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The Triple A Kidney Project
Mark S. MacGregor1, David E. Boag2, Malcolm McClelland2, Andrew Hardy3, Andrew Innes1
1. The John Stevenson Lynch Renal Unit. 2. Department of Biochemistry.
3. Department of Knowledge Management.
Introduction Phase 2 Results
Phase 3
•The introduction of eGFR reporting will lead In phase 2, we are creating a system of links Once phase 2 is operational we plan a cluster
to dramatic increase in the identification of between existing computer systems. randomised trial of three models of care.
chronic kidney disease.
Key Components Initially the three arms were to be:
•The most challenging group to manage will Laboratory systems.
be stage 3 CKD, as they represent 4-5% of In Scotland, every NHS Board has a central A. Standard care (i.e. serum creatinines with
patients, and have significant disease computerised repository of patient data no eGFR)
requiring interventions. (mainly biochemistry and haematology
results at the moment, but eventually all B. eGFR reporting plus an annual one page
•NHS Ayrshire & Arran has a population of lab reports and clinical letters), called SCI- guideline reminder
367,590, and is served by 2 wte nephrologists. Store. However, individual clinical
chemistry systems could be substituted for C. eGFR reporting plus IT decision support
•An estimated 4.3% of the population with this part. plus 3 specialist nurses (education, clinics,
CKD 3 equates to 18,380. referral to nephrologists)
CKD Registry.
•If these patients are seen for just 15 minutes, We are initially constructing our system using Arm A is no longer possible because of the
twice a year, an additional 7.3 wte CCL Proton, the Renal Unit’s electronic GMS QOF changes, so arm C will be divided in
nephrologists would be required! patient record. However, a dedicated new two, with or without the specialist nurses.
SCI system, or adaptation of existing
•As CKD 3 will need to be managed in primary systems such as SCI-DC, the diabetic Estimated population 18,000
care, we wanted to develop systems to aid registry, could also be used. 6,000 per arm
primary care in the monitoring and Expected mortality 24.3% over 5 years
management of CKD 3. Primary care systems. Powered to detect a 9% improvement in
We plan to use the SCI-ECS system to mortality (a 0.05, b 0.8) or a 12% improvement
The Triple A Kidney Project integrate GP data. This database (a 0.01, b 0.9)
downloads records of patients’ drugs to a
•The entire population of NHS Ayrshire & central repository from almost all GP Challenges
Arran is served by a single biochemistry practices in Ayrshire (which use GPASS),
laboratory, and by a single renal unit, with and is currently used as a tool to assist Funding!
minimal cross-boundary leakage. casualty doctors out of hours (ECS: Phase 1 is underway and requires no funding.
emergency care summary). This system We are currently seeking funding for phase 2
•NHS Ayrshire & Arran is a microcosm of can be developed to download virtually any from the Centre for Change & Innovation (an
Scotland, with a similar age distribution, a data on the GP systems e.g. Read coded NHS Scotland organisation that supports
relatively poor industrial town, a more wealthy diagnoses, blood pressures and innovation in healthcare). We will seek
market town, mining and rural communities urinalyses. funding for phase 3 from charity and industry,
and an island population. once phase 2 is nearing completion.
When a sample has an eGFR of <60
Phase 1 ml/min/1.73m2, this patient’s data will be Data protection issues.
uploaded to the local CKD Registry from Our proposed IT system involves
SCI-store, and a flag will be set ensuring automatically extracting patient-identifiable
•We are currently auditing all serum that a specified dataset will continue to be data from several sources and linking the
creatinines measured in NHS Ayrshire & uploaded regardless of the patient’s records in a central database, which is
Arran in 2004, to provide baseline data. subsequent eGFR. essentially a registry. Seeking consent from
Additional patient data will be extracted by the every patient is clearly impractical. However,
•347,635 samples were measured in 105,363 Registry from the Patient Administration we believe our system can be construed as an
patients (3.3 samples per patient) in 2004. Systems and from SCI-ECS. “added value” laboratory reporting system.
Furthermore, as primary and secondary care
•In 2004 serum creatinine was checked in: Initially, the CKD registry will simply prompt are a single organisation in Scotland, there is
•28.7% of the total population the GP practices at the appropriate time to no sharing of data outwith the organisation.
•35.4% of the adult population check blood and urine tests (e.g. annual We are in discussion with our Caldicott
•65.7% of the population over 65 PTH). As the system develops, it might also Guardian about these issues.
prompt action on blood pressure
•We are currently examining the prevalence according to pre-defined thresholds, and Engaging primary care.
of stage 3-5 CKD and whether those patients eventually advise on specific drugs such Until recently we have found it difficult to
attend renal services. as ACE-I, aspirin or statins. engender interest in primary care. The QOF
seems to have changed that!
•We will go on to establish whether or not It is possible for the blood forms to be
patients renal function and other parameters automatically generated in GP practices.
are being examined at an appropriate interval.
30000 100
3. Maintain
Serum Creatinine Not Checked
Serum Creatinine Checked accurate patient data
% With Serum Creatinine Checked
24000 80 CKD 3 Register
1. Initial eGFR <60 (CCL Proton?)
18000 60
Triggers upload (SCI-DC?)
N % to Register PAS
12000 40
2. Register flags patients
6000 20
for indefinite
upload of dataset 5. Prompt GP’s to
0 0
check bloods,
0-4
5-9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80 - 84
85 - 89
90 & over
advise on BP targets
Age (years)
and meds
Percentage of Population with Creatinine Assay NHS A&A 2004 Laboratory Results 4. Extract data on
100
Computer drugs, diagnoses, (BP,
90
Male (SCI-Store) UA)
Female
80
70
60
%
50
40
30
20
10
Emergency Care
0
Summary
0-4 5-9 10 -
14
15 -
19
20 -
24
25 -
29
30 -
34
35 -
39
40 -
44
45 -
49
50 -
54
55 -
59
60 -
64
65 -
69
70 -
74
75 -
79
80 -
84
85 -
89
90 &
over (SCI-ECS)
Age (years)
GPASS
Contact: Mark MacGregor, John Stevenson Lynch Renal Unit, Crosshouse Hospital, Kilmarnock, KA2 0BE
