Monitoring Long Term Conditions in Primary Care

Aims and Objectives To improve the management of chronic conditions in Primary Care by optimising the utility and frequency of tests used for monitoring on two specific areas arranged as two work streams: chronic kidney disease (CKD) and chronic heart failure (CHF). Background and rationale Focus for the management of chronic conditions has gradually changed from hospital based (secondary care) to GPs (primary care), as conditions are recognized earlier in their disease process. Once diagnosed, a major aspect of management is monitoring. However, for many conditions there is no or poor evidence on how, what, and when to monitor. Our group has produce evidence for better monitoring in several areas. This proposal aims to extend our work into two clinical areas that represent two ends in the spectrum of the monitoring carried out in Primary Care; renal monitoring in Chronic Kidney disease (CKD) and monitoring people with Chronic Heart Failure (CHF). In CKD, the majority of monitoring occurs in mild/moderate disease with the final stages of disease (renal failure necessitating dialysis or transplantation), rarely occurring or occurring after many years. Conversely, in CHF, the prognosis is poor and therefore the majority of monitoring is conducted in the latter stages of disease. Research environment This work will be carried out by three world leading centres in their respective fields, the Oxford Centre for Monitoring and Diagnosis in Primary Care (MaDOx), the Health Experiences Research Group (HERG) and the Health Economics Research Centre (HERC). Two of which are based at the Department of Primary Care Health Sciences, ranked highest in its field (primary care research) in the Research Assessment Exercise 2008. Research plan The proposed programme will allow us to develop and populate a clinical and economic model of renal function decline, to then estimate the effectiveness and cost-effectiveness of different models used for monitoring CKD in Primary Care – Workstream 1. For CHF we will explore the use of B-type Natriuretic Peptide (BNP) and weight as monitoring tests as well as evaluating the costs of different monitoring strategies – Workstream 2. Workstream 1: Monitoring Chronic Kidney Disease in Primary Care WS 1.1 Current practice in monitoring CKD WS 1.2 Systematic reviews of CKD management WS 1.3 Estimation of variability of eGFR and related measures WS 1.4 Prospective cohort study of eGFR for monitoring CKD in primary care WS 1.5 Qualitative evaluation of monitoring CKD WS 1.6 Cost-effectiveness model of monitoring strategies for CKD Workstream 2: Monitoring Chronic Heart Failure WS 2.1 Evaluation of Intervention Components of managing CHF WS 2.2 Systematic reviews of CHF management WS 2.3 Estimation of variability of BNP and weight for monitoring CHF WS 2.4 Feasibility study of the use of POC-BNP in Primary Care WS 2.5 Qualitative evaluation of monitoring CHF WS 2.6 Economic issues of monitoring CHF patients Projected Outputs and Dissemination plans This programme will provide new evidence that will inform adequate management in Chronic Kidney disease and Chronic Heart Failure in Primary care. An important part of the focus will go into understanding the impact our findings will have on patients and health professionals. We will use links with NICE and GP commissioners in Oxfordshire to disseminate these findings. Relevant expertise and experience of the research team The team includes research groups with complementary expertise in diagnosis and monitoring from Primary Health Care, evaluation and analysis of Patients Health Experiences, and Health Economics at Oxford University; along with clinical experts on Renal Function and Cardiovascular Disease specifically focused in Primary Care. Programme Management Perera Programme Lead, Bankhead and Stevens Deputy Leads Six monthly Steering group 1-3 monthly Senior Management group (teleconfere