Background
Chronic Kidney Disease (CKD) is one of the major public health problems across the world. According to the Global Burden of Disease study 2015, kidney disease was the 12th most common cause of death, accounting for 1.1 million deaths per year worldwide [
1]. CKD has affected about 11–13% of the population worldwide [
2] and about 91% of them are unaware of getting it [
3]. Diabetes mellitus and hypertension are the major associated risk factors for the development of CKD [
4,
5], which may turn CKD into a final and fatal condition of the end stage renal disease (ESRD). Furthermore, CKD of unknown origin (CKDu) is alarming the experts in various places of the world [
6‐
8].
In 2009, the Thai- Screening and Early Evaluation of Kidney Disease (SEEK) study group reported that the prevalence of CKD in Thailand is 17.5% with stages I, II, III and IV 3.3, 5.6, 7.5 and 1.1%, respectively [
9]. The highest prevalence was noted in Bangkok (23.9%), followed by the Northeast (22.2%) and North (20.4%) regions [
9]. In the Northeast Thailand, not only the incidence of kidney stone, but also of probable kidney diseases are high compared to other regions [
10,
11]. Moreover, awareness of the CKD among the Thai population is extremely low [
9]. This is vital because earlier detection of CKD allows timely intervention, potentially slower the progression of disease, and decrease mortality [
12,
13]. Based on the high prevalence of CKD, the policy to mitigate CKD burden was developed in Thailand by setting up CKD clinics in various hospitals. However, we have explored and found the barriers of CKD reduction including;- (i) lack of national registry of CKD, (ii) insufficient number of trained case-manager nurses, (iii) unawareness of risk factors or unable to change behavior of people, (iv) no early CKD detection measures and (v) inadequate supports from society, community and policy makers.
The Northeast Thailand covers 20 provinces in the area of about 168,000 km
2 with cities, smaller towns and rural settings, and has a population of about 22 million. Agriculture is the largest sector of economy and the majority of the population relay on government health services as such all districts have a hospital and all sub-districts have clinics providing primary health care. Comprehending the CKD burden, socio-economic factors and health facilities in the region, a quality improvement project, “Chronic Kidney Disease Prevention in the Northeast Thailand” (CKDNET), has been established for activities such as screening, surveillance, diagnosis, treatment, awareness and management of kidney diseases. The main objectives of the CKDNET include i) revealing CKD burden, associated risk factors and prevention; ii) developing CKD registry system; iii) providing comprehensive care; and iv) developing a cost-effective model care. These goals of the CKDNET will be achieved through various sub-projects as listed in Table
1. In other words, the CKDNET is a quality improvement project by holistic approach to promote best practice and outcomes.
Table 1
List of the sub-projects under the CKDNET
1 | Prevention and reduction of chronic kidney disease in urban areas |
2 | Kidney disease prevention and reduction program in rural communities |
3 | Development and maintenance of information technology systems for CKD |
4 | Development of the comprehensive care in CKD |
5 | Cost-effectiveness analysis of viewing programs in patients with CKD |
6 | Innovative engineering projects in kidney disease |
7 | Impact of climate change and global warming in chronic non-communicable diseases |
This article outlines strategies and activities of the CKDNET including the preliminary findings from CKD screening program in general population, surveillance of CKD patients among hospitals in the Northeast Thailand and provide the results of cost effectiveness analysis of our comprehensive care model in comparison to the conventional care. We believe that our findings will provide a direction for further improvement including research, knowledge, funding distribution and capacity in the care of CKD patients.
Discussion
The CKDNET is the first project of this kind in the Northeast Thailand. During a short period of 3 years since its establishment, the project has already reached a milestone in terms of CKD surveillance, while other activities are in progress. Our general rural population screening program revealed that one in four people in the region has CKD, which is a pathetic situation compared to 11–13% prevalence worldwide [
2]. Although diabetes and hypertension were found to be the major CKD-associated risk factors in our study, CKD of unknown causes is also disturbing the local nephrologists by contributing nearly one third of the observed total CKD burden. Researches to elucidate the pathogenesis of unknown CKD are crucial and under investigation by our researchers. CKD screening activities promote public awareness and education, and serve as medical outreach to underserve populations [
21,
22].
