Service Redesign in Primary Care: Cardio Vascular Risk

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Service Redesign in Primary Care Cardio
Vascular Risk CKD

• Dr Kevin Harris
• Clinical Director Renal Services and Urology
• John Walls Renal Unit
• University Hospitals of Leicester

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Why Bother? Thats why we have Nephrologists!
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Why Bother? This is a condition primary care
never sees!

• End stage Kidney Disease is caused by common
  conditions which are frequently seen in primary
  care (Diabetes, Hypertension, atherosclerotic
  vascular disease)
• Less than 10 have a glomerulonephritis

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The Renal NSF Part 2

• Quality requirements
• Prevention and early detection of chronic kidney
  disease (CKD)
• Minimising the progression and consequences of
  CKD
• Acute renal failure
• End of life care

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Classification of CKD according to GFR
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CKD the real challenge for the health community
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Key Facts ESRF

• Dialysis programs growing at 6-8 pa
• 22-57 present as Acute Uraemic Emergencies
• 3-54 get Pre-emptive transplant listing
• Dialysis survival 1st year 75-93
• High Cost
• 0.4B / year (2002/03)
• gt0.8B / year (2010/11)

(Wanless)
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What needs to be done?

• Identify the patients (early)
• Prevent Progression of Renal Disease
• Delay time to dialysis and transplant
• Reduce morbidity
• Do No Harm!
• Medicines management
• Early referral

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What do you need to measure?
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What do you need to measure?
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eGFR reporting

• Modified MDRD
• GFR (mL/min/1.73m2) 186 x serum creatinine
  (µmol/L)/88.4 -1.154 x age (years) - 0.203 x
  0.742 if female
• (Difficult for me but not a computer)

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How does knowing about these patients help
prevent or delay progression?

• Potentially modifiable risks-
• Lifestyle
• Smoking
• Obesity
• Lack of exercise
• Treat diabetes (if present)
• Treat blood pressure
• ACE inhibitors
• Lipid lowering

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How does knowing about these patients help? The
importance of BP control
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How does knowing about these patients help? The
importance of ACE inhibition
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How does knowing about these patients help? A
patient-centred service the renal NSF

• Markers of good practice
• Provision of high quality, culturally appropriate
  and comprehensive information and education
  programmes
• Education programmes tailored to the needs of the
  individual
• Individual care plans, regularly audited,
  evaluated and reviewed
• Access to a multi-skilled renal team whose
  members have the appropriate training, experience
  and skills

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How does knowing about these patients help? Do no
harm

• 30 of patients staring RRT crash land
• 50 of these could have been identified
• Increased morbidity and mortality
• Opportunity to manage end of life care

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What really happens to patients with CKD?
CKD is an independent and major risk factor for
cardiovascular disease
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What really happens to patients with CKD?
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What (really) needs to be done?

• Identify the patients (early)
• Improve Clinical Outcome
• Reduce cardiovascular death rate
• Reduce morbidity and mortalilty
• Do No Harm!

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How does knowing about these patients help
improve clinical outcome?

• Potentially modifiable risks-
• Lifestyle
• Smoking
• Obesity
• Lack of exercise
• Treat diabetes (if present)
• Treat blood pressure
• ACE inhibitors
• Lipid lowering

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Wont this be a lot of extra work?

• 85 of patients with Chronic Kidney Disease will
  be identified by looking in registries for
  Diabetes, Hypertension, Ischaemic Heart Disease
• More common in
• Elderly
• Ethnic minorities
• Socially disadvantaged

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Who has already been tested
100
90
80
measurement
70
CKD3,4 5
60
50
of population
40
30
20
10
0
90
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
Total 15
Age Bands
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What we know about people already tested
Co-morbidities for pts by age in CKD 3-5
350
Four or more of co-morbidities
Three or more of co-morbidities
300
Two or more of co-morbidities
(1837)
(1842)
One or more of co-morbidities
(1539)
(1087)
Hypertensive disease
250
(1136)
Diabetes
(692)
Peripheral vascular disease
(840)
200
Stroke/TIA
Ischaemic heart disease
of population
(674)
150
(324)
(4)
(199)
100
(11)
(118)
(74)
(35)
50
0
90
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
Age bands
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What we know about people already tested

• Prevalence of CKD 3-5 was 7
• (20 of those in whom measurement made)
• 60 had hypertension
• 27 had ischaemic heart disease
• 18 had diabetes
• Uncontrolled risk factors common
• 17.93 had systolic BP gt 150mmHg
• 37.93 had total cholesterol gt 5.0 mmol/L
• 22.83 were current smokers

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What needs to be done?

