national audit of ckd in primary care
TRANSCRIPT
National Audit of CKD in Primary Care
David C WheelerRoyal Free CampusUniversity College London
Kidney for General PhysiciansRCP London24th November 2017
Who looks after CKD patients (UK)?
Primary Care Nephrology Other
secondary
care
CKD 3 84.6 1.6 13.9
CKD 4 57.2 28.8 14.0
CKD 5 19.8 70.0 10.1
% of total by stage
Data from NHS England Donal O'Donoghue, Personal communication
May 11th, 2006
GPs Shoulder the Burden of CKD
The history of CKD in the UK
• 2005 Renal National Service Framework
• 2007 Standardisation of creatinine measurements
• 2007 Mandatory eGFR reporting
• 2008 NICE CKD Guideline
• 2008 Quality Outcomes Framework
• 2010 Quality Outcomes Framework update
• 2014 NICE CKD Guideline updated
NICE CG 182 (2014): Suggested Frequency of CKD monitoring
GFRCategory
GFRmL/min/1.73m2
GFRDescription
Frequency of monitoringeGFR (times per year)
A1 A2 A3
G1 ≥90 Normal or high ≤ 1 1 ≥1
G2 60-89 Mildly decreased ≤ 1 1 ≥1
G3a 45-59Mildly to Moderately decreased
1 1 2
G3b 30-44Moderately to severely decreased
≤ 2 2 ≥2
G4 15-29 Severely decreased 2 2 3
G5 <15 Kidney failure 4 ≥ 4 ≥ 4
ACR Categories: A1 (normal to mildly increased) < 3 mg/mmol, A2 (moderately increased) 3-30 mg/mmol, A3 (severely increased) > 30 mg/mmol
The NCKDA
• 3 year project funded by NHS England as part of the National Clinical Audit and Patient Outcomes Programme and by the Welsh Government
• Commissioned by HQIP.
• Delivered by a partnership between BMJ Informatica and 3 academic institutions.
• Electronic audit and quality improvement tool
• Focus on stages 3-5 CKD (reduced eGFR)
The National Primary Care CKD Audit
Aims of the audit
1. Improve identification of CKD in primary care• Increase number of patients coded
• Improve testing of ‘at risk’ groups
2. Improve management of CKD not requiring specialist review• Audit against NICE targets (e.g. Monitoring, BP, CV risk assessment)
3. Improve timely referral of CKD patient requiring specialist review • Audit referrals through HES linkage
• Snapshot of referral pathways across CCGs
4. Develop QI tools to help GPs manage CKD
Screen shot of the audit tool dashboard
coded
Possibly Uncoded
Possibly Miscoded
eGFR tested
eGFR not testedTested for Proteinuria
Not tested for Proteinuria
Screen shot of audit tool dashboard (management of CKD)
Pilot
2014 2015 2016
Round 1
(Baseline)
Round 2
(Audit)
For any practice was a QI Period
between Baseline and Audit of
circa 10 monthsPilot
Report
Practice
Reports
CCG & National
Report
Audit timetable
Coverage of Audit
The GPSoC (GP Systems of
Choice) contract was due to
change to allow free access to
commercial software and
provide useable data for audit.
Audit Demographics
• 990 practices provided data
• 817 practices submitted 2 rounds of adequate data (5.2 million adults)
• Corresponding to 8% of English practice population and 70% in Wales
• Data was extracted from those with risk factors for CKD and those with CKD totaling 2,079,101 patients
• Practice populations were representative in terms of age and sex for the population of England and Wales but tended to be from rural, white areas
Practice Performance: Coding CKD
Mean
99.8% control95.0% control
Improvement in coding between audit cycles
Overall 4% of practices improved coding according to our criteria within 3 months.
Coding with CKD 3-5
• 3.97% of people over 18 were coded with CKD
• Prevalence related to coded diabetes, hypertension and CVD
• No link with Deprivation Index or ethnicity
• 11% of people with CKD code had 2 last eGFR > 60 ml/min/1.73m2 and were therefore potentially miscoded
• Coding rates low in those of black ethnicity because correction factor had not been used
CKD prevalence: Patients with last 2 eGFRs <60
3.97% of people over 18 were coded with CKD
67% of people with CKD were coded
CKD coding: Key findings
• 33% did not have a GP CKD code.
• Patients more likely to be coded:
– Males
– Older age
– More severe CKD
– Diabetes or hypertension
– Statin prescription
• Patients without any kidney diagnosis were less likely to receive
optimal care than those coded for CKD [e.g. odds ratio for meeting
blood pressure target 0.78 (95% confidence interval 0.76-0.79)].
