Pathways for Chronic Kidney Disease Diverse and Inconsistent

A scoping review published in Nephrology Dialysis Transplantation has found that clinical pathways for chronic kidney disease (CKD) are diverse in their design, content, and implementation. This information may be useful to teams or institutions currently developing their own pathways for this condition. 

CKD is a burdensome condition associated with increased morbidity, mortality, and substantial health care costs. Identifying CKD early is extremely important in managing the disease, as effective therapeutic options can help to prevent or slow the progression of CKD to kidney failure. However, despite the availability of effective treatments, use of evidence-based interventions for CKD remains suboptimal. Clinical pathways aim to incorporate evidence-based practice guideline recommendations into care in order to improve outcomes and reduce health care costs. 

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In order to provide more insight on pathway use for CKD, researchers led by Meghan J Elliott, Li Ka Shing Knowledge Institute, St Michael’s Hospital (Toronto, Canada), performed a scoping review to examine the availability, characteristics, and credibility of various pathways developed for adult patients with CKD managed in the primary care setting. 

The electronic databases Medline, Embase, and CiNAHL as well as targeted internet sites were searched from inception to October 31, 2014 for articles related to clinical pathways and CKD or kidney failure. Two reviewers independently extracted data from selected studies and, due to the nature of their review, researchers noted that a formal assessment of study quality was not undertaken. 

The final analysis included 41 different clinical pathways, 7 from published articles (excellent agreement) and 34 grey literature resources (fair agreement). The majority of the clinical pathways included in the study were from the United Kingdom (32%), followed by the United States (24%) and Canada (22%). 

The majority of pathways (66%) indicated that they were static with no online interactive features. Almost all of the pathways (93%) included content to CKD screening and diagnosis while 76% also described both drug and lifestyle management. However, specific recommendations were highly variable. 

Most notably, recommendations for who should be screened for CKD differed significantly between pathways and, while most pathways included mainstay treatments such as angiotensin-converting enzyme inhibitors to slow progression, other specific treatments in the pathways were not consistently reported and had varying levels of detail. 

Further, implementation and dissemination plans were reported in only 7% (n = 3) of articles. Value and cost were also not often reported, with only 10% and 5% of the pathways providing data, respectively, including that related to qualitative and quantitative outcomes before and after pathway implementation. Only one article reported 100% of the data extraction variables based on criteria of availability, characteristics, and credibility. 

Overall, based on guideline assessments using the AGREE II instrument, 75% (n = 15) of the clinical pathways identified in the review were recommended for use in practice. Those not recommended generally contained recommendations related to dialyses, not earlier stages of CKD. 

From these data, researchers concluded that there is a wide range of variability in clinical pathway use, credibility, and implementation. They hope that data from their study will help interested parties better develop and adapt pathways for use in their own practices to improve outcomes while driving down costs.—Sean McGuire

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Elliot MJ, Gil S, Hemmelgarn BR, et al. A scoping review of adult chronic kidney disease clinical pathways for primary care [published online ahead of print June 2, 2016]. Nephrol Dial Transplant. 2016. doi:10.1093/ndt/gfw208.