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Disease Management for Chronic Kidney Disease

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					    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                                     (normal GFR)   3.3%
       – Stage 2                                     (GFR 60-90)    3.0%
       – Stage 3                                     (GFR 30-60)    4.3%
       – Stage 4                                     (GFR 15-30)    0.2%
       – Stage 5                                     (GFR 0-15)     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                                                            England
   70
   60                                                            West Lincolnshire
   50
                                                                 East Lincolnshire
   40
   30                                                            Lincolnshire South
   20                                                            West
   10
    0


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)
                                                                     1o Care
                                    Care team                     - Clinical data
    Pathology data                 -Clinical data                 - Activity data            2o Care
    -New patients                                                                         - Clinical data
    -Old patients                                                                         - Activity data


                                                                             Alerts for action
    QOF data                                     ORCA                        -Failure to meet targets
 Disease registry                                                            -Perform test (eg HbA1c)
 Commissioning


               Reports                                           GFR alerts            Other systems
               -Patient’s progress                               -To care team      e.g. National registry
               -Audit against targets                            -To 1o care
               -Intervention history                             -To 2o care
Renal Association Clinical Services Meeting. Implementing eGFR
                                            Targets

                 Parameter                                           Target
      Haemoglobin                                         >11 g/dl
      Ferritin (patients on EPO)                          >150µg/l
      Calcium                                             2.10 – 2.60 mmol/l
      Phosphate                                           0.84 – 1.45 mmol/l
      Parathyroid hormone                                 < 4 x upper limit of range
      Bicarbonate                                         22-26 mmol/l
      Potassium                                           3.5-6.0 mmol/l
      Referral to smoking cessation                       100% of smokers
        programme

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                                                                            GFRs
                                                                                      Patients
     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



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                                                                            Primary
                                                                                     Secondary
      600
                                                                                     JL/GW
      400

      200

          0
              1      3       5      7      9     11      13      15   17   19   21


Renal Association Clinical Services Meeting. Implementing eGFR
               Primary Care CKD 2 & 3

       900
       800
       700
       600
       500
                                                                                     CKD 2
       400                                                                           CKD 3
       300
       200
       100
           0
               1      3       5      7       9      11     13    15   17   19   21


Renal Association Clinical Services Meeting. Implementing eGFR
               Primary Care CKD 4 & 5

        30

        25

        20

        15                                                                           CKD 4
                                                                                     CKD 5
        10

          5

          0
              1      3       5       7      9      11      13    15   17   19   21


Renal Association Clinical Services Meeting. Implementing eGFR
         Secondary Care CKD 2 & 3

       700

       600

       500

       400
                                                                                     CKD 2
       300                                                                           CKD 3
       200

       100

          0
              1       3       5      7       9      11      13   15   17   19   21


Renal Association Clinical Services Meeting. Implementing eGFR
         Secondary Care CKD 4 & 5

       40
       35
       30
       25
       20                                                                            CKD 4
                                                                                     CKD 5
       15
       10
         5
         0
             1       3       5      7       9      11      13    15   17   19   21


Renal Association Clinical Services Meeting. Implementing eGFR
 Source of Secondary Care Patients

     60%

     50%

     40%
                                                                         A&E
     30%
                                                                         Inpatient
     20%                                                                 Outpatient


     10%

       0%
                 CKD 2              CKD 3              CKD 4     CKD 5


Renal Association Clinical Services Meeting. Implementing eGFR
   CKD 2 Range GFR - Urinalysis

                                               Practice 1        Practice 2   Practice 3


        Not tested                             180               180          153
        Normal                                 179               177          154
        Abnormal                               17                21           9
        % Abnormal                             8.6               10.6         5.5
        Total                                  376               378          316



Renal Association Clinical Services Meeting. Implementing eGFR
                    Prevalence Estimates

                              WLPCT London NHANES                        Patients

 CKD 2 range 18.9%                                 57.9%                 16650

 CKD 2                        1.73%                              3.3%    1532

 CKD 3                        8.76%                4.0%          4.3%    7716

 CKD 4                        0.57%                0.25%         0.20%   503

 CKD 5                        0.19%                0.32%         0.20%   163

Renal Association Clinical Services Meeting. Implementing eGFR
                      Patient Identification

                                        2004-2005                2005-2006
                                        Nephrology               Identified by
                                        Referrals                Optimal (wk 21)
 CKD 4                                                 32             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%
                                                                 Males
  30%                                                            Females

  20%

  10%

    0%


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%                       70%               80%     55%
      50%
                                                                               <20
      40%                                                                      20-39
                                                                               40-49
      30%
                                                                               50-59
      20%                                                                      60-69
                                                                               70-70
      10%                                                                      >80

        0%
                   CKD 2                CKD 3               CKD 4      CKD 5


Renal Association Clinical Services Meeting. Implementing eGFR
                          CKD 4 Age Profile

   60.00%

   50.00%

   40.00%
                                                                       Primary
   30.00%
                                                                       Secondary
   20.00%                                                              Nephrologists


   10.00%

     0.00%
                 <20      20-39 40-49 50-59 60-69 70-70          >80


Renal Association Clinical Services Meeting. Implementing eGFR
                          CKD 5 Age Profile

   60.00%

   50.00%

   40.00%
                                                                       Primary
   30.00%
                                                                       Secondary
   20.00%                                                              Nephrologists


   10.00%

     0.00%
                 <20      20-39 40-49 50-59 60-69 70-70          >80


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
                                                                              N=70
                     70

                     60
              GFR




                     50

                     40

                     30

                     20

                     10

                      0



                                         Initial GFR             Lowest GFR

Renal Association Clinical Services Meeting. Implementing eGFR
                     Rising GFR >5 ml/min

                     100

                      90

                      80
                                                                               N=44
                      70

                      60
               GFR




                      50

                      40

                      30

                      20

                      10

                       0

                                         Initial GFR             Highest GFR

Renal Association Clinical Services Meeting. Implementing eGFR
                                         Recovery

                  100

                  90

                  80                                                    N=37
                  70

                  60

                  50
            GFR




                  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%
Achieving target




                   80%

                   70%

                   60%

                   50%

                   40%
                          -6   -5   -4      -3      -2       -1   0    1       2   3   4


Renal Association Clinical Services Meeting. Implementing eGFR
                Haemoglobin >11 gm/dl
                                                          Entry to programme
      100%
        95%
        90%
        85%
        80%
        75%
        70%
        65%
        60%
        55%
        50%
                  -6      -5       -4       -3      -2       -1   0    1       2   3   4


Renal Association Clinical Services Meeting. Implementing eGFR
                                   Iron Deficiency
                                                        Entry to programme

                   95%
                   90%
                   85%
Achieving target




                   80%
                   75%
                   70%
                   65%
                   60%
                   55%
                   50%
                         -6   -5   -4      -3      -2       -1   0   1       2   3   4


Renal Association Clinical Services Meeting. Implementing eGFR
                                         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