IMproving Patient care and Awareness of Kidney disease

progression Together

The IMPAKT CKD Tool

www.impakt.org.uk

11th May 2006

The West Lincs Project

Disease management programme:

- patient education

- medicine management

- dietetic advice

- optimisation of clinical management

34 practices

483 patients with CKD 3/4, 4 and 5 enrolled

computerised records for data

Richards et al: NDT 2008

The West Lincs Project

Richards et al: NDT 2008

Does primary care intervention

help the bulk of CKD patients???

A Primary-Secondary Care Partnership to

Prevent Adverse Outcomes in

Chronic Kidney Disease

A Cluster Randomised Clinical Trial

“Intensive primary care led disease management programmes

for CKD, supported by input from secondary care

specialists will improve blood pressure control,

slow progression of CKD and

reduce cardiovascular events in patients on CKD registers”

Hypothesis

• take a number of general practices

• identify all CKD patients

• divide practices into 2 groups

• 1 group continues to provide ‘normal’ CKD care

• 1 group provides nurse led ‘intensified’ CKD care

• team of CKD nurses supported by secondary care

• compare CKD outcomes after an appropriate time period

How to test the hypothesis

National average PCT CKD Prevalence figures

(07-08 QoF)

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Northants 2.6% Leic. City 2.3%

Leic. County & Rutland 3.6%

National Average 2.8%

A robust data extraction tool applicable

to all GP computer systems

What do we need to do this?

A practice computer search tool

1. find total population over 17

2. find those with eGFR <60 ml/min/1.73m2 ever

3. find those with read code of renal impairment

4. 2 OR 3

5. find in 4 those with RRT

6. 4 NOT 5 to get the target population minus exclusions

7. search 6 for the data needed

Other data also extracted

• Past medical history

• Medication history

• Blood pressure

• Smoking history

• BMI if recorded

• Other blood biochemistry and haematology

• Nurses keep reflective diaries of experiences

Outcomes

Primary outcome measure:

-difference in mean CKD register patient eGFRs

between groups after 3.0 years of study

Secondary outcome measures:

- blood pressure control

- proteinuria

- incidence of cardiovascular events

- other biochemical parameters

- referrals to secondary care and hospitalisations

- mortality

-reflective experience of nurse intervention team

The CLAHRC LNR PSP-CKD

Study

48 practices recruited

Total population >17yrs = 343,743

31,274 – most recent eGFR <60 ml/min

20,383 – confirmed by 2nd value within 3 months

= confirmed CKD prevalence of 5.93%

Quality/Practice benefits “Even if we don’t do anything (meaning as a control practice) this’ll validate our QoF data” “it's a bit of a no brainer really- a free nurse for 3 years” Space/Accommodation for service “We are in the middle of building an extension and just don’t have the space - if we could be sure we would be a control practice, I’d sign today- but we just can’t” Workload/Role “It will add to an already busy workload”, “Could you provide some training for our nurses, we wouldn’t want a nurse coming to see our patients, we would prefer to manage them ourselves”

Nurse Reflections on GP Participation

Credibility of the approach “the fact that they were approached by a doctor seemed to play a big part in the decision to see me” “Once they saw I was a nurse and not a drug company rep they seemed to relax” “He said “oh, that’s the PBC group commissioning project” An interest or belief in the topic “It (CKD) was a particular interest of mine” “One GP told me that there’s no evidence that CKD actually exists..so there’s no point in doing anything” Professional issues/Patient care “it will help me update my knowledge” (GP) “We are already doing everything we need to...looking after our patients adequately so there’s no need” (to take part)

Nurse Reflections on GP Participation

What the tool does

• Register – Accuracy of existing coding of CKD

– Identifies uncoded patients

• Risk – Identifies high risk of progression and CVD

– Medicines managment

• Audit – Against NICE standards

– Benchmarking

• Manage – Advice on BP, proteinuria, ACE/ARB

– Referral

– Medicines management – NSAIDs, metformin etc

www.impakt.org.uk

REGISTER 1: Patients coded with CKD

Do I have the 'right' patients on my CKD register?

