Disease Management for Chronic Kidney Disease

Disease Management for Chronic Kidney Disease Dr Nick Richards Medical Director Optimal Renal Care UK Renal Association Clinical Services Meeting. Implementing eGFR Summary  Multidisciplinary DM project launched April 2005 in Lincolnshire  Based in Primary Care  Automated patient identification  Risk stratification of patients  Patient education  Medicines management  Algorithm based referral and management  Defined and audited clinical outcomes  Independent evaluation by ScHARR Renal Association Clinical Services Meeting. Implementing eGFR Why Disease Management for Chronic Kidney Disease in The UK? Renal Association Clinical Services Meeting. Implementing eGFR Prevalence of CKD in USA NHANES: 11.2% of the US population have chronic kidney disease: – Stage 1 – Stage 2 – Stage 3 – Stage 4 – Stage 5 (normal GFR) (GFR 60-90) (GFR 30-60) (GFR 15-30) (GFR 0-15) 3.3% 3.0% 4.3% 0.2% 0.2% Coresh J. AJKD (2003), 41: 1-12 Renal Association Clinical Services Meeting. Implementing eGFR Prevalence of CKD UK  East Kent: Clinical biochemistry lab survey – Prevalence of SCr (µmol/l) > 180 (m) or >135 (f) – 5554 per million of population • • • • Age related: 78.3 pmp <40y, 58913 pmp >80y Only 15.2% known to renal service Only 5.7% referred over the subsequent 12 months 1 year mortality 31.5% – Incidence of new CKD of this severity: – 2425 per million population John I. AJKD (2005) 43(5): 825-835. Renal Association Clinical Services Meeting. Implementing eGFR Prevalence of CKD in the UK  London life sciences prospective study  Population based investigation of CVD risk  1,000 pats. From 58 GP practices in west London Stage 2 (GFR 60-90) 57.9% Stage 3 (GFR 30-59) 4.0% Stage 4 (GFR 15-29) 0.25% Stage 5 (GFR < 15) 0.32%  DM, CVD or BP identifies 85% of CKD Renal Association Clinical Services Meeting. Implementing eGFR Consequences of Late Referral for Patients With Chronic Kidney Disease  Loss of chance for patients  30-50% of patients present < 3 months prior to dialysis  Mortality in late presenters in greatly increased  50% could have been referred earlier  Commonest late referrals are diabetics (13%) Roderick, P et al. QJM (2002) 95: 363 - 370 Renal Association Clinical Services Meeting. Implementing eGFR Consequences of Late Referral for Patients With Chronic Kidney Disease  Financial cost  1391 patients started renal replacement therapy 1989-2000  Late referral - less than 3 months in 30%  Preventable cause in 6.8% (= 95 patients)  Life time cost £14,250,000 Prof Paul Jungers, NDT (2002) 17: 371-375 Renal Association Clinical Services Meeting. Implementing eGFR Pre Dialysis  Pre dialysis care > 1 year is associated with – – – – – – – – Slower progression to dialysis Lower co morbidity at start of dialysis Lower hospitalisation rates Improved survival Improved rehabilitation Greater likelihood of maintaining employment Better response to vaccination Higher % with AVF Renal Association Clinical Services Meeting. Implementing eGFR Current Situation Current system is unable to cope with the problem Have to create a new way of managing these patients. Renal NSF & Joint Royal Colleges:  Automatic patient identification by eGFR from labs  Primary care based multidisciplinary management  Protocol/algorithm based management  Defined indications for referral to nephrologist  Audited outcome targets e.g. BP & cholesterol Renal Association Clinical Services Meeting. Implementing eGFR The Optimal Programme  Automatic patient identification  Algorithm based referral and management  Improve performance against defined clinical targets  Reduce comorbidity  Reduce resource utilisation  Reduce cost per patient  18 month initial period  Independent analysis by ScHARR Renal Association Clinical Services Meeting. Implementing eGFR West Lincolnshire Primary Care Trust Rural community Population about 218,000 750 