National Audit of CKD in Primary Care

Transcription

1 National Audit of CKD in Primary Care David C Wheeler Royal Free Campus University College London d.wheeler@ucl.ac.uk Kidney for General Physicians RCP London 24 th November 2017

2 Who looks after CKD patients (UK)? Primary Care Nephrology Other secondary care CKD CKD CKD % of total by stage Data from NHS England Donal O'Donoghue, Personal communication

3 GPs Shoulder the Burden of CKD May 11 th, 2006

4 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

5 NICE CG 182 (2014): Suggested Frequency of CKD monitoring GFR Category GFR ml/min /1.73m 2 GFR Description Frequency of monitoring egfr (times per year) A1 A2 A3 G1 90 Normal or high G Mildly decreased G3a G3b Mildly to Moderately decreased Moderately to severely decreased G Severely decreased G5 <15 Kidney failure ACR Categories: A1 (normal to mildly increased) < 3 mg/mmol, A2 (moderately increased) 3-30 mg/mmol, A3 (severely increased) > 30 mg/mmol

6 The NCKDA The National Primary Care CKD Audit 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)

7 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

8 Screen shot of the audit tool dashboard coded Possibly Uncoded Possibly Miscoded egfr tested Not tested for Proteinuria egfr not tested Tested for Proteinuria

9 Screen shot of audit tool dashboard (management of CKD)

10 Audit timetable Pilot Pilot Report Round 1 (Baseline) For any practice was a QI Period between Baseline and Audit of circa 10 months Round 2 (Audit) Practice Reports CCG & National Report

11 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.

12 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

13 Practice Performance: Coding CKD 99.8% control 95.0% control Mean

14 Improvement in coding between audit cycles Overall 4% of practices improved coding according to our criteria within 3 months.

15 Coding with CKD % 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/1.73m 2 and were therefore potentially miscoded Coding rates low in those of black ethnicity because correction factor had not been used

16 CKD prevalence: Patients with last 2 egfrs < % of people over 18 were coded with CKD 67% of people with CKD were coded

17 CKD coding: Key findings Of patients with biochemical CKD: 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 )].

18 Practice variation egfr testing (at risk)

19 Practice variation urinary ACR testing (at risk)

20 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

21 Percentage of people with coded CKD 3-5 on a statin, by age (below 65 years vs above) and diabetes

22 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

23 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

24 Are we protecting CKD patients? Flu vaccination rates Percentage of Coded CKD Patients Vaccinated Against Flu in Last Year by Age and Diabetes No Diabetes Diabetes No Diabetes Diabetes Age <= 65 Age > 65

25 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 Kim 1,2, Faye Cleary 1, David C Wheeler 3, Ben Caplin 3, Dorothea Nitsch 1, Sally A Hull 4 On behalf of the UK National Chronic Kidney Disease Audit (In Press Nephrology, Dialysis Transplantation)

26 Recommendations (from 1 st 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.

27 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?

28 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.

29 Virtual CKD clinic? Primary Care A 67 year old with diabetes, an egfr of 23 ml/min/1.73sq and ACR of 203 mg/mmol EMIS web Secondary Care

30 Acknowledgements 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