0 hours
These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
0.5 hours
These are activities that require reflection on feedback about your work.
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These are activities that use your work data to ensure quality results.
These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
Kidney Health Australia’s ambition to End Dialysis by 2050 is bold, but it is achievable with the practical, everyday work of general practice: identifying people at risk, completing Kidney Health Checks, coding CKD accurately, and acting early.
Chronic kidney disease (CKD) is common, harmful and too often missed. A significant proportion of an active adult general practice population will have at least one risk factor for CKD, including diabetes, hypertension, cardiovascular disease, older age, obesity, smoking or vaping, previous acute kidney injury, family history of kidney failure or First Nations origin.
Yet many people with CKD are unaware they have it. This matters because CKD can progress silently, increase cardiovascular risk, and lead to kidney failure— but it is also increasingly treatable when detected and managed early.
A Kidney Health Check is simple and can be integrated into routine primary care. It includes a blood pressure check, a blood test for creatinine and estimated glomerular filtration rate (eGFR), and a urine test for albumin creatinine ratio (uACR).
CKD needs to be diagnosed, coded in the practice software, and visible to the whole team. If people are not coded, they are harder to find, recall, review and support. Practice extraction tools such as PENCAT, POLAR or Primary Sense can help identify patients who may be at risk, overdue for testing, or likely to benefit from review. Turning this data into action is where general practice teams can make a real difference.
One practical approach is to build Kidney Health Checks into chronic condition care planning (MBS item 965) and regular reviews, (MBS item 967). A proactive checklist for patients can help everyone involved in the patient’s care know when the last Kidney Health Check was completed and when the next one is due. This reduces reliance on memory or individual clinicians and supports more consistent, team-based care.
CKD also lends itself well to quality improvement. Practices could set a clear SMART goal, such as increasing the proportion of active adults with a coded diagnosis of CKD. The team at Bollen Health suggest making CKD a QI activity. Focus on a QI SMART goal such as:
Converting percentages into patient numbers can make the goal more tangible and help teams decide how many people need to be reviewed each week or month.
Better kidney outcomes depend on better systems and supported teams. Responsibility for proactive care cannot rest solely with the GP, particularly in busy practices with part-time clinicians, seven-day rosters and patients seeing different providers. Nurses, practice managers, reception teams and data leads all have a role in identifying care gaps, supporting recall and reminders, and embedding kidney health into routine workflows.
As Atul Gawande highlights in The Checklist Manifesto, simple checklists can help reduce variation and prevent important steps being missed in complex systems. In primary care, a Kidney Health Checklist can be a practical tool for early detection, safer prescribing, timely management and appropriate referral. Primary care is where prevention, early diagnosis and long-term management come together.
By making Kidney Health Checks routine, coding CKD consistently, using practice data well and involving the whole team, general practice can help prevent progression, improve lives and contribute to a future where fewer Australians need dialysis.
This article was first published on Kidney Health Australia’s website. Read the original article here.
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