Of 256 000 patients with biochemical CKD:
Practice variation eGFR testing (at risk)
Practice variation urinary ACR testing (at risk)
Practice performance in percentage of people meeting blood
pressure targets by target and diabetes status
<140/90 mmHg, No diabetes
<130/80 mmHg, No diabetes and ACR >70 mg/mmol
<130/80 mmHg, Current diabetes
Includes data from 900 of 910 practices
29.2% of strata-specific measures excluded
with denominator <10
Percentage of people with coded CKD 3-5 on a statin, by age
(below 65 years vs above) and diabetes
Practice variation in percentage of people with coded CKD with annual
repeat tests of eGFR by diabetes status
Includes data from 872 of 910 practices.
4.2% of strata-specific measures
excluded with denominator <10
Practice variation in percentage with coded CKD stage 3-5 who have
repeat urinary ACR tests stratified by diabetes
Includes data from 872 of 910 practices
4.2% strata-specific measures excluded with
denominator <10
Are we protecting CKD patients?Flu vaccination rates
48.8
70.272.5
77.1
020
4060
8010
0
Per
cent
age
Vac
cina
ted
in L
ast Y
ear
Age <= 65 Age > 65
No Diabetes Diabetes No Diabetes Diabetes
Percentage of Coded CKD Patients Vaccinated Against Flu in Last Yearby Age and Diabetes
How do primary care doctors in England and
Wales code and manage people with chronic
kidney disease?
Results from the National Chronic Kidney
Disease Audit
Lois G Kim1,2, Faye Cleary1, David C Wheeler3,
Ben Caplin3, Dorothea Nitsch1, Sally A Hull4
On behalf of the UK National Chronic Kidney
Disease Audit
(In Press –Nephrology, Dialysis Transplantation)
Recommendations (from 1st Report)
• Recommendation 1. For people at high risk of CKD, GPs should review practice to ensure that they are including both blood tests for eGFR and urinary testing for albumin to creatinine ratio (ACR).
• Recommendation 2. GPs should review practice to improve the coding of patients with CKD. – The proportion of CKD cases that were uncoded ranged between 0% to 80%.
– Computerised quality improvement tools, can assist GPs with appropriate coding, which in turn supports improvements in management.
–
• Recommendation 3. Having identified patients with CKD, effort should be focused on regular review, management of high blood pressure, prescribing cholesterol lowering treatments, and performing vaccinations to improve health outcomes. – Whilst 75% of people with identified CKD had a flu vaccination in accordance with
NICE Guidance, only 23% of people with CKD stages 4 and 5 had the recommended pneumococcus vaccination.
Linking primary and secondary care data
• What are the rates of death for people with CKD? • What are the rates of unplanned hospital admission for people
with CKD? • For people with CKD who were admitted to hospital: What are the
rates of admission for acute kidney injury (AKI) and for acute cardiovascular (CV) disease?
• Do these rates vary by CKD severity and coding status? • Are GP referrals for people with CKD being seen by a specialist
within 18 weeks?
Lessons form the CKD audit
• It is feasible to conduct an electronic audit in primary care• The audit tool needs to run on all GP computer systems• There is wide variation in the use of CKD 3-5 codes with under
diagnosis, and misdiagnosis• Blood tests seem easier to perform than urine tests• Some practices do very well with 90% testing and follow up• Some practices improved their coding between the 2 rounds of
data extraction but the majority did not• There is room for improvement in management of BP, CVD risk
with statins and immunisation• Primary and secondary care need to collaborate better to
achieve optimal patient outcomes.
Virtual CKD clinic
A 67 year old with diabetes, an eGFR of 23 ml/min/1.73sq and ACR
of 203 mg/mmol EMIS web
Primary Care
Secondary Care
?
Kathryn Griffith Project Board Chair and RCGP Clinical Champion
Nick Wilson CKD project manager Wales
Paul Myers GP and Public Health Wales
Paul Wright GP Manchester
Sally Hull GP London and QMUL
Fiona Loud Patient Representative
Richard Fluck National Kidney Director
Maarten Taal Nephrologist Derby
Hugh Gallagher Nephrologist St Helier
Dorothea Nitsch LSHTM
Andy Syme Informatica Project Manager
Richard Gunn Informatica
Matthew Harker BMJ
Lois Kim Researcher LSHTM
Fay Clearly Researcher LSHTM
All the GP’s and Practice Managers
Acknowledgements