Primary care-based disease management of chronic kidney disease (CKD), based on estimated glomerular filtration rate (eGFR) reporting, improves patient outcomes.

Background. The majority of patients with chronic kidney disease (CKD) stages 3–5 are managed within primary care. We describe the effects, on patient outcomes, of the introduction of an algorithm-based, primary care disease management programme (DMP) for patients with CKD based on automated diagnosis using estimated glomerular filtration rate (eGFR) reporting. Methods. Patients within West Lincolnshire Primary Care Trust, UK, population 223, 287 with CKD stage 4 or 5 were enrolled within the DMP between March 2005 and October 2006. We have analysed the performance against clinical targets looking at a change in renal function prior to and following joining the DMP and the proportion of patients achieving clinical targets for blood pressure control and lipid abnormalities. Results. Four hundred and eighty-three patients with CKD stage 4 or 5 were enrolled in the programme. There were significant improvements in the following parameters, expressed as median values (interquartile range) after 9 months in the programme, compared to baseline and percentage values patients achieving target at 9 months: total cholesterol 4.2 (3.45–5.0) mmol/l versus 4.6 (3.9–5.4) mmol/l (P < 0.01), 75.0% versus 64.5% (P < 0.001); LDL 2.2 (1.6–2.8) mmol/l versus 2.5 (1.9–3.2) mmol/l (P < 0.01), 81.9% versus 69.2% (P < 0.05); systolic blood pressure 130 (125–145) mmHg versus 139 (124–154) mmHg (P < 0.05), 56.2% versus 37.1% (P < 0.05) and diastolic blood pressure 71 (65–79) mmHg versus 76 (69–84) mmHg (P < 0.01), 68.4% versus 90.3% (P < 0.01). The median fall (interquartile range) in eGFR in the 9 months prior to joining the programme was 3.69 (1.49–7.46) ml/min/1.73 m2 compared to 0.32 (−2.61–3.12) ml/min/1.73 m2 in the 12 months after enrolment (P < 0.001). One hundred and twenty-two patients experienced a fall in eGFR of ≥5 ml/min/1.73 m2, median 9.90 (6.55–12.36) ml/min/1.73 m2 in the 9 months prior to joining the programme, whilst in the 12 months after enrolment, their median fall in eGFR was −1.70 (−6.41–1.64) ml/min/1.73 m2 (P < 0.001). In the remaining patients, the median fall in eGFR was 1.92 (0.41–3.23) ml/min/1.73 m2 prior to joining the programme and 0.86 (−1.03– 3.53) ml/min/1.73 m2 in the 12 months after enrolment (P = 0.082). Conclusions. These data suggest that chronic disease management in this form is an effective method of identifying and managing patients with CKD within the UK. The improvement in cardiovascular risk factors and reduction in the rate of decline of renal function potentially have significant health benefits for the patients and should result in cost savings for the health economy.