CKD prevalence CKD 2 CKD 3 CKD 4 CKD 5Total

CKD 3-5Accuracy of coding Total

Number of patients on existing CKD register 31 337 20 3 360 Correctly coded CKD 74

Observed % prevalence 3.7 0.2 0.0 4.0 Potential number of misdiagnosed patients 193

Estimated number of patients 508 26 8 542 Potentially incorrect CKD staging 87

Estimated % prevalence 5.6 0.3 0.1 6.0 Potentially incorrect proteinuria assessment 6

Why is CKD important?

CKD is a major risk factor for strokes, heart attacks, renal failure or death. Current evidence

suggests that the national average prevalence of CKD (stages 3-5) is about 6%. IMPAKT

models your estimated CKD prevalence using age/sex data from your population. You can use

this estimate to see how closely your practice matches this estimate. Variances in ethnicity and

deprivation are possible causes of variation from this estimate.

IMPAKT has modelled your observed vs.

estimated prevalence by stage. The outcome of

improvements from this sheet will give you a

good idea of how many patients are 'missing' at

each stage.

This is the breakdown of your current CKD register. Details

on which patients this data relates to can be found on the

REGISTER1 page of your IMPAKT results.

This is the total number of possible actions that IMPAKT has

identified for you to investigate in order to make your CKD

register accurate. Improvements since the last audit have

resulted in 14 fewer identified actions in this report than

your previous audit.

TotalPrevious

Total

Reduced

by value

286 300 14

CKD 1

0

Practice Name

20/11/2012 P12345

360

542

0%

1%

2%

3%

4%

5%

6%

7%

Observed Estimated

CKD 3-5 prevalence

CKD5

CKD4

CKD3

74

193

87

0

50

100

150

200

250

300

350

400

Current register status

Potentially incorrect CKDstaging

Potential number ofmisdiagnosed patients

Correctly coded CKD

193 87 6

0 100 200 300 400

Total actionsPotential number ofmisdiagnosed patients

Potentially incorrect CKDstaging

Potentially incorrectproteinuria assessment

Reduced by value sinceprevious report

REGISTER 2: Patients not coded as CKD

How many CKD patients are 'missing' at my practice?

CKD prevalence CKD 1 CKD 2 CKD 3 CKD 4 CKD 5Total

CKD 3-5Patients with significant eGFR results Total

0 31 337 20 3 360 High priority for coding 193

3.7 0.2 0.0 4.0 Low priority for coding 87

508 26 8 542 No action required 6

5.6 0.3 0.1 6.0

%

137

5.5

182

280

Why is CKD important?

CKD is a major risk factor for strokes, heart attacks, renal failure or death. Current evidence

suggests that the national average prevalence of CKD (stages 3-5) is about 6%. IMPAKT

models your estimated CKD prevalence using age/sex data from your population. You can

use this estimate to see how closely your practice matches this estimate. Variances in

ethnicity and deprivation are possible causes of variation from this estimate.

Practice Name

20/11/2012 P12345

Number of patients on existing CKD register

Observed % prevalence

Estimated number of patients

Estimated % prevalence

This is the total number of possible actions IMPAKT can suggest in case finding CKD patients.

High priority actions are patients that you are likely to be able to code straight away. Low

priority cases have evidence of CKD but need further investigation.

Please select a target % from the drop down menu below. Your

selected % will be converted to a number of patients to find on

the graph on the left, mapped against your estimated prevalence.

You have chosen to find 75% of your 'missing' CKD patients. This

would give you a CKD register size of 497 patients. The IMPAKT

REGISTER2 sheet will support you identify which patients you can

code or investigate.

You have selected to find 75% of the missing patients

Selected target % prevalence

Total number of missing patients

Total number of actions

360 542

497

0%

1%

2%

3%

4%

5%

6%

7%

Observed Estimated

CKD 3-5 prevalence

75% Selected Target

193

87

6

Patients with eGFR results <60

High priority for coding Low priority for coding

No action required

193 87

0 50 100 150 200 250 300

Total number of actions

High priority for coding Low priority for coding

75

MANAGE 1: Stratifying risk of progressive CKD Practice Name

Controlling risk factors for my CKD patients

Albuminura stages, description and range (mg/mmol) Risk factor stratification

A1 A2 A3 Score

10 or more 0

9 0

<10 10-29 30-299 300-2000 >2000 8 0

7 1

6 4

5 9

4 29

CKD3a Mild-moderate 204 15 13 1 3 68

CKD3b Moderate-severe 64 4 6 2 2 120

CKD4 Severe 12 1 2 1 160

CKD5 Kidney failure 1 1 391

Some medication

Proteinuria heat map - what does it mean?