• Will require whole Health Community Approach
• Integration with Diabetes, CHD, Long Term
  Conditions, Palliative Care,Primary care
• Redesign (to be affordable)

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A Joined Up Approach? Cardiovascular Risk
Management
Anti coagulationAnti arrhythmicsMedical
treatment of CHF
CKD Stage 1, 2,3 EducationBlood
pressureSmoking cessationLipid
controlMedicines ManagementDiet
adviceExercisePsychosocial support
CKD Stage 4 AnaemiaAcidosisBone
diseasePreparation/choice
Glycaemic control
DM
CHD
Complicationseyesfeetkidney
CKD Stage 5 RRTPDHPTp
RadiologySurgical interventions
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An effective Disease Management Program A Health
Community Issue

• Management structure which involves all
  stakeholders in the shaping of the service
• Clinical staff (primary and secondary care)
• Commissioners
• Managers
• Provider units (Hospitals, PCTs, GPs and Private
  companies)
• Patients
• Agreed Management Protocols
• Single patient record
• IT support
• A MAJOR CHALLENGE!

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Why must we do this?

• Patients will receive a personalised, timely and
  integrated service
• Reduction in patient bed days
• Reduction in unplanned readmissions
• Cost of reduction of around 10
• 10 more patients treated for the same cost

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Drivers The new QOF
Payment Stages
Points
Indicator
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ChKD 1 The practice can produce a register of
patients aged 18 years and over with ChKD. (US
National Kidney Foundation Stage 3-5 ChKD)
40-90
6
ChKD 2 The percentage of patients on the ChKD
register whose notes have a record of blood
pressure in the previous 15 months
40-70
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ChKD 3 The percentage of patients on the ChKD
register in whom the last blood pressure reading,
measured in the previous 15 months, is 140/85 or
less
40-80
4
ChKD 4 The percentage of patients on the ChKD
register who are treated with an angiotensin
converting enzyme inhibitor (ACE-I) or
angiotensin receptor blocker (ARB) (Unless a
contraindication or side effects are recorded)
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An integrated cardiovascular QOF?
Payment stages
Points
Coronary Heart Disease
Payment stages
Points
Chronic Kidney Disease
Payment stages
Points
Diabetes
4
CHD 1. The practice can produce a register of
patients with coronary heart disease
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CKD1 The practice can produce a register of
patients aged 18 years and over with CKD (US
National Kidney Foundation Stage 3 to 5 CKD)
6
DM 19.The practice can produce a register of all
patients aged 17 years and over with diabetes
mellitus, which specifies whether the patient has
Type 1 or Type 2 diabetes
REGISTER
40-90
7
CHD 5. The percentage of patients with coronary
heart disease whose notes have a record of blood
pressure in the previous 15 months
40-90
6
CKD2 The percentage of patients on the CKD
register whose notes have a record of blood
pressure in the previous 15 months
40-90
3
DM 11. The percentage of patients with diabetes
who have a record of the blood pressure in the
previous 15 months
MEASURE BP
40-70
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CHD 6. The percentage of patients with coronary
heart disease in whom the last blood pressure
reading (measured in the previous 15 months) is
150/90 or less
40-70
11
CKD3 The percentage of patients on the CKD
register in whom the last blood pressure reading,
measured in the previous 15 months, is 140/85 or
less
40-60
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DM 12. The percentage of patients with diabetes
in whom the last blood pressure is 145/85 or less
TARGET BP
40-90
3
DM 13. The percentage of patients with diabetes
who have a record of micro-albuminuria testing in
the previous 15 months (exception reporting for
patients with proteinuria) 
MEASURE PROTEINURIA
40-90
3
DM 22. The percentage of patients with diabetes
who have a record of estimated glomerular
filtration rate (eGFR) or serum creatinine
testing in the previous 15 months 
MEASURE RENAL FUNCTION
40-80
7
CHD 8. The percentage of patients with coronary
heart disease whose last measured total
cholesterol (measured in the previous 15 months)
is 5 mmol/l or less
40-80
4
CKD4 The percentage of patients on the CKD
register with hypertension who are treated with
an angiotensin converting enzyme inhibitor
(ACE-I) or angiotensin receptor blocker (ARB)
(unless a contraindication or side effects are
recorded)
40-80
3
DM 15. The percentage of patients with diabetes
with a diagnosis of proteinuria or
micro-albuminuria who are treated with ACE
inhibitors (or A2 antagonists)
PRESCRIBE ACEi/ARB
40-90
7
CHD 7. The percentage of patients with coronary
heart disease whose notes have a record of total
cholesterol in the previous 15 months
40-90
3
DM 16. The percentage of patients with diabetes
who have a record of total cholesterol in the
previous 15 months
MEASURE CHOLESTEROL
40-70
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CHD 8. The percentage of patients with coronary
heart disease whose last measured total
cholesterol (measured in the previous 15 months)
is 5 mmol/l or less
40-70
6
DM 17. The percentage of patients with diabetes
whose last measured total cholesterol within the
previous 15 months is 5 mmol/l or less
TARGET CHOLESTEROL
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CKD
Cardiac
Kidney
Diabetes
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Any Questions?
Perhaps that pain wasnt your kidneys after all!