ANALYSIS OF LONGITUDINAL CLINICAL DATA TO EVALUATE CHANGES IN THE SCREENING FOR AND MANAGEMENT OF CKD IN SELECT NT PRIMARY HEALTH SERVICES.

G GORHAM1, M CHATFIELD1, P LAWTON1, A CASS1

1Menzies School of Health Research, Darwin, NT

Aim: To identify changes in processes of care and clinical target attainment for people with chronic kidney disease (CKD) attending Northern Territory (NT) community-controlled primary health services (PHS) between 2004 and 2014.

Background: In 2007 the Australian and NT Governments funded nursing positions within NT community and government controlled PHS, to improve the identification and management of people with CKD. The resources focussed on the effective coordination of an individual’s care across multiple services and sectors utilising a protocol-driven approach.

Methods: De-identified clinical information for patients over 18 years old with a documented risk factor for kidney disease, was extracted from clinical information systems of seven community-controlled primary health services. Data (2004 to 2014) from all health services were aggregated and analysed comparing changes in management processes and clinical outcomes before and after implementation of the programs.

Results: There was increased yearly screening for CKD (12% to 28%) and substantial improvements in the diagnosis of CKD stage 3 or worse (45% to 85%) from 2006 to 2014, although a considerable proportion of ‘at risk’ people (53%) remained unscreened. In 2014, 85% of CKD patients had at least one blood pressure (BP) measurement and 65% of patients with diabetes and kidney disease had at least one HbA1c test, results better than the National Aboriginal Key Performance Indicators. In 2014, approximately 40% of CKD patients attained clinical targets for BP and HbA1c control across all centres.

Conclusions: This first analysis of longitudinal, aggregated, de-identified NT primary health data to explore the impact of nurse-led programs showed improved identification and management of CKD. However, with the growing burden of chronic disease and CKD, substantial evidence-practice gaps persist.

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