the national quality standards for chronic kidney disease · the national quality standards for...

The National Quality Standards for Chronic Kidney Disease

Dr Robert Lewis Chief of Service, Wessex Kidney Centre, Portsmouth

Specialist Committee Member

Quality Standard for Chronic Kidney Disease, NICE

Content

• An introduction to the New NICE Quality Standard for CKD

• Arriving at the quality indicators and what has changed

• Quality Statement 1: why is this important to outcomes?

Why should we be concerned about CKD?

Two eGFR estimations <60 mL/min/1.73 m2 over a period not less than 90 days

OR

ACR >3 mg/mmol

NICE 2014: Diagnosis of CKD

ACR=albumin:creatinine ratio; CKD=chronic kidney disease; eGFR=estimated glomerular filtration rate.

NICE (2014) Available at: https://www.nice.org.uk/cg182 (accessed 22.10.2014)

https://www.nice.org.uk/guidance/cg182

KDIGO guideline for management of CKD 2012

Classification of CKD: NICE guidelines

2014 ACR categories (mg/mmol), description and range

A1 (<3)

Normal to mildly

increased

A2 (3–30)

Moderately increased

A3 (>30)

Severely increased

GF

R c

ate

go

ries (

mL

/min

/1.7

3 m

2),

descri

pti

on

an

d r

an

ge

G1 (≥90)

Normal and high

G2 (60–89)

Mild reduction related to normal

range for a young adult

G3a (45–59)

Mild–moderate reduction

G3b (30–44)

Moderate–severe reduction

G4 (15–29)

Severe reduction

G5 (<15)

Kidney failure

ACR: albumin:creatinine ratio CKD: chronic kidney disease GFR: glomerular filtration rate.

NICE (2014) Available at: https://www.nice.org.uk/cg182

Incre

asin

g r

isk

Increasing risk

https://www.nice.org.uk/guidance/cg182

Projections of growth in expected number of people in England with CKD stage 3-5, 2011 – 2036

Chronic kidney disease prevalence model. Public Health England 2014

Summary of CKD stage 3-5 prevalence in England 2014

Chronic kidney disease prevalence model. Public Health England 2014

The effect of CKD on life expectancy A: eGFR B: ACR

The Lancet 2013 382, 339-352DOI: (10.1016/S0140-6736(13)60595-4

Estimating the financial cost of chronic kidney disease to the NHS in England Nephrol Dial Transplant. 2012;27(suppl_3):iii73-iii80. doi:10.1093/ndt/gfs269

Estimated cost of CKD to the NHS (2010)

The overall annual cost of CKD is estimated at £1.44 to £1.45 billion. This is equivalent to ∼£795 for every person recorded with a diagnosis of CKD in the QOF.

What does good primary care for patients with CKD look like?

Early diagnosis Early intervention to reduce risk

Intelligent monitoring Appropriate referral to specialist services

Screening for CKD

• True positive

– Early diagnosis allows early intervention

– Early intervention in CKD may slow progression

– Lifestyle changes and CV risk reduction

• False positive

– Anxiety and medicalisation

– Unnecessary intervention

– Insurance premiums

Is cost justified for: (1) population based screening? (2) targeted screening?

Adults at risk of CKD

• diabetes • hypertension • acute kidney injury • cardiovascular disease • structural renal tract disease, recurrent renal calculi or prostatic

hypertrophy • multisystem diseases with potential kidney involvement – for example,

systemic lupus erythematosus • family history of end-stage kidney disease (GFR category G5) or hereditary

kidney disease e.g. autosomal dominant polycystic kidney disease • opportunistic detection of haematuria • prescribed drugs that have an impact on kidney function e.g. calcineurin

inhibitors, lithium and NSAIDs.

Pitfalls in diagnosis

• eGFR

– MDRD vs CKDEPI

– Body habitus

– Dehydration

– Meat intake

– Drugs (e.g trimethoprim)

• ACR

– Exercise

– BP control

Early intervention

• Patient education and activation • Accurate assessment of risk

– BP monitoring (patient?) – CV risk assessment – Rate of decline in eGFR – Quantification of proteinuria (frequency?)