square miles Low proportion of ethnic minority groups 40 GP practices 109 General Practitioners 2 Nephrologists Renal Association Clinical Services Meeting. Implementing eGFR Take on Rates for Renal Replacement Therapy in Lincolnshire 100 90 80 70 60 50 40 30 20 10 0 England West Lincolnshire East Lincolnshire Lincolnshire South West Renal Association Clinical Services Meeting. Implementing eGFR Patient Identification Calculated GFR by laboratory –MDRD equation (abbreviated 4 variable) 186 x (serum creatinine/88.5 (µmol/l) ) -1.154 x (age) -0.203 If a woman change 186 to 138 Primary care Secondary care Known CKD patients Renal Association Clinical Services Meeting. Implementing eGFR How It Works In Practice  Automatic patient identification from lab To GP and to Optimal For patients with CKD 4 and 5  GP contacted by Optimal care team  GP may contact Optimal care team directly  Patient contacted by care team  Patient enrolled in programme  Risk stratified  Treated as per algorithms Renal Association Clinical Services Meeting. Implementing eGFR Optimal Renal Care Application (ORCA - The IT Solution) Pathology data -New patients -Old patients Care team -Clinical data 1o Care - Clinical data - Activity data 2o Care - Clinical data - Activity data QOF data Disease registry Commissioning ORCA Alerts for action -Failure to meet targets -Perform test (eg HbA1c) Reports -Patient’s progress -Audit against targets -Intervention history Renal Association Clinical Services Meeting. Implementing eGFR GFR alerts -To care team -To 1o care -To 2o care Other systems e.g. National registry Targets Parameter Haemoglobin >11 g/dl Target >150µg/l 2.10 – 2.60 mmol/l 0.84 – 1.45 mmol/l < 4 x upper limit of range 22-26 mmol/l Ferritin (patients on EPO) Calcium Phosphate Parathyroid hormone Bicarbonate Potassium Referral to smoking cessation programme 3.5-6.0 mmol/l 100% of smokers Renal Association Clinical Services Meeting. Implementing eGFR Results to Date Renal Association Clinical Services Meeting. Implementing eGFR GFRs and New Patients Per Week 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 GFRs Patients Renal Association Clinical Services Meeting. Implementing eGFR GFR Requests From Primary Care 1400 1200 1000 800 600 400 200 0 1 3 5 7 9 11 13 15 17 19 21 Renal Association Clinical Services Meeting. Implementing eGFR New Patients Primary & Secondary Care 1400 1200 1000 800 600 400 200 0 1 3 5 7 9 11 13 15 17 19 21 Primary Secondary JL/GW Renal Association Clinical Services Meeting. Implementing eGFR Primary Care CKD 2 & 3 900 800 700 600 500 400 300 200 100 0 1 3 5 7 9 11 13 15 17 19 21 CKD 2 CKD 3 Renal Association Clinical Services Meeting. Implementing eGFR Primary Care CKD 4 & 5 30 25 20 15 10 5 0 1 3 5 7 9 11 13 15 17 19 21 CKD 4 CKD 5 Renal Association Clinical Services Meeting. Implementing eGFR Secondary Care CKD 2 & 3 700 600 500 400 300 200 100 0 1 3 5 7 9 11 13 15 17 19 21 CKD 2 CKD 3 Renal Association Clinical Services Meeting. Implementing eGFR Secondary Care CKD 4 & 5 40 35 30 25 20 15 10 5 0 1 3 5 7 9 11 13 15 17 19 21 CKD 4 CKD 5 Renal Association Clinical Services Meeting. Implementing eGFR Source of Secondary Care Patients 60% 50% 40% 30% 20% 10% 0% CKD 2 CKD 3 CKD 4 CKD 5 A&E Inpatient Outpatient Renal Association Clinical Services Meeting. Implementing eGFR CKD 2 Range GFR - Urinalysis Practice 1 Practice 2 Practice 3 Not tested Normal Abnormal % Abnormal Total 180 179 17 8.6 376 180 177 21 10.6 378 153 154 9 5.5 316 Renal Association Clinical Services Meeting. Implementing eGFR Prevalence Estimates WLPCT London NHANES Patients CKD 2 range 18.9% CKD 2 1.73% 57.9% 3.3% 16650 1532 CKD 3 CKD 4 CKD 5 8.76% 0.57% 0.19% 4.0% 4.3% 7716 503 163 0.25% 0.20% 0.32% 0.20% Renal Association Clinical Services Meeting. Implementing eGFR Patient Identification 2004-2005 Nephrology Referrals CKD 4 32 2005-2006 Identified by Optimal (wk 21) 503 CKD 5 6 163 Renal Association Clinical Services Meeting. Implementing eGFR Nephrology Outpatient Referrals April May June July Aug 2004 28 19 23 34 18 2005 32 38 59 61 76 Renal Association Clinical Services Meeting. Implementing eGFR Managing Demand Referral clinical assessment service Jointly with WLPCT – 26 referrals (from ~ 2 weeks) – 9 followed referral guidelines Renal Association Clinical Services Meeting. Implementing eGFR Gender 60% 50% 40% 30% 20% 10% 0% Males Females Renal Association Clinical Services Meeting. Implementing eGFR Age breakdown 25% 20% 15% 10% 5% 0% <20 20-39 40-49 50-59 60-69 70-79 >80 Renal Association Clinical Services Meeting. Implementing eGFR Age Breakdown by CKD (%) 60% 28% 50% 40% 30% 20% 10% 0% CKD 2 70% 80% 55% <20 20-39 40-49 50-59 60-69 70-70 >80 CKD 3 CKD 4 CKD 5 Renal Association Clinical Services Meeting. Implementing eGFR CKD 4 Age Profile 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% <20 20-39 40-49 50-59 60-69 70-70 >80 Primary Secondary Nephrologists Renal Association Clinical Services Meeting. Implementing eGFR CKD 5 Age Profile 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% <20 20-39 40-49 50-59 60-69 70-70 >80 Primary Secondary Nephrologists Renal Association Clinical Services Meeting. Implementing eGFR Initial Risk Stratification 60% 50% 40% 30% 20% 10% 0% High Medium Low Renal Association Clinical Services Meeting. Implementing eGFR Co-morbid Conditions at Presentation 35% 30% 25% 20% 15% 10% 5% 0% 0 1 2 3 4 5 Renal Association Clinical Services Meeting. Implementing eGFR Co-morbid Conditions 30% 25% 20% 15% 10% 5% 0% BP IHD CHF Dys DM COPD CVD PVD Malig Renal Association Clinical Services Meeting. Implementing eGFR Change In CKD Status 196 patients identified from Primary care changed CKD status 70 deteriorated 44 improved 37 deteriorated then improved 44 oscillated about the boundary Renal Association Clinical Services Meeting. Implementing eGFR GFR Fallers > 5 ml/min 100 90 80 70 60 N=70 GFR 50 40 30 20 10 0 Initial GFR Renal Association Clinical Services Meeting. Implementing eGFR Lowest GFR Rising GFR >5 ml/min 100 90 80 70 60 N=44 GFR 50 40 30 20 10 0 Initial GFR Renal Association Clinical Services Meeting. Implementing eGFR Highest GFR Recovery 100 90 80 70 60 N=37 GFR 50 40 30 20 10 0 Initial GFR Trough Peak Renal Association Clinical Services Meeting. Implementing eGFR Progression From CKD 2 100 90 80 70 60 GFR 50 40 30 20 10 0 0 20 40 60 80 100 120 140 Days Renal Association Clinical Services Meeting. Implementing eGFR Correction of Acidosis 100% Entry to programme 90% Renal Association Clinical Services Meeting. Implementing eGFR Achieving target 80% 70% 60% 50% 40% -6 -5 -4 -3 -2 -1 0 1 2 3 4 Haemoglobin >11 gm/dl 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% -6 -5 -4 -3 -2 -1 0 1 2 3 4 Entry to programme Renal Association Clinical Services Meeting. Implementing eGFR Iron Deficiency Entry to programme 95% 90% 85% Renal Association Clinical Services Meeting. Implementing eGFR Achieving target 80% 75% 70% 65% 60% 55% 50% -6 -5 -4 -3 -2 -1 0 1 2 3 4 Problems Lack of GP buy in due to: – Increased work load – Increased cost – No payment (not in QOF) GPs don’t routinely test urine Failure to follow guidelines Lack of IT integration Renal Association Clinical Services Meeting. Implementing eGFR In conclusion  Identified majority of patients with CKD within WL PCT  Instituted patient education programme  Changed the referral process  Ensure that patients are referred appropriately and in a timely manner  Improves patient outcomes?  Reduction in resource utilisation? Renal Association Clinical Services Meeting. Implementing eGFR Optimal Renal Care UK Saracen House Crusader Road Lincoln LN6 7AF 01522 563580 Dr Nick Richards nick.richards@optimalrenalcareuk.com 07768 936192 Renal Association Clinical Services Meeting. Implementing eGFR