Integrated primary and secondary care optimizes the management of people with CKD-the LUCID project

Rupert W Major^{1

2}, Niraj Lakhani³, Yaseen Ahmed^{2

4}, Jade Atkin⁵, Richard Baines², Rose Balment⁴, Chee Kay Cheung^{2

6}, Matthew P Graham-Brown^{2

6

7}, Claire Ellwood⁵, Laura Harding⁴, Osasuyi Iyasere^{2

6}, Tracy Jesa⁵, Jorge Jesus-Silva², Yusuf Jinadu², Arshad Khalid⁸, Jibran Khatri², Yahya Makkeyah², Maria Martinez², Helen Mather⁵, James F Medcalf^{2

6}, Kirk Moore⁴, James Ogle⁹, Eleanor Oseya¹⁰, Dipesh Patel², Reena Patel¹¹, Tracy Pollard¹⁰, William Priestman⁹, Amit Rastogi¹⁰, Nil Sanganee⁵, Mark Shaffu¹², Michael Steiner^{2

5

13}, Tun Than¹⁴, Gang Xu², Fahad Rizvi^{3

5}, James O Burton^{2

6

7}

Affiliations

¹ Department of Population Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK.
² University of Hospitals of Leicester NHS Trust, Leicester, UK.
³ Willows Health Primary Care Network, Leicester, UK.
⁴ North West Leicestershire Primary Care Network, Leicestershire, UK.
⁵ Leicester, Leicestershire and Rutland Integrated Care Board, Leicester, UK.
⁶ Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK.
⁷ NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK.
⁸ Fosseway Primary Care Network, Leicestershire, UK.
⁹ Bosworth Primary Care Network, Leicestershire, UK.
¹⁰ Leicester City South Primary Care Network, Leicester, UK.
¹¹ Belgrave and Spinney Hill Primary Care Network, Leicester, UK.
¹² Oadby and Wigston Primary Care Network, Leicester, UK.
¹³ Department of Respiratory Sciences, College of Life Sciences, University of Leicester, Leicester, UK.
¹⁴ Salutem Primary Care Network, Leicester, UK.

PMID: 40207101
PMCID: PMC11980979
DOI: 10.1093/ckj/sfaf049

Integrated primary and secondary care optimizes the management of people with CKD-the LUCID project

Rupert W Major et al. Clin Kidney J. 2025.

. 2025 Feb 12;18(4):sfaf049.

doi: 10.1093/ckj/sfaf049. eCollection 2025 Apr.

Authors

Affiliations

¹ Department of Population Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK.
² University of Hospitals of Leicester NHS Trust, Leicester, UK.
³ Willows Health Primary Care Network, Leicester, UK.
⁴ North West Leicestershire Primary Care Network, Leicestershire, UK.
⁵ Leicester, Leicestershire and Rutland Integrated Care Board, Leicester, UK.
⁶ Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK.
⁷ NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK.
⁸ Fosseway Primary Care Network, Leicestershire, UK.
⁹ Bosworth Primary Care Network, Leicestershire, UK.
¹⁰ Leicester City South Primary Care Network, Leicester, UK.
¹¹ Belgrave and Spinney Hill Primary Care Network, Leicester, UK.
¹² Oadby and Wigston Primary Care Network, Leicester, UK.
¹³ Department of Respiratory Sciences, College of Life Sciences, University of Leicester, Leicester, UK.
¹⁴ Salutem Primary Care Network, Leicester, UK.

PMID: 40207101
PMCID: PMC11980979
DOI: 10.1093/ckj/sfaf049

Abstract

Background: Early diagnosis, risk stratification and medication optimization are essential to improve the management of chronic kidney disease (CKD) and other long-term conditions. The introduction of Integrated Care Systems (ICS) in England provides the opportunity to revolutionize the management of these conditions. Annual National Health Service kidney disease costs are ∼£6.4 billion.

Methods: We designed, piloted and implemented at scale an ICS-level virtual care programme for CKD, the 'Leicester, Leicestershire, and Rutland Chronic Kidney Disease Integrated Care Delivery Project' (LUCID), based on the principles of patient and professional education, early disease identification, medicines optimization and disease surveillance.

Results: In April 2022, virtual multidisciplinary team (MDT) meetings were piloted in Leicester, Leicestershire and Rutland, UK. Since April 2023 virtual MDT meetings have been available to all general practices in Leicester, Leicestershire and Rutland, representing a population of approximately 1.2 million people. As of 31 March 2024, general practices representing an estimated population of 700 000 (58.3%) were participating in the LUCID programme. Some 1085 consultations took place for 821 patients, 590 (54.4%) of which were medicines optimization consultations.

Conclusions: LUCID may represent an efficient and cost-effective model to deliver patient and professional education, medicine optimization and risk stratification for people living with CKD at an ICS-wide population level. This model may be adaptable for other long-term physical and mental health conditions.

Keywords: CKD; CVD; KFRE; integrated care; medicine optimisation.

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Conflict of interest statement

From April 2023 to November 2024 LUCID was part funded as part of a Joint Working Initiative with AstraZeneca UK. Major, Lakhani, Baines, Graham-Brown, Burton declare speaker honorarium from AstraZeneca. Jinadu and Steiner declare support from AstraZeneca for travelling to meetings. Major, Lakhani, Graham-Brown and Burton declare speaker honoraria from Boehringer Ingelheim and Bayer. Baines declares fees from George Clinical. Lakhani also declares speaker honoraria from Amarin, Eli Lilly, Novartis, Novo Nordisk, Daiichi-Sankyo and Viatris.

Figures

**Figure 1:**
Flowchart demonstrating change to clinical processes related to LUCID. Blue, existing and ongoing process; purple, new processes related to LUCID.

**Figure 2:**
Cumulative outcomes for the LUCID project. Vertical black dotted line represents the beginning of the full programme. A&G, Advice and guidance.

See this image and copyright information in PMC

References

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1. Major RW, Shepherd D, Medcalf JF et al. The kidney failure risk equation for prediction of end stage renal disease in UK primary care: an external validation and clinical impact projection cohort study. PLoS Med 2019;16:e1002955. 10.1371/journal.pmed.1002955 - DOI - PMC - PubMed
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Integrated primary and secondary care optimizes the management of people with CKD-the LUCID project

Affiliations

Integrated primary and secondary care optimizes the management of people with CKD-the LUCID project

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

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