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Early Detection of Chronic Kidney Disease in Aboriginal People

Northern NSW Local Health District
Project Added:
18 January 2016
Last updated:
8 April 2016

Early Detection of Chronic Kidney Disease in Aboriginal People


Northern NSW Local Health District (NNSWLHD) developed an algorithm that was applied to the electronic medical records (eMR) of patients at Bugalwena General Practice, to identify whether they had early-stage chronic kidney disease (CKD). 

This project was the recipient of the Integrated Healthcare Category in the 2015 NSW Health Awards. Watch a video on this project (opens in a new window).


To improve the early identification and management of CKD in Aboriginal and Torres Strait Islander people.


  • Allows general practitioners (GPs) to rapidly identify patients with early indicators of CKD, to delay or halt the progression of the disease.
  • Upskills community services in the identification, management and referral of early-stage CKD.
  • Empowers patients to take control of their health and provide them with support in managing their chronic illness.
  • Reduces preventable hospitalisations for Aboriginal and Torres Strait Islander people and provides services in a culturally-safe environment.
  • Provides patient-centred care for people living with chronic illness.
  • Streamlines patient records and avoids duplication of clinical testing.
  • Delays or avoids the need for dialysis, reducing the huge burden that dialysis services place on the healthcare system.
  • Provides integrated care to the right patients, in the right setting, at the right time.
  • Shares knowledge and resources across organisational boundaries in an open and respectful manner.


Chronic kidney disease is a silent disease that often produces no symptoms in its early stages, but requires early intervention to prevent deterioration and achieve optimal patient outcomes.  If it’s detected early and managed appropriately, the deterioration of kidney function can be reduced by as much as 50% and may even be reversible.

Diseases of the kidney and urinary tract ate the ninth leading cause of death in Australia. Dialysis patients are the most frequently admitted patients to hospital each year, so if CKD is detected early, the need for dialysis can often be delayed or avoided. For the 18% of adult Aboriginal people who have indicators for CKD, early identification of the disease also means that treatment can be provided in a culturally-safe environment within their local community, rather than the foreign environment of a large hospital.

Research suggests that CKD is significantly under-recognised and under-treated in the primary care setting. As 85% of Australians visit a GP each year, it is a logical setting for the early detection of CKD.


  • In collaboration with North Coast Primary Health Network, NNSWLHD designed an algorithm which was applied to the eMRs of patients at Bugalwena General Practice, an Aboriginal Health Service located in Tweed Heads. This provided an effective means of identifying CKD patients for early management and referral.
  • Following the identification of patients with CKD, a nurse practitioner delivered a one-day education program for Bugalwena General Practice staff. This improved their knowledge of CKD management and referral, with real patients used as examples to increase engagement and facilitate the development of specific management plans.
  • The one-day training session was designed so it could be delivered to other Aboriginal Health services and GP clinics in rural and remote areas.
  • Bugalwena General Practice embedded a number of other clinical practice changes as part of the project, including following up patients that required further testing and incorporating urine albumin creatinine ratio testing into all Aboriginal health checks.

Project status

  • Sustained - the initiative has been implemented and is sustained in standard business. 

Key dates 

  • Start date: May 2014
  • Finish date: November 2014 

Implementation sites

  • Bugalwena General Practice


  • North Coast Primary Health Network
  • Bugalwena General Practice


  • Prior to the project, 2% of Bugalwena General Practice adult patients were identified as having CKD, a total of 17 clients. This increased to 10.7% or 77 people following implementation of the project. These patients received management plans which were developed in consultation with their GP, while those requiring specialist review were referred to nephrologists.
  • Appropriate patients were triaged and referred to specialist nephrologists and/or chronic kidney disease nurse practitioner clinics held in the community health setting.
  • In the 12 months following implementation, the project has been rolled out to three Aboriginal Health Services and six mainstream GP clinics in NNSWLHD. The application of the project was tailored to each practice and patient group.
  • Bugalwena General Practice is now in discussion with NNSWLHD about providing co-located clinics, so the CKD nursing practitioner can see patients in the Bugalwena General Practice facility.
  • A remote database audit, presentation of the program via telehealth technology and search algorithms for identification of other chronic diseases are possible areas for future development.


  • 2015 NSW Health Awards – Integrated Healthcare Recipient
  • 2015 NNSWLHD Quality Awards – Integrated Healthcare Winner

Lessons Learnt

  • The project is transferable to other Aboriginal Health Services and mainstream GP clinics. As 90% of GPs in Australia use eMR, the program could be used to identify and manage CKD in the majority of the adult Australian population.
  • GPs deal with patients with a wide variety of health problems and the patients focus is primarily on acute health issues.
  • Patient engagement regarding chronic disease is challenging in primary healthcare and is a barrier to CKD identification by GPs
  • Electronic medical record audit tools are already available to most GPs. Developing searches within this software to use existing records to identify patients with indicators for CKD allows GPs to focus efforts to identify CKD in appropriate patients.
  • Using GP's own patients in a case study increased GP engagement in education and CKD management of their patients.

Further reading

  • Razavian, M., Heeley E.L., Perkovic, V. et al. Cardiovascular risk management in chronic kidney disease in general practice (the AusHEART study) Nephrol Dial Transplant 2011;18(10):2766-72
  • Australian Bureau of Statistics.  Australian Aboriginal and Torres Strait Islander Health Survey: Biomedical Results, 2012-13. 2014 Report No.:4727.0.55.003, Canberra
  • Australian Bureau of Statistics, Causes of Death 2012. 2014
  • Johnson D.W. Evidence-based guide to slowing progression of early renal insufficiency. Intern Med J 2004 January;34(1-2):50-7
  • NSW Government, NSW Dialysis Costing Study 2008: Volume 1: Main Report New South Wales Department of Health: Sydney 2009
  • McInnes, D.K., Saltman, D.C., Kidd, M.R. General practitioners’ use of computers for prescribing and electronic health records: results from a national survey. Medical Journal of Australia 2006; 185: 88-91
  • Improving CKD in Aboriginal Patients. Health Speak, Issue 10, Summer 2015 (opens in a new window). p12.  North Coast Medicare Local.


Graeme Turner
Nurse Practitioner (Chronic Kidney Disease)
Northern NSW Local Health District
Phone: 02 66202609

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