Regional solutions to the problem

The approach to resolve these problems has been the adoption of a public health model to CKD (Fig. 2) and the development of evidence-based clinical practice guidelines (CPG) to guide their management using algorithms. The need for guidelines stems from the current information overload, increased number of new and effective treatments and diagnostic tools, and a growing body of outcomes research. This makes it difficult for the busy practitioner desiring to practice evidence-based medicine to keep abreast of the exponential increase of a rather disparate body of information. CPGs draw on systematic reviews of the literature and make specific recommendations to assist practitioners and patients in making decisions about appropriate healthcare in specific conditions. Rigorously developed evidence-based CPGs, when implemented, can reduce variability of care, improve patient outcomes, and ameliorate the efficiency of healthcare (29).

The practical specificity of guideline statements facilitates their translation into clinical practice and differentiates them from other evidence-based approaches such as meta-analyses and systematic reviews, which distill and analyze the evidence but usually do not make

Fig. 2. Stages in progression of chronic kidney disease (CKD) and therapeutic strategies. GFR, glomerular filtration rate.

practical recommendations, and leave it to chance for the practitioner to integrate them into clinical practice. In fact, the very process of developing the evidence base of CPGs depends on meta-analysis and systematic reviews (30). Essentially, it is the actionable recommendations of CPGs that make them now one of the best tools available to practice using evidence-based medicine and hence the statement that, "the implementation of rigorously developed practice guidelines can lead to even greater improvements in patient care than the introduction of new technologies" (29).

Another value of guidelines is that by establishing targets of therapy and providing actionable items, they allow for the cooperative care of patients with CKD by specialists and primary care providers (Fig. 3). The care of patients with CKD by nephrologists only will overwhelm the manpower resources of any country. The algorithms provided in guidelines allow the cooperative utilization of the entire manpower of healthcare providers (specialists, primary care physicians, dietitians, nurse clinicians, social workers, and physician assistants) as well as those of informed patients in providing appropriate care, without burdening any one segment of the system.

Fig. 3. The use of guideline recommendations and targets for the co-management of chronic kidney disease patients at its various stages by primary care providers (P.C.P.) and kidney doctors.

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