During 2018/19 the national GP super-partnership Modality Partnership collaborated with healthcare startup companies Healthy.io and inhealthcare to introduce a new and innovative home-based albumin screening service in primary care.
People with diabetes that are at risk of Chronic Kidney Disease (CKD) would get annual screening using a smartphone urinalysis test kit and app. The service was piloted in 12 GP practices across Hull and Yorkshire. Diabetic patients with no previous albumin-to-creatinine ratio (ACR) measurement were offered a home albumin test kit, allowing them to conveniently self-test at home for early signs of CKD. Test results were sent through inhealthcare to the clinical system and reviewed by a clinician. 72% of patients who received a kit completed the test.
This resulted in 11% newly found patient cases of elevated protein- indicating previously unknown CKD. There was no patient followup if results were normal, saving time for clinicians and patients. However, as part of the evaluation, the project support contacted patients with normal results to obtain feedback on their experience.
Chronic Kidney Disease (CKD) affects 1 in 10 adults across the UK, costing the NHS £1.5bn each year. Early detection of albumin in urine helps avoid complications and reduce the burden of CKD. Therefore, NICE guidelines recommend that every person with diabetes or hypertension receives annual urine testing. Despite its importance in the prevention of kidney disease, urine albumin testing is the worst performing of the diabetes care processes, making increasing compliance to testing a critical area for improvement.
The vision was to use Healthy.io’s home albumin testing innovation as an alternative to current care approaches, which requires patients to bring a urine sample to the surgery for testing. Only 66% of people with diabetes have a recorded albumin test with the standard of care. With home albumin testing, patients are posted a kit to their home whereby they self-test for albumin and share results with their clinician for follow-up via their smartphone device.
The solution was piloted from September 2018 until January 2019 in 12 Modality GP practices. York Health Economics Consortium (YHEC) led the cost-effectiveness evaluation. Healthy.io’s smartphone urinalysis is CE marked. Efficacy was measured by the number of albumin results reported, new cases of CKD diagnosed and patient/clinician feedback.
A total of 2,196 patients with diabetes and no albumin measurement recorded were offered the service and 695 (32%) consented to receiving a test kit. 499 (72%) of the patients who received a kit completed the test resulting in 11% newly found cases of abnormal albumin- indicating previously unknown CKD.
96% of the patients were able to complete the test successfully, 92% said the test was easy or very easy and 96% said they prefer testing at home rather than in the surgery. The YHEC evaluation found that home albumin testing can yield cost savings of £14 per patient over 1 year and £472 over 5 years. Nurse Rachel Barnes, Research and Clinical Development Lead at Modality Hull, says that “patients soon began to comment about the speed and convenience of the service, with benefits including reduced appointments, travel and reduced anxiety about supplying samples.
There were diabetic patients in our pilot cohort that we knew had never been seen in the surgery whose results came back as normal. Interventions like this can reduce costs and free up valuable clinical time to spend with patients, it is a win-win for everyone.”
Learnings from this innovative pilot project have been shared with across Modality Partnership, and with CCGs to encourage spread and adoption. The YHEC evaluation concluded that the use of home albumin screening is a cost-effective solution that improves compliance with routine testing. As a result, there has been an increase in the number of CKD diagnoses, allowing more people to benefit from treatment, reduce progression to end-stage renal disease (ESRD), and reduce the incidence of cardiovascular events.
If this project was scaled to the entire population of England, home albumin testing could result in 3,463 cases of ESRD, and 523 deaths prevented over 5 years due to an additional 22,946 cases of CKD being diagnosed, yielding savings of £214.7m.
There is great potential for expanding our project across the NHS, as well as extending its technology to a range of different pathways. The technology can measure several parameters, indicating a range of infections as well as chronic illnesses and pregnancy-related complications.
The innovation is integrated to the GP practice clinical system: SystmOne using inhealthcare, enabling patients to test at home and share results with a clinician for follow-up. This improved patient experience in terms of speed and convenience of the service, with benefits including fewer appointments, less travel, and reduced anxiety about supplying samples. In the service survey, 96% of patients that attempted the test succeeded, 96% stated they prefer home-testing over testing at the clinic and 92% said the test was easy to use.
The staff identified the potential for time and money savings. As the testing process is done by the patient via their smartphone, you are not using a clinician’s time to take the sample off the patient, label it and send it off to the lab, which also has a cost-benefit. Interventions like this can reduce costs and release valuable clinical time to spend with patients, making it a win-win for everyone.
The innovation identified 11% new cases of abnormal albumin- indicating previously unknown CKD. This allowed identified patients to benefit from treatment, reduce progression to ESRD, and reduce the incidence of cardiovascular events. There was no follow-up if results were normal, saving time for clinicians and patients.
This pilot project was jointly led by Modality Partnership and Healthy.io working closely with inhealthcare and a team of clinical leads, GP, and nurses to deliver the innovation. The value of the innovation was very clear, making it easy for team members and stakeholder to positively adapt and endorse it.
The service flow was adjusted as the project developed in response to patient behavior and feedback. For example, the phone system was changed to make call extensions come from an undisclosed number after realizing it was harder to reach patients when calling from different area codes. Similarly, ‘hard to reach patients’ who did not answer any phone calls where sent a text message- 17% of these patients replied with a consent.
The teams involved worked together to provide joint project management collaboration and on the ground coordination to ensure a successful rollout and delivery of results.