All Wales National Audit 2013 f ACKD. Anaemia of CKD. Chris Brown SWW Renal Unit. David Jackson Anke Hagemi North Wales Renal Unit 10/21/2013 1

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1 All Wales National Audit 2013 f ACKD Anaemia of CKD Chris Brown SWW Renal Unit David Jackson Anke Hagemi ABMU HB North Wales Renal Unit 10/21/2013 1

2 Governance: are reconfigured services robust? Contractual: inform procurement obligations Critical appraisal: what s done well or not? Defining National standards: registry shortfalls Practice development: consider our treatment approaches Future opportunities: procurement & clinical 2

3 Anaemia of Chronic Kidney Disease Treated when HB consistently below 10g/dl with: Iron repletion: Ferritin > 200 ng/ml TSAT >20% ESAs Hb g/dl Treatment is effective BUT expensive AND also labour intensive because of the need for tight target control HB: too low is harmful & too high harmful We need to use ESAs sparingly & with care 10/21/2013 3

4 Set by the UK Renal Association for: Hb Ferritin (shift 2011) TSAT Determined by the Renal Registry for: Hb Ferritin In HD and PD patients. All Wales audit 2012: Hb, Feritin, TSAT In Pre-dialysis & Tx 4

5 Audit of routine monthly / quarterly bloods March 2013 Inclusion/exclusion criteria Excel data proforma N = ~ 3000 patients (~ 2700 after QC) Analysis: compliance with national targets Excel calculator developed for analysis 10/21/2013 5

6 Inclusion: Haemodialysis = All pts Peritoneal / Tx / Pre-dialysis = only ESA pts Study MONTH Study PERIOD January February March ESA dose Venofer Cosmofer / Monofer / Ferinject / Rienso Blood results = latest recorded 10/21/2013 6

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9 = 2 x Month mg 1gm 1gms = 1 x per day 1-gram 1g 1 g 10/21/2013 9

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11 Hospital No. Yes Yes yes Unit Hub Yes Yes Yes CKD Status Yes Yes Yes Date dialysis initiated Yes Yes No Incident vs Prevalent Yes Yes No ESA Brand Yes Yes Yes ESA Route Yes Yes Yes Weekly ESA dose Yes Yes Yes Freq of administration Yes Yes Yes Monthly / Quart. Iron dose Yes Yes No IV Iron brand Yes Yes No Supp. oral Iron Yes Yes No HB Yes Yes Yes Ferritin Yes Yes Yes TSAT Yes Yes N/A CRP Yes Yes No Pre and Post urea Yes Yes No URR Yes Yes No Vascular access Yes Yes No 10/21/

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13 % Patients in Hb range Mean Hb (g/dl) 100% Patient Numbers % % % % 50% % % 20% 56.2% 46.4% 56.0% 55.1% % above target (>12g/dl) % in target (10-12g/dl) 10% 59.7% 7.0 % below target (<10g/dl) 0% 49.4% Bangor Cardiff Rhyl Swansea Wrexham All Wales 6.0 Mean

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15 % Patients in Hb range Mean Hb (g/dl) 100% 90% 80% 70% Patient numbers Bangor % Cardiff % Rhyl % Swansea % Wrexham % All Wales % 60% % % % 20% 10% 62.2% 56.4% 57.1% 60.9% 65.6% 59.2% % above target (>12g/dl) % in target (10-12g/dl) % below target (<10g/dl) 0% Bangor Cardiff Rhyl Swansea Wrexham All Wales 6.0 Mean

16 Swansea Bangor Rhyl Wales Cardiff Wrex 61% 62% 57 % Wales % 66% 59% 56% 60% 46 % Wales % 50% 55% 67% 59% 58 % RR % 49% 59% 10/21/

17 % Patients in ferritin range Mean Ferritin ng/ml 100% 90% 80% 70% Patient Numbers % 2.6% 13.5% 12.6% 11.7% 12.9% 11.0% 7.7% 17.9% 27.0% 22.3% 26.4% Bangor % Cardiff % Rhyl % Swansea % Wrexham 93 98% All Wales % 60% % % 30% 20% 62.8% % % 41.8% 55.6% % above target (>800ng/ml) % above target ( ng/ml) % in target ( ng/ml) % below target ( ng/ml) 10% 0% 18.9% 13.2% 17.6% 15.4% 55.4% 14.3% 2.7% 5.7% 1.4% 2.5% 3.3% 3.3% Bangor Cardiff Rhyl Swansea Wrexham All Wales % below target (<100ng/ml) Mean

18 Rhyl Cardiff Swansea Wales Bangor Wales % 100% 97% 94% 97% Wales % 100% 97% 91% 95% RR % 97% 96% 91% 95% Iron Dose mg mg mg mg 10/21/