• CV risk reduction – Lifestyle adjustment – Antiplatelet therapy – Lipid management – BP control (RAAS blockade?)

ACR categories (mg/mmol), description and range

A1 <3

Normal to

mildly increased

A2 3–30

Moderately

increased

A3 >30

Severely

increased

GFR

cat

ego

ries

(m

l/m

in/1

.73

m2),

des

crip

tio

n a

nd

ran

ge

G1 ≥90

Normal and high ≤1 1 ≥1

G2 60–89

Mild reduction

related to normal

range for a young

adult

≤1 1

≥1

G3a 45–59

Mild–moderate

reduction

1 1 2

G3b 30–44

Moderate–severe

reduction

≤2 2 ≥2

G4 15–29

Severe reduction 2 2 3

G5 <15

Kidney failure 4 ≥4 ≥4

Abbreviations: GFR, glomerular filtration rate, ACR, albumin creatinine ratio

Adapted with permission from Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group

(2013) KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney

disease. Kidney International (Suppl. 3): 1–150

Frequency of monitoring of GFR

“Appropriate” monitoring

Determined by: • the underlying cause of CKD • past patterns of eGFR and ACR (but be aware that

CKD progression is often non-linear) • comorbidities, especially heart failure • changes to their treatment (such as renin–

angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)

• intercurrent illness • whether they have chosen conservative

management of CKD.

How do we know if we’re doing well?

Outcome data?

Reiterative audit

Benchmarking against best practice

QOF 2014/15

• QOF indicator CKD005: The contractor establishes and maintains a register of patients aged 18 years or over with CKD with classification of categories G3a to G5 (previously stage 3 to 5).

• QOF indicator CKD004: The percentage of patients on the CKD register whose notes have a record of a urine albumin:creatinine ratio (or protein:creatinine ratio) test in the preceding 12 months.

• QOF indicator CKD002: The percentage of patients on the CKD register in

whom the last blood pressure reading (measured in the preceding 12 months) is 140/90 mmHg or less.

• QOF indicator CKD003: The percentage of patients on the CKD register with hypertension and proteinuria who are currently treated with an ACE-I or ARB.

QOF 2016/17

• QOF indicator CKD005: The contractor establishes and maintains a register of patients aged 18 years or over with CKD with classification of categories G3a to G5 (previously stage 3 to 5).

• QOF indicator CKD004: The percentage of patients on the CKD register whose notes have a record of a urine albumin:creatinine ratio (or protein:creatinine ratio) test in the preceding 12 months.

• QOF indicator CKD002: The percentage of patients on the CKD register in

whom the last blood pressure reading (measured in the preceding 12 months) is 140/90 mmHg or less.

• QOF indicator CKD003: The percentage of patients on the CKD register with hypertension and proteinuria who are currently treated with an ACE-I or ARB.

Comparison of deaths between uncoded and coded patients with biochemical CKD stages 3-5

National Chronic Kidney Disease Audit - National Report (Part 2) December 2017

• Quality standards set out the priority areas for quality improvement covering: - areas where there is variation in care - topics across health and social care

• Each standard contains a set of statements to help improve quality. It also describes how to measure progress against the statement

• NICE quality standards are not guidelines, they sit alongside and complement guidelines

NICE quality standards

Process of identifying CKD Quality Standards

• 8 stake holders invited to suggest 5 areas for quality improvement during consultation period October-November 2016 – British Kidney Patient Association – Kidney Research UK – NHS Improvement: patient safety – Renal Psychologists – Royal College of Nurses – Specialist Committee Members – UK Renal Association – AstraZeneca

• NICE Quality Standards Committee: December 2016 • Draft Quality Standards: consultation March 1st-28th 2017 • Final Quality Standards: July 2017

• Support national frameworks • Commissioning processes including incentives • CQC inspection activities • National audits • Choices website • Quality Accounts • Patient/service users and representative

organisations

NICE quality standards – use in practice

• An assessment showing that a local service meets the quality standard, informed by readily available evidence, can:

– provide assurance to those involved in the governance of the services

(governments, boards, regulators, insurers, consumers and service users)

• An assessment indicating areas that require quality improvement can: – help inform local quality improvement programme planning – identify priority areas for annual audit programmes – inform local risk management planning

NICE quality standards – use at local level

https://www.nice.org.uk/process/pmg30/chapter/introduction-and-background

CKD Quality Standards 2011 • People with CKD who may benefit from specialist care are referred for specialist assessment in accordance

with NICE guidance.

