Disease Management for Chronic Kidney Disease

1
Disease Management for Chronic Kidney Disease

• Dr Nick Richards
• Medical Director
• Optimal Renal Care UK

2
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

3
Why Disease Management for Chronic Kidney Disease
in The UK?
4
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

5
Prevalence of CKD UK

• East Kent Clinical biochemistry lab survey
• Prevalence of SCr (µmol/l) gt 180 (m) or gt135 (f)
• 5554 per million of population
• Age related 78.3 pmp lt40y, 58913 pmp gt80y
• 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.

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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 lt 15) 0.32
• DM, CVD or BP identifies 85 of CKD

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Consequences of Late Referral for Patients With
Chronic Kidney Disease

• Loss of chance for patients
• 30-50 of patients present lt 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

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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

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Pre Dialysis

• Pre dialysis care gt 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

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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

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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

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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

13
Take on Rates for Renal Replacement Therapy in
Lincolnshire
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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

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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

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Optimal Renal Care Application (ORCA - The IT
Solution)
1o Care - Clinical data - Activity data
Care team -Clinical data
Pathology data -New patients -Old patients
2o Care - Clinical data - Activity data
ORCA
Alerts for action -Failure to meet
targets -Perform test (eg HbA1c)
QOF data Disease registry Commissioning
Other systems e.g. National registry
GFR alerts -To care team -To 1o care -To 2o care
Reports -Patients progress -Audit against
targets -Intervention history
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Targets
Parameter Target
Haemoglobin gt11 g/dl
Ferritin (patients on EPO) gt150µg/l
Calcium 2.10 2.60 mmol/l
Phosphate 0.84 1.45 mmol/l
Parathyroid hormone lt 4 x upper limit of range
Bicarbonate 22-26 mmol/l
Potassium 3.5-6.0 mmol/l
Referral to smoking cessation programme 100 of smokers
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Results to Date
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GFRs and New Patients Per Week
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GFR Requests From Primary Care
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New Patients Primary Secondary Care
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Primary Care CKD 2 3
23
Primary Care CKD 4 5
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Secondary Care CKD 2 3
25
Secondary Care CKD 4 5
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Source of Secondary Care Patients
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CKD 2 Range GFR - Urinalysis
Practice 1 Practice 2 Practice 3 Not
tested 180 180 153 Normal 179 177 154 Abnorm
al 17 21 9 Abnormal 8.6 10.6 5.5 Total 37
6 378 316
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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
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Patient Identification
2004-2005 Nephrology Referrals 2005-2006 Identified by Optimal (wk 21)
CKD 4 32 503
CKD 5 6 163
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Nephrology Outpatient Referrals
April May June July Aug
2004 28 19 23 34 18
2005 32 38 59 61 76
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Managing Demand

• Referral clinical assessment service
• Jointly with WLPCT
• 26 referrals (from 2 weeks)
• 9 followed referral guidelines

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Gender
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Age breakdown
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Age Breakdown by CKD ()
28
70
80
55
35
CKD 4 Age Profile
36
CKD 5 Age Profile
37
Initial Risk Stratification
38
Co-morbid Conditions at Presentation
39
Co-morbid Conditions
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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

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GFR Fallers gt 5 ml/min
N70
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Rising GFR gt5 ml/min
N44
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Recovery
N37
44
Progression From CKD 2
45
Correction of Acidosis
Achieving target
46
Haemoglobin gt11 gm/dl
47
Iron Deficiency
Achieving target
48
Problems

• Lack of GP buy in due to
• Increased work load
• Increased cost
• No payment (not in QOF)
• GPs dont routinely test urine
• Failure to follow guidelines
• Lack of IT integration

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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?

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Optimal Renal Care UK

• Saracen House
• Crusader Road
• Lincoln LN6 7AF
• 01522 563580
• Dr Nick Richards
• nick.richards_at_optimalrenalcareuk.com
• 07768 936192