IMPAKT reads how many of your CKD patients have been

tested for proteinuria and plots them on the above heat

map. The more severe grouping represents a higher risk of

the patient suffering from progressive CKD. Use IMPAKT to

find the patients at highest risk so that you can control

their risk factors.

Low risk

Mild risk

Moderate risk

Severe risk

Very severe risk

Total patients

Risk groups

Use this page to stratify risk factors for your CKD patients and make adjustments

to how they are managed to reduce the risk of progressive CKD. This report

contains details on what risk each of your patients' readings for proteinuria

represents against their latest eGFR evidence, a breakdown of the number of risk

factors per CKD patient on your register, CKD patients that are prescribed

nephrotoxic drugs, and CKD patients that may meet the criteria for referral to

secondary care specialists.You can find each category of patient within IMPAKT on

your practice system.

How do I use the information on this page?

IMPAKT analyses 12 unweighted risk factors for

progressive CKD and calculates how many risk factor

categories each of your CKD patients fall into. Use

IMPAKT to investigate those patients appearing most

frequently to manage their risk factors.

No. of patients with referral advice markersIMPAKT has identified this as the number of your CKD patients that may meet NICE CKD guidelines (2008) criteria

for referral to specialist renal services.20

0

233

76

15

2

326

Total patients

Stratifying risk factors

GFR stages,

description and

range

(ml/min/1.73m2)

CKD1

CKD2

Optimal

Low-normal

30-44

15-29

<15

Total patients

>105

90-104

75-89

60-74

45-59

20/11/2012 P12345

Composite ranking for relative risks by GFR and

albuminuria (KDIGO 2009)Optimal to high-

normal

High Very high to

nephrotic

No. of

patients

Ranked by combined

risk score

150

0 50 100 150 200

Patients with advice markers for prescribed drugs

Number of patientscoded with CKD

MANAGE 2: Proteinuria testing and BP control Practice Name

Managing blood pressure in my CKD patients 20/11/2012 P12345

Proteinuria testing Total % Blood pressure management

BP

recorded

in last

year

BP

treated to

target

% treatedTotal left

to treat

% left to

treat

CKD patients tested for proteinuria 326 83 Of those with proteinuria status recorded:

CKD patients not tested for proteinuria 65 17 BP 140/90 (CKD without proteinuria) 259 180 69 79 31

Of those tested: BP 130/80 (CKD with proteinuria) 42 11 26 31 74

CKD patients with proteinuria 43 0 Patients treated to appropriate BP target 301 191 63 110 37

CKD patients tested but not coded 17

%

35

\

NICE sets two different blood pressure recommendations for patients with CKD, based on the presence of proteinuria. Therefore it is important to test all of your CKD

patients for proteinuria (QOF suggests that this is done at least every 15 months) so that you can define which of the two targets you should use for your patients. NICE

recommendations are that patients with proteinuria are controlled to 130/80, and those without proteinuria to 140/90.

CKD patients without proteinuria 266 3Please select or input a target % of patients treated to appropriate BP target from the drop down

menu below. Your selected % will be converted to a number of patients to find on the graph below.

Controlling blood pressure - what do I need to know?

You have chosen to find 75% of your total patients treated

326

65

0

10

20

30

40

50

60

70

80

90

100

ACR testing

% Tested % Not Tested

43

266

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Number of patients tested for proteinuria

With proteinuria

Without proteinuria

11

180

191

13

213

226

42

259

301

0% 20% 40% 60% 80% 100%

BP 130/80 (CKD with

proteinuria)

BP 140/90 (CKD without

proteinuria)

Patients treated toappropriate BP target

% of patients treated

Blood pressure management

75% Target

% missing

75

CKD Implementation Work

E-consultation

National Audit CKD 2012