West and South Yorkshire and Bassetlaw Commissioning Support Unit. QIPP Programmes CKD QIPP

Transcription

1 West and South Yorkshire and Bassetlaw Commissioning Support Unit QIPP Programmes CKD QIPP May 2013

2 Contents Introduction...2 Overall approach...2 Results Discussion...5 Conclusion...5 Appendix 1...6

3 Introduction CKD is an independent risk factor for cardiovascular diseases/stroke therefore increasing mortality and morbidity. (Perkovic, 2007; Schiffrin, 2007; Lee et al., 2010; Di Angelantonio et al., 2010). Additionally, CKD patients are more likely to be hospitalized (Go et. al., 2004) leading to an increased demand for secondary care services. Approximately 1.5% of patients with CKD will progress to end stage renal disease (Fell, 2008) requiring lifelong dialysis. When patients reach a stage where they need to be dialyzed the five-year survival rate is significantly reduced (29% estimated five-year survival). An audit conducted in 2010 indentified the following quality gaps: A gap (~7000) between expected and recorded CKD prevalence (de Luisagane et al., 2009) A quality gap defined by BP management. Health inequality gap (2 proxy measures) o o Correlation coefficient between prevalence gap and practice deprivation score (r2=0.62) which suggests that practices with more socioeconomically disadvantaged patients are more likely to have a bigger gap thus leading to a hypothesis that management may be poorer with poorer outcomes. For example GP will be prompted and incentivised by QOF to achieve lower BP target if patient is added to the CKD register. % of CKD patients that achieved BP target was lower in practices with more deprived populations. Overall approach An improvement cycle was used as a framework. The collaborative breakthrough series was used as a model for improvement (IHI, 2004). During the project 10 evidence based strategies (appendix 1) were applied to drive change (AHRQ, 2004). The model was well received and it appears to be an effective tool for improvement. Lessons learned will be used to enhance this model and use it in other projects (e.g., AFQIP). Collaboration was supported by a Knowledge Transfer Associate who facilitated the adoption of good practices and local small innovations between practices. The project aim was to minimize the gap between expected and recorded prevalence by 50% (11,381 patients on CKD register ); and for 75% of patients on the CKD register (existing patients and previously unfound patients newly added ) to achieve QOF blood pressure (BP) target 140/85. Over 55% of practices (45) joined the project, covering a population of 317,741. 2

4 Results In the last year the prevalence gap was closed by 45%. This equates to 1,685 (p<0.001) 1 new CKD patients added to the CKD register in the population of 317,741. In the previous year prior to the project all practices added 340 patients in the same time period (12 months). The percentage of patients that achieved QOF BP increased from 65.2% to 68.4% (p=0.003) 1 which means an additional 1,442 patients (additional 1,442 who now have control (QOF BP target) who may not have had controlled BP this time last year. Evidence suggests that well controlled BP in patients with CKD leads to reduction in mortality and morbidity mainly CVD and End Stage Renal Disease (ESRD). o NNT dyslipidemia to prevent one CVD event =100 o NNT hypertension to prevent one CVD event =90 o In addition, though not testable here improving BP management in a large population will slow progression and may prevent progression to ESRD (estimates of NNT are available) Health inequality Mean % of patients that achieved BP Jan 2011 Mean % of patients that achieved BP Jan 2012 ~Deprived % ~ Affluent 64.4% ~Deprived % 68.1% ~Affluent 65.8% The absolute improvement % of patients with BP controlled in practices with more deprived populations was higher than those with affluent populations. Moreover, early identification and appropriate management in primary care can reduce cost in secondary care. A simple calculation was conducted based on the results from the CKD QIP and literature (Fig.1 and Fig.2). For secondary care usage two comparisons were made (the analysis was conducted from the payer perspective). 1. Nephrology outpatient and inpatient visits between intervention and control group. In CKD QIP practices outpatient visits were reduced by 1.3pts/1000 (p=0.01) and inpatient admissions by 0.05pts /1000 (p=0.62) (Fig.1). Note the simplicity and weaknesses of self selected control etc 2. Before and after/during the time of CKD QIP (Fig.2). 1 We used a t-test to compare variables before and after the project. 2 Practices were ranked according to deprivation score. Practices above the mode were defined as affluent and below as deprive. 3

5 Results Figure 1 3 participating practices v non participating Potential savings based on the observations during the time of the project. Intervention vs. control group. Reduction in health checks. Patients years old added to CKD register are excluded from health check program. CKD QIP practices added 631 patients in this age range that will be excluded from the health check. For most of those patients the check will cost plus cost of lab tests. Net Savings -631* cost of tests = - 16, Cumulative net Total - 16, Reduction in outpatient visits (nephrology). Outpatient visits were compared between 2 groups. After the project CKD QIP practices had fewer outpatient visits -1.3p/1000 (p=0.01) which equates to total of CKD QIP vs. Non CKD QIP 2011 Reduction in inpatients visits -8 (CKD QIP vs. Non CKD QIP 2011). Inpatient visits were compared between 2 groups. After the project CKD QIP practices had fewer inpatient visits 0.05/1000 this equates to -8 however difference was not statistically significant 4 p=0.68 (average cost 2000) Potential savings - 29, , * 2,000 = - 16,000-62, Net Potential Savings Total Potential 1 ESRD prevented per year (NNT hypertension = 632 There is a limited number of studies that report NNT hypertension to prevent ESRD. Patients involved in those studies are at higher risk of ESRD hence the results should be interrupted with caution. -2* 30,000 (cost of medication included see below) = - 60, , Potential 16 CVD events prevented per year (NNT hypertension = 90) Ogden et al., Evidence suggests that by treating hypertension in 90 patients with CKD 1 CVD could be prevented in one year. -16* 4,620 = - 73, ,821 (cost of medications) = - 27, , Estimated cost of the implementation - 60,000 This analysis presents monetization of health gains not a real impact on health and wellbeing of the local population. Epidemiologic analysis will be conducted to measure true health impact. 3 We are going to conduct a sensitivity analysis to validate assumptions made in these calculations. 4 Possibly due to small sample size. 4

6 Discussion There are a number of limitations and uncertainties in this analysis such as: NNT hypertension to prevent ESRD Assumptions regarding uncontrolled blood pressure prior to being added to the CKD register Lack of randomization/self selection Uncontrolled environment. Authors bias In order to reduce limitations and uncertainties most of the variables used are based on the worst case scenario (e.g., UCL from studies, NNT for primary prevention only, we compare intervention vs. control group which is uncommon in reports from real life QI projects). Despite that this analysis should be interpreted with caution. Conclusion During the CKD QIPP a new framework for improvement was developed and implemented. The CKD QIP is an example of a project that addresses each domain of the QIPP. Quality- BP quality gap and prevalence gaps. Innovation- using IT tool and 10 evidence based tools for QI. New CKD and ESRD risk assessment tool in pilot stage. Productivity-Reduction in utilization of secondary care. GPs focused on high risk cohorts. Prevention- Primary/secondary prevention of CVD and ESRD. The observations during the time of the project suggest positive cost and health gains. 5

7 Appendix 1 1. Physician reminder systems 2. Facilitated relay of clinical data (S1 searches) 3. Audit and feedback 4. Physician education 5. Outreach visits 6. Patient education 7. Promotion of disease self management 8. Organizational changes (Total Quality Management and Continuous Quality Improvement) 9. Financial incentives QOF 10. Local opinion leaders 6

8 West and South Yorkshire and Bassetlaw CSU Douglas Mill Bowling Old Lane Bradford BD5 7JR