Moreover, the CKDNET hospital-based surveillance system provides a well-designed data for monitoring of population at risk of developing CKD, in particular, those who had diabetes and/or hypertension and once they developed CKD. This surveillance system hopes to facilitate research, professional development, and most importantly, health care/service improvement in Thailand. For instance, the number of patients at various stages of CKD and their status during the course of time can be tracked as well as survival estimates can be performed with ease. Therefore, we conduct annual training to physicians, nurses, and IT officers from all the public health sectors in the registry system. Through screening and surveillance, the CKDNET targets to screen at least 0.1 million population every year. One of such registry systems in Australia, CKD: QLD has brought about notable success to address the CKD problem [
23].
Use of the pamphlets, posters and brochures for the awareness and prevention activities is an old but still successful methods. We used verities of contents including CKD, causes, risk groups, risk factors, salt content in common foods/drinks, diet and much more. We were aware that limited health literacy in rural areas may bound the usefulness of such written pamphlets. Nonetheless, our awareness materials are in use for the counselling of CKD patients in hospitals throughout the region. YouTube, Facebook, website, digital kiosk and mobile applications were also approached as modern methods and found resourceful for awareness and self-monitoring. We feel strongly motivated from the finding that mobile application assisted self-checking of CKD has satisfactory outcome in developing countries [
24]. Our salt reduction campaign was effective to reduce the salt content in 8.7% of food menu prepared in the university canteens. Although the data are from small scale studies, still it gives a positive remark. It is well known that high salt intake is associated with hypertension and control of hypertension can reduce the risk of developing CKD [
25].
Modification of the standard CKD treatment guidelines was one of our important strategy. Such modification is inevitable for comprehensive care because implementation of established guidelines for CKD in practice is challenging [
26]. For example, in Thailand, nephrologist-to-patient ratio is extremely low. Our guideline instructed the treatment of stage 1 to 3 CKD patients at primary and secondary health care units by general physicians and nurses, while stage 4 to 5 CKD patients to be treated by the nephrologist at tertiary care units. It can thus reduce the constraint on nephrologist and co-ordinate the care.
Trained case-manager nurses for the self-management support is an effective method for the care and management of CKD patients. Our randomized cohort study at primary hospitals revealed that case managers can slower the CKD progression [
20,
27]. However, we found it difficult at the beginning because of the shortage of the number of case-manager nurses. The situation is being dealt with the development and training of new case managers annually.
Next, an important part of our project was the cost effectiveness analysis of CKDNET care model compared to conventional CKD care in Thailand. The results show that our program is a best buy intervention because it not only increases QALYs but also slow down the progression of CKD to ESRD in about 25% of patients, hence avoids the need for dialysis or transplant. Furthermore, the ICER would touch the cost-effectiveness threshold if the annual cost of the CKDNET activities increased to 15,000 Baht per patient. We used Markov models for cost effective analysis as these are a type of decision-analysis model used to analyze uncertain processes, such as chronic kidney disease in which costs and outcomes occur over a long period of time [
28].
The CKDNET project has wide-range of tasks to accomplish, among which, expansion of the project to entire nation is of prime importance. Moreover, the focus is in the CKDNET care model which is under several aspects of implementation throughout Don Chang Sub-district. Nutritional factors including environmental (water, air and soil) contaminants are on a list to be investigated for risk factors especially associated with CKDu. Discovery of biomarkers and sensors must be accelerated. Expansion and development of existing biobank is another central priority. In longer timespan, the CKDNET is collaborating with important stakeholders at national and international levels.
There are some limitations in our findings and strategies. Firstly, our CKD prevalence represents the status of Khon Kaen Province, and it is higher than the previously reported national data by Thai SEEK study. Therefore, the current incidence rate may not represent the true figure of all Thailand. Secondly, CKDNET registry is based on the hospital data so that the information from community level is missing. Thirdly, although we have trained nurse to work as a case manager, they were assigned with many other routine duties. Accordingly, we plan to provide training to CKD patients to empower other patients.
Acknowledgements
The authors would like to thank Professor Yukifumi Nawa for editing the manuscript via Publication Clinic KKU, Thailand. CKDNET group would like to acknowledge all the faculty members involved in sub-projects, provincial governor, provincial health officers, health personnel’s and participants for their active participation in the project.
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