in 2007 (24%), an increase that may be attributed to an increase in the number of veterans who receive VHA care, aging of the

The VHA Electronic Record and Clinical Reminders

Since 1985, the VHA has used a system-wide electronic database system for both administration and clinical care, which by December 2005 contained 779 million clinical documents, more than 1.5 billion orders, and 425 million images. In the late 1990s, a graphical user interface, CPRS, was added to facilitate access to the database, making it possible for clinicians to securely update a patient's medical history, place orders, and review test results and drug prescriptions from personal computers

VHA CKD Guideline and ESRD Management

The VHA and the Department of Defense first published an evidence-based Pre-ESRD Guideline for Primary Care in 2001 to provide a tool for primary care providers to follow and manage patients with CKD and made it available online.21 The current guideline has been extensively updated to include new evidence, the use of eGFR, and management based on the stages of CKD and is targeted to primary care providers, residents, students, and fellows. It also addresses the issue of preparing patients for

Conclusion

It clearly is important to identify patients at high risk of CKD, to conduct regular screening of renal function, preferably using eGFR, and to provide education to all providers about how to prevent or slow the progression of CKD. The VHA experience shows that effective measures to accomplish screening and implement recommended management include the establishment of clinical guidelines and performance measures based thereon, with regular monitoring of and feedback to facilities and individual

Acknowledgements

The opinions expressed by the authors’ do not necessarily reflect the opinions of the Department of Veterans Affairs or the authors’ affiliated institutions.

Support: None.

Financial Disclosure: None.

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