Proactive disease management

Professor
Aled Phillips

Increasing numbers of patients with renal impairment, together with improved monitoring of at-risk patients, had increased demand for renal replacement therapy.

Delayed diagnosis, late referral and limited resources were combining to increase morbidity and mortality. Better managing renal impairment, now recognised as the biggest cardiovascular risk, was important for the entire healthcare community.

The role for Map of Medicine

The Welsh healthcare system needed to ensure timely referrals and manage increased patient numbers. The Map of Medicine was key in the creation and implementation of a pathway at a time of increased awareness of Chronic Kidney Disease.

Welsh Nephrology Pathway: Prof Aled Phillips (3:23)

The project aimed to develop a pathway to manage patients’ entry into, and exit from renal health services more effectively. The project also aimed to manage increased patient numbers within a limited commissioned resource while ensuring appropriate and timely referrals.

The positive results of the pilot implementation of the Welsh Nephrology patient Pathway in Gwent has consequently allowed the roll out of the pathway across Wales.

Milestones 

• Gaining an understanding of Gwent’s nephrology services and identifying potential problems. Referrals needed to be appropriate and accompanied with adequate patient information
• Designing a patient Pathway
• Engaging with key stakeholders
• Following a period of assessment, extending the pilot to the whole of Wales.

Challenges

• Communicating to GPs that the majority of renally impaired patients don’t need secondary care management
• Achieving early interaction with the key players who would dictate the success or failure of the project.

Results

The new pathway enables patients to be managed more effectively on the journey from primary to secondary care and back again.  The number of referral letters received containing inadequate information has been reduced, as well as a fall in the total number of referral letters received. Referrals from GP practices registered to use the Map were more likely to be appropriate and thus require follow up, and less likely to generate referrals containing inadequate clinical information.

First piloted in Gwent Health Community, now part of Aneurin Bevan Health Board, the Welsh Nephrology patient Pathway is now being rolled out across Wales..