July 14, 2015

Overcoming care gaps for chronic kidney disease patients

Kaiser Permanente’s quest for quality improvement is at the center of a recent study published by the American Journal of Medicine. Kaiser Permanente Southern California developed Creatinine SureNet, a program designed to ensure that patients with an abnormal kidney function measurement received a follow-up evaluation.

The program monitors the Kaiser Permanente medical records of patients identified as being late for follow-up testing. Of more than 12,000 patients who had not received follow-up despite abnormal creatinine levels, a potential marker of chronic kidney disease, more than 3,000 patients were newly diagnosed with the condition.

CKD is a gradual loss of kidney function and is typically diagnosed with a creatinine blood test. Creatinine is a blood measurement that provides an indication of kidney health. An abnormal creatinine level can be an indication of CKD. The Centers for Disease Control and Prevention estimates that 1 in 10 Americans has CKD, but the disease is difficult to detect due to the nature of diagnosis, the need for timely follow-up and challenges in the ambulatory care setting. Often, patients with initial abnormal creatinine levels are overlooked, resulting in delayed or missed diagnoses.

Cute young male physician with spikey hair and a smile sitting in his office with a bookshelf behind him.
John J. Sim, MD, Kaiser Permanente Los Angeles Medical Center

“This study demonstrates how we can effectively utilize an integrated health system to close a major care gap among people at risk for chronic kidney disease,” said John J. Sim, MD, lead author and researcher at the Kaiser Permanente Los Angeles Medical Center. “Thousands of CKD diagnoses were made thanks to the additional testing ensured through the Creatinine SureNet program. Early detection of CKD is crucial because it gives us the best chance at decreasing or delaying disease-related morbidity and mortality.”

The Creatinine SureNet Program is part of Kaiser Permanente’s Complete Care Program, a collaborative approach to improve outcomes for patients. The program leverages technology, the integrated system and dedicated care teams to ensure that patients with complex chronic conditions receive the support, coordinated care and follow-up they need to maintain optimal health and reduce the risk of future complications.

Using Kaiser Permanente HealthConnect®, Kaiser Permanente’s comprehensive electronic health record, the Creatinine SureNet Program staff identified eligible patients who met the clinical requirements deemed necessary for follow-up testing. Doctors and patients were notified of the need for additional testing, and second creatinine measurements, subsequent CKD diagnoses and visits with nephrologists were all tracked and evaluated for this study.

Michael Kanter, MD, the medical director of quality and clinical analysis for the Southern California Permanente Medical Group and a co-author of the study, notes that this program is a perfect example of how Kaiser Permanente is setting a precedent for other health systems and organizations to improve patient outcomes. Recent literature indicates that errors in the diagnostic process are not uncommon throughout the country and programs like this are one approach to this widespread problem.