• People with CKD have a current agreed care plan appropriate to the stage and rate of progression of CKD.

• People with CKD are assessed for cardiovascular risk.

• People with CKD are assessed for disease progression.

• People with CKD who become acutely unwell have their medication reviewed, and receive an assessment of volume status and renal function.

• People with anaemia of CKD have access to and receive anaemia treatment in accordance with NICE guidance.

• People with progressive CKD whose eGFR is less than 20 ml/min/1.73 m2, and/or who are likely to progress to established kidney failure within 12 months, receive unbiased personalised information on established kidney failure and renal replacement therapy options.

• People with established renal failure have access to psychosocial support (which may include support with personal, family, financial, employment and/or social needs) appropriate to their circumstances.

NICE Quality statements 2017

• Statement 1: Adults with, or at risk of, chronic kidney disease (CKD) have eGFRcreatinine and albumin:creatinine ratio (ACR) testing at the frequency agreed with their healthcare professional. [2011, updated 2017]

• Statement 2: Adults with CKD have their blood pressure maintained within the recommended range. [2011, updated 2017]

• Statement 3: Adults with CKD are offered atorvastatin 20 mg. [new 2017]

Practice variation in percentage of people with coded CKD with annual repeat tests of eGFR by diabetes status

National Chronic Kidney Disease Audit - National Report (Part 1) January 2017

Practice variation in percentage with coded CKD stage 3-5 who have repeat urinary ACR tests stratified by diabetes


Practice variation in percentage of patients at risk of CKD but not on the CKD 3-5 Register who are receiving recommended eGFR testing (past year for diabetes and CNI/Li; past 5 years for others), by risk factor


Practice variation in percentage of patients at risk of CKD but not on the CKD 3-5 Register who are receiving recommended urinary ACR testing (past year for diabetes; past 5 years for others), by risk factor


Gathering data to assess Quality Standards

• Structure

• Process

• Outcomes

Structure

• Evidence of local systems that invite adults with, or at risk of, CKD to have eGFRcreatinine and ACR testing.

• Data source: Local data collection, for example, through local

protocols on appointment reminders.

Process

Proportion of adults with CKD who had eGFR testing in the past year. • Numerator – the number in the denominator who had

eGFRcreatinine testing in the past year.

• Denominator – the number of adults with CKD.

• Data source: Local data collection, for example, audit of health records.

Process

Proportion of adults at risk of CKD who had eGFR testing at the frequency agreed with their healthcare professional. • Numerator – the number in the denominator who had

eGFRcreatinine testing at the frequency agreed with their healthcare professional.

• Denominator – the number of adults at risk of CKD.


Process

Proportion of adults with CKD who had ACR testing at the frequency agreed with their healthcare professional. • Numerator – the number in the denominator who had ACR

testing at the frequency agreed with their healthcare professional.

• Denominator – the number of adults with CKD.


Outcomes

Prevalence of undiagnosed CKD. • Data source: QOF vs CKD prevalence model

Stage of CKD at diagnosis. • Data source: Local data collection, for example, audit of

health records

Summary

• CKD is associated with increased mortality and morbidity

• Early intervention and management improve outcomes

• CKD can be detected early and economically in at-risk populations (eGFR and ACR)

• Management of CKD is no longer a QOF priority • Measurement of the quality of early

management of CKD (in primary care) remains desirable.

Quality Standards: Key learning points

• CKD Quality Standards are not guidelines

• CKD Quality statements aim for:-

– Simplicity in practice

– Measurability

– Impact (evidence base)

• CKD Quality Standards aim to drive quality.

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