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8 1. Improve identification of CKD in primary care Increase coding Improve testing of at risk groups Develop QI tools for diagnosis and staging 2. Improve management of CKD patients not requiring specialist review Audit against NICE targets (e.g. BP, CV risk assessment, CKD monitoring) Develop QI tools for primary care management 3. Improve timely referral of CKD patient requiring specialist review Audit referrals through HES linkage Snapshot of referral pathways across CCGs Develop QI tools to prompt for specialist advice
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10 ,!- David Wheeler Project lead and UCL 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 Richard Fluck National Kidney Director Maarten Taal Nephrologist Derby Hugh Gallagher Nephrologist St Helier Dorothea Nitsch LSHTM Andy Syme Informatica Project Manager Matthew Harker BMJ
11 Potential low practice uptake : What is in it for the practices? 2. Loss of interest in Wales with change in QOF and loss of CKD indicators 3. Getting software installed in practices without existing Informatica software and paying an exorbitant fee. Hope that this would resolve in 2015 with change in contracting with primary care software providers: Pilot through practices with existing Informatica software
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28 .!. %*; Total CKD Prevalence, by Age Group (England) Total CKD Prevalence, by Age Group (Wales) A g e - S tr a ti fi e d T o t a l C K D P r e v a le n c e ( % ) A g e - S tr a tifie d T o ta l C K D P r e v a le n c e ( % ) Coded CKD Uncoded CKD Coded CKD Uncoded CKD Uncoded CKD includes confirmed biochemical CKD over 3 months only. Uncoded CKD includes confirmed biochemical CKD over 3 months only.
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30 ;" 45 "! ; Practice Variation in Percentage of Coded CKD Patients with egfr Test in Last Year, by Diabetes Diabetes No Diabetes Percentage with GFR Test in Last Year Includes data from 931 of 980 practices; 5% of strata-specific measures excluded with denominator < 10
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32 Practice Variation in Percentage of Coded CKD Patients with ACR Test in Last Year, by Diabetes Diabetes No Diabetes Percentage with ACR Test in Last Year Includes data from 931 of 980 practices; 5% of strata-specific measures excluded with denominator < 10
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35 C!-. *. ** Percentage of Coded CKD Patients Meeting Target BP Based on Last Measure, by Age Target BP Percentage Meeting T Overall, 55.5% of patients met target BP based on their last recorded measure
36 ) Percentage of Coded CKD Patients Prescribed Statins or Contraindicated by Age and Diabetes, stacked by CVD Percentage St tatin Use No Diabetes Diabetes No Diabetes Diabetes Age <= 65 Age > 65 CVD No CVD
37 "!. 0 ;!! Percentage of Coded CKD Patients Vaccinated Against Flu in Last Year by Age and Diabetes in Last Year Percentage Vaccinated No Diabetes Diabetes No Diabetes Diabetes Age <= 65 Age > 65
38 ;. $ ( CVD: cardiovascular disease CVD CNI/Li: prescription of calcineurin inhibitor or lithium; The line in the middle of each bar is the median) percentage tested per practice. The boxes show the interquartile range, which is half of all practices have tested a given percentage of people for an egfr in the range of the box. The whiskers show the upper and lower 2.5centile tested per practice, i.e. 95% of practices are within the whisker range. The dots
39 @. $ ( CVD: cardiovascular disease. CNI/Li: prescription of calcineurin inhibitor or lithium; The line in the middle of each bar is the median (-? percentage tested per practice. The boxes show the interquartile range, which is half of all practices have tested a given percentage of people for an ACR test in the range of the box. The whiskers show the upper and lower 2.5centile tested per practice, i.e. 95% of practices are within the whisker range. The dots are practices outside the 95% range
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