Major Rupert W, Lakhani Niraj, Ahmed Yaseen, Atkin Jade, Baines Richard, Balment Rose, Cheung Chee Kay, Graham-Brown Matthew P, Ellwood Claire, Harding Laura, Iyasere Osasuyi, Jesa Tracy, Jesus-Silva Jorge, Jinadu Yusuf, Khalid Arshad, Khatri Jibran, Makkeyah Yahya, Martinez Maria, Mather Helen, Medcalf James F, Moore Kirk, Ogle James, Oseya Eleanor, Patel Dipesh, Patel Reena, Pollard Tracy, Priestman William, Rastogi Amit, Sanganee Nil, Shaffu Mark, Steiner Michael, Than Tun, Xu Gang, Rizvi Fahad, Burton James O
Department of Population Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK.
University of Hospitals of Leicester NHS Trust, Leicester, UK.
Clin Kidney J. 2025 Feb 12;18(4):sfaf049. doi: 10.1093/ckj/sfaf049. eCollection 2025 Apr.
Early diagnosis, risk stratification and medication optimization are essential to improve the management of chronic kidney disease (CKD) and other long-term conditions. The introduction of Integrated Care Systems (ICS) in England provides the opportunity to revolutionize the management of these conditions. Annual National Health Service kidney disease costs are ∼£6.4 billion.
We designed, piloted and implemented at scale an ICS-level virtual care programme for CKD, the 'Leicester, Leicestershire, and Rutland Chronic Kidney Disease Integrated Care Delivery Project' (LUCID), based on the principles of patient and professional education, early disease identification, medicines optimization and disease surveillance.
In April 2022, virtual multidisciplinary team (MDT) meetings were piloted in Leicester, Leicestershire and Rutland, UK. Since April 2023 virtual MDT meetings have been available to all general practices in Leicester, Leicestershire and Rutland, representing a population of approximately 1.2 million people. As of 31 March 2024, general practices representing an estimated population of 700 000 (58.3%) were participating in the LUCID programme. Some 1085 consultations took place for 821 patients, 590 (54.4%) of which were medicines optimization consultations.
LUCID may represent an efficient and cost-effective model to deliver patient and professional education, medicine optimization and risk stratification for people living with CKD at an ICS-wide population level. This model may be adaptable for other long-term physical and mental health conditions.
早期诊断、风险分层和药物优化对于改善慢性肾脏病（CKD）及其他长期疾病的管理至关重要。英格兰引入综合医疗系统（ICS）为变革这些疾病的管理提供了契机。英国国家医疗服务体系每年用于肾病的费用约为64亿英镑。
我们基于患者和专业人员教育、疾病早期识别、药物优化及疾病监测原则，设计、试点并大规模实施了一项针对CKD的ICS层面虚拟护理项目，即“莱斯特、莱斯特郡和拉特兰慢性肾脏病综合护理交付项目”（LUCID）。
2022年4月，虚拟多学科团队（MDT）会议在英国莱斯特、莱斯特郡和拉特兰进行了试点。自2023年4月起，莱斯特、莱斯特郡和拉特兰的所有全科诊所均可参加虚拟MDT会议，覆盖人口约120万。截至2024年3月31日，代表约70万人口（58.3%）的全科诊所参与了LUCID项目。共为821名患者进行了约1085次会诊，其中590次（54.4%）是药物优化会诊。
LUCID可能是一种高效且具成本效益的模式，可在ICS范围内的人群层面为CKD患者提供患者和专业人员教育、药物优化及风险分层。该模式可能适用于其他长期身心健康状况。