19 Cardiff Rhyl Bangor Swansea Wales 63% 71% 55% 46% Wales % 57% 64% 54% 45% Wales % 64% 63% 58% 50% RR % 10/21/

20 Rhyl Bangor Swansea Cardiff Wales 2.6% 14% 13% 3.2% Wales % 2.9% 3% 7% 4.6% Wales % 10/21/

21 % Patients in TSAT range Mean TSAT % 100% 90% 80% 70% 60% Patient Number with test reult % 55.0% 85.6% 64.6% Bangor 74 0% Cardiff 456 0% Rhyl % Swansea % Wrexham 93 97% All-Wales % 50% 40% 30% % in target (>=20% 20% 45.0% 35.4% 10 % below target (<20%) 10% 19.5% 14.4% 0% 0.0% 0.0% 0.0% 0.0% Bangor Cardiff Rhyl Swansea Wrexham All-Wales 0 Mean

22 HB : Targets > UK benchmarks Consistent across Wales HB: Improvement from 2012 Ferritin: target > UK benchmarks Appropriate iron strategies Maintaining standards 2013 RRR looks bright Similarities: same outcomes Differences: management strategies 10/21/

23 % Patients in Hb range Mean Hb (g/dl) 100% 90% 80% 70% Patient Number Bangor % Cardiff % Rhyl 3 100% Swansea % Wrexham 2 100% All Wales % 60% % 40% % % % % % 61.5% 9.0 % above target (>12g/dl) 20% 8.0 % in target (10-12g/dl) 10% 7.0 % below target (<10g/dl) 0% 100.0% Bangor Cardiff Rhyl Swansea Wrexham All Wales 6.0 Mean

24 % Patients in ferritin range Mean Ferritin ng/ml 100% 90% 80% 70% Patient Number % 18.7% 32.0% Bangor % Cardiff 36 89% Rhyl 3 100% Swansea % Wrexham 2 100% All Wales 79 95% 60% % % % % 30% 20% 10% 0% 61.5% 25.0% % 24.0% 21.3% 20.0% 15.4% 21.9% 12.0% 14.7% 7.7% 100.0% Bangor Cardiff Rhyl Swansea Wrexham All Wales % above target (>800ng/ml) % above target ( ng/ml) % in target ( ng/ml) % below target ( ng/ml) % below target (<100ng/ml) Mean

25 % Patients in TSAT range Mean TSAT % 100% 90% 80% 70% Patient Numbers for test result % 32.0% 0.0% 37.9% Bangor 13 0% Cardiff 36 0% Rhyl 3 100% Swansea % Wrexham 2 50% All-Wales 79 37% 60% 50 50% 40% % 20% 10% % in target (>=20% % below target (<20%) 0% 0.0% 0.0% Bangor Cardiff Rhyl Swansea Wrexham All-Wales 0 Mean

26 Surly more Home HD patients achieve target? HB, Ferritin and TSAT: In target : Home HD < Unit HD This must be because they over achieve target? 10/21/

27 % Patients in Hb range Mean Hb (g/dl) 100% 90% 80% 70% Patient Bangor % Cardiff 43 98% Rhyl 8 100% Swansea 51 98% Wrexham % All Wales % 60% % % 54.8% % 56.0% 59.8% 9.0 % above target (>12g/dl) 20% 10% 70.0% 75.0% 75.0% % in target (10-12g/dl) % below target (<10g/dl) 0% Bangor Cardiff Rhyl Swansea Wrexham All Wales 6.0 Mean

28 % Patients in ferritin range Mean Ferritin ng/ml 100% 90% 80% 70% Patient Numbers % 11.6% 6.0% 13.0% 21.4% 20.9% Bangor % Cardiff 43 65% Rhyl 8 88% Swansea 51 84% Wrexham % All Wales % 60% 50% % 42.9% 48.0% % 20% 10% 0% % 66.7% 71.4% 19.0% 70.0% 9.3% 14.3% 16.7% 35.7% 7.0% 14.0% Bangor Cardiff Rhyl Swansea Wrexham All Wales % above target (>800ng/ml) % above target ( ng/ml) % in target ( ng/ml) % below target ( ng/ml) % below target (<100ng/ml) Mean

29 % Patients in TSAT range Mean TSAT % 100% 90% 80% 70% Patient Numbers % 63.8% Bangor 10 0% Cardiff 43 0% Rhyl 8 0% Swansea 51 92% Wrexham 12 0% All-Wales % 60% 50% % 15 30% 20% 10% 36.2% 36.2% 10 5 % in target (>=20% % below target (<20%) 0% 0.0% 0.0% 0.0% Bangor Cardiff Rhyl Swansea Wrexham All-Wales 0.0% 0 Mean

30 HB : Targets > UK benchmarks Less consistent across Wales (vs HD) HB: similar to 2012 Ferritin: New target by authorities Ferritin: target > UK benchmarks Significant improvement to /21/

