CKD Transformation – Dr Pam Brown’s Insights

Dr. Pam Brown, a dedicated healthcare professional, shares her valuable perspective in an interview with Professor Ahmet (Medical Director at Oberoi Consulting) on the impact of the Oberoi Disease Management Digital Audit Platform for Chronic Kidney Disease (CKD) in her practice
Discover how this innovative platform has transformed the way they prioritise and allocate resources, ultimately ensuring that high-risk patients receive the focused care they need.
Dr. Brown’s insights shed light on the platform’s pivotal role in optimising patient care.
Professor Ahmet Fuat: Can you share your career journey in becoming a general practitioner, including your years of experience, and describe your current role and responsibilities?

Dr Pam Brown: “I commenced my GP career in Swansea, South Wales in 1983, marking 40 years in the field this summer. My professional focus has consistently revolved around lifestyle, preventive medicine, and diabetes, initially sparked during my student Elective in Newfoundland and Labrador. This elective exposed me to the profound impact of Western lifestyles on the indigenous Inuit and American Indian populations we were dedicated to serving.”
Professor Ahmet Fuat: How would you describe your specific areas of specialisation or particular professional interests within your field?

Dr Pam Brown: “At present, I have the privilege of overseeing complex diabetes care clinics in a long-term locum capacity. Additionally, I play an integral role in managing a Tier 2 weight management programme and participate in tribunal panels focused on benefit appeals in Swansea and West Wales. Moreover, I serve as a tutor for the Warwick University/iHeed MSc in Diabetes and hold the position of Editor-in-Chief for Diabetes Distilled. In this role, I curate and provide fortnightly summaries of clinical papers, specifically tailored for primary care teams involved in diabetes and related chronic disease management.”
Professor Ahmet Fuat: How has leveraging the Oberoi Disease Management Digital Audit Platform for CKD in your practice helped in patient stratification and prioritisation?

Dr Pam Brown: “Given the demanding time constraints in primary care, the Oberoi Disease Management Digital Audit Platform’s use of the KIDIGO risk scoring system, which stratified patients from high to low-risk categories, greatly assisted me in focusing my attention where it mattered most. This approach allowed me to allocate my resources more effectively, ensuring that patients received the appropriate level of care based on their risk profile. Without this risk-based stratification, managing the sheer volume of patients with CKD could have been considerably more overwhelming.”
Professor Ahmet Fuat: Could you provide any specific examples where on f how the use of the Oberoi Disease Management Digital Audit Platform for CKD led to some key clinical practice changes?

Dr Pam Brown: “Our observed prevalence of CKD was lower than anticipated. Further investigation revealed inaccuracies in coding, particularly historical usage of terms such as ‘chronic renal failure.’ Despite our diligence in coding and monitoring individuals with both CKD and diabetes under our care, we discovered instances of young patients who had previously sought care at renal clinics for acute issues, were subsequently discharged back to our care, and required ongoing annual follow-up blood tests. These individuals have now been accurately coded and included in our recall system for annual reviews”
Professor Ahmet Fuat: In what ways has the Oberoi Disease Management Digital Audit Platform for CKD enhanced your capacity to optimise resource allocation, ensuring that the most high-risk patients receive the precise level of care they require?

Dr Pam Brown: “Currently, we do not have a dedicated doctor or nurse within our practice with a specialised focus on CKD. This is partially attributed to the elimination of specific CKD QIAF targets in Wales. As a result, I have taken the initiative to conduct reviews myself, striving to prioritise individuals at the highest risk with greater confidence. There is optimism that one of our registrars may choose to assist in expediting the audit process.” The platform is going to ensure whoever leads on reviews has a clear focus on which patients to review.”
Professor Ahmet Fuat: What key insights or significant learnings have you gained from this experience?

Dr Pam Brown: “We systematically code all results from secondary care diabetes and cardiovascular disease (CVD) clinic letters. However, this practice is not consistently applied to all renal clinic letters. Consequently, the coding for some individuals remained at the CKD stage when they were initially referred. This created an appearance in the audit that these individuals had not undergone blood and urine testing. Up was highlighted through the process we found that the results were indeed available on the hospital portal and in letters. Subsequently, I updated the electronic records accordingly. This adjustment is anticipated to reflect substantial improvement in our next quarterly report “
Professor Ahmet Fuat: Would you recommend the service to other practices and why?

Dr Pam Brown: “Indeed, I firmly believe that effective management of CKD is of paramount importance, given the potential for substantial morbidity and mortality if left unaddressed. The significance lies not only in managing the progression of CKD but also in mitigating the significantly heightened risks of cardiovascular disease and mortality. The availability of the Oberoi Disease Management Digital Audit Platform for CKD can positively influence these outcomes and underscores the essence of prevention at its pinnacle.”