Department of Nephrology, Western Health, Melbourne, VIC, Australia.
School of Public Health, Department of Medicine, Monash University, Clayton, VIC, Australia.
Nephrol Dial Transplant. 2018 Jan 1;33(1):121-128. doi: 10.1093/ndt/gfw366.
The increasing burden of chronic kidney disease (CKD) underpins the importance for improved early detection and management programs in primary care to delay disease progression and reduce mortality rates. eMAP:CKD is a pilot program for primary care aimed at addressing the gap between current and best practice care for CKD.
Customized software programs were developed to integrate with primary care electronic health records (EHRs), allowing real-time prompting for CKD risk factor identification, testing, diagnosis and management according to Kidney Health Australia's (KHA) best practice recommendations. Primary care practices also received support from a visiting CKD nurse and education modules. Patient data were analyzed at baseline (150 910 patients) and at 15 months (175 917 patients) following the implementation of the program across 21 primary care practices.
There was improvement in CKD risk factor recognition (29.40 versus 33.84%; P < 0.001) and more complete kidney health tests were performed (3.20 versus 4.30%; P < 0.001). There were more CKD diagnoses entered into the EHR (0.48 versus 1.55%; P < 0.001) and more patients achieved KHA's recommended management targets (P < 0.001).
The eMAP:CKD program has shown an improvement in identification of patients at risk of CKD, appropriate testing and management of these patients, as well as increased documentation of CKD diagnosis entered into the EHRs. We have demonstrated efficacy in overcoming the verified gap between current and best practice in primary care. The success of the pilot program has encouraging implications for use across the primary care community as a whole.
慢性肾脏病（CKD）负担不断增加，这凸显了在初级保健中加强早期检测和管理计划的重要性，以延缓疾病进展并降低死亡率。eMAP：CKD 是一项针对初级保健的试点计划，旨在解决当前和最佳 CKD 护理实践之间的差距。
开发了定制软件程序，与初级保健电子健康记录（EHR）集成，根据澳大利亚肾脏健康（KHA）的最佳实践建议，实时提示识别、检测、诊断和管理 CKD 风险因素。初级保健实践还得到了一名访问 CKD 护士和教育模块的支持。在该计划在 21 个初级保健实践中实施后的 15 个月（175917 名患者）和基线（150910 名患者）分析了患者数据。
CKD 风险因素识别率有所提高（29.40%比 33.84%；P < 0.001），进行了更完整的肾脏健康检查（3.20%比 4.30%；P < 0.001）。EHR 中输入的 CKD 诊断更多（0.48%比 1.55%；P < 0.001），更多患者达到 KHA 推荐的管理目标（P < 0.001）。
eMAP：CKD 计划显示出在识别 CKD 风险患者、对这些患者进行适当的检测和管理方面有所改善，并且 EHR 中输入的 CKD 诊断记录也有所增加。我们已经证明，在克服初级保健中当前实践与最佳实践之间已证实的差距方面是有效的。该试点计划的成功为整个初级保健社区的使用带来了令人鼓舞的启示。