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33 Why repatriated to a tertiary care service? 10/21/

34 1. Increasing prevalence & patient no. Increasing recognition & referral 2. Tighter clinical targets 3. Increasing options & complexity 4. Increasing costs & need to reduce expenditure 10/21/

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36 % Patients in Hb range Mean Hb (g/dl) 100% 90% 80% 70% Patient Numbers Bangor 4 100% Cardiff 98 83% Rhyl 9 100% Swansea % Wrexham 0 #DIV/0! All Wales % 60% % 40% % % 75.0% 9.0 % above target (>12g/dl) 20% 59.3% 60.9% 60.7% 8.0 % in target (10-12g/dl) 10% 7.0 % below target (<10g/dl) 0% 0.0% Bangor Cardiff Rhyl Swansea Wrexham All Wales 6.0 Mean

37 % Patients in ferritin range Mean Ferritin ng/ml 100% 90% 80% 70% 0.0% 8.9% 11.1% 10.0% 9.4% 10.7% 11.1% 10.0% 10.4% 467 Patient Numbers Bangor 4 25% Cardiff 98 57% Rhyl 9 100% Swansea 46 87% Wrexham 0 #DIV/0! All Wales % 60% 50% 23.2% 23.2% % % 30.2% % 30% 0.0% 35.0% 25.5% % 10% 0% 33.9% 33.3% 10.0% 100.0% 0.0% 0.0% 0.0% % Bangor Cardiff Rhyl Swansea Wrexham All Wales % above target (>800ng/ml) % above target ( ng/ml) % in target ( ng/ml) % below target ( ng/ml) % below target (<100ng/ml) Mean

38 % Patients in TSAT range Mean TSAT % 100% 90% 80% 70% Patient Numbers % 67.5% 68.3% Bangor 4 25% Cardiff 98 0% Rhyl 9 0% Swansea 46 87% Wrexham 0 #DIV/0! All-Wales % 60% 50% % 15 30% 20% 10% 32.5% 31.7% 10 5 % in target (>=20% % below target (<20%) 0% 0.0% 0.0% Bangor Cardiff Rhyl Swansea Wrexham All-Wales 0.0% 0 Mean

39 % Patients in Hb range Mean Hb (g/dl) 100% 90% 80% 70% Patient Numbers Bangor % Cardiff % Rhyl % Swansea % Wrexham % All Wales % 60% % % % 64.7% 9.0 % above target (>12g/dl) 20% 10% 66.3% 73.2% 63.6% 65.2% 65.4% % in target (10-12g/dl) % below target (<10g/dl) 0% Bangor Cardiff Rhyl Swansea Wrexham All Wales 6.0 Mean

40 % Patients in ferritin range Mean Ferritin ng/ml 100% 90% 80% 70% 60% 50% % % Patient Numbers % 40.3% Bangor % Cardiff % Rhyl % Swansea % Wrexham % All Wales % 40% 30% % 60.7% % above target (>800ng/ml) % above target ( ng/ml) % in target ( ng/ml) 20% 100 % below target ( ng/ml) % below target (<100ng/ml) 10% 50 Mean 0% Bangor Cardiff Rhyl Swansea Wrexham All Wales 0

41 % Patients in TSAT range Mean TSAT % 100% 90% 80% 70% Patient Numbers % 77.9% 56.0% 87.0% 65.4% Bangor 100 9% Cardiff 451 0% Rhyl % Swansea % Wrexham % All-Wales % 60% % % 15 30% 20% 10% 44.0% 13.0% 34.6% 10 5 % in target (>=20% % below target (<20%) 0% 0.0% 0 Bangor Cardiff Rhyl Swansea Wrexham All-Wales 0 Mean

42 HB, Ferritin & TSAT: Improvement on All Wales 2012 benchmarks HB: consistent across Wales New thinking : from ESA to Iron 10/21/

43 Share the results of our All-Wales audit of ESA for ACKD Demonstrate the levels of target achievement in accordance with current national standards & comparative benchmarks Consider what we do with these results and how to make best use of this information How we go forward from here on an All Wales level 43

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45 % Pt on IV iron Venofer Cosmofer Monofer Ferinject Rienso Bangor 14% 14% 7% 0% 79% 0% Cardiff Rhyl 31% 5% 0% 0% 95% 0% Swansea 12% 96% 0% 4% 0% 0% Wrexham 11% 96% 0% 0% 4% 0% 10/21/

46 % patients in Hb target range Influeunce of CRP on Hb levels - Unit HD 100% 90% 80% 70% 60% 50% Unit HD Hb > target Unit HD Hb in target Unit HD Hb < target 40% 30% 20% 10% 0% CRP <10 CRP CRP CRP CRP CRP >200 10/21/

47 The pessimist sees difficulties in every opportunity. The optimist sees opportunities in every difficulty Winston Churchill 10/21/