Dialysis Mortality Regional Clinical Audit Report 2011

Transcription

1 Dialysis Mortality Regional Clinical Audit Report 2011 Clinical Audit Lead: Authors: Dr Iren Szeki Consultant Nephrologist, Manchester Royal Infirmary Dr Iren Szeki, Consultant Nephrologist Dr Helen Alderson, SpR Rasheeda Kholwadia, Regional Renal Audit Facilitator Tracey Powell, Regional Renal Audit Co-ordinator Contact Address: NW Renal Audit Programme Renal Audit C/O Renal Wards 36/37 Manchester Royal Infirmary Oxford Road Manchester M13 9WL TELEPHONE NUMBER: WEB ADDRESS:

2 CONTENTS Contributors 1 1. Introduction and Background 2 2. Aims and Objectives 2 3. Evidence Base 2 4. Standards 3 5. Methodology 3 6. Results Summary 4 7. Discussion Recommendations Action Plan 12 Appendix 1 Project plan 3 Appendix 2 Glossary of Terms and Abbreviations 2 Appendix 3 Data parameters 2

3 CONTRIBUTORS Established in 1992, the North West Renal Audit Programme is a standards based programme of continuous quality improvement through clinical audit. The programme is directed by the North West Renal Audit Steering Group and the daily management carried out by the North West Renal Audit Team with support from other renal professionals The following adult renal units took part in the dialysis mortality audit: Aintree University Hospital Manchester Royal Infirmary Salford Royal Hospital The following people contributed to the data collection and/or analysis for this audit. Dr Iren Szeki, Manchester Royal Infirmary Dr Ed O Riordan, Salford Royal Foundation Trust Dr Sana Tahir, Aintree University Hospital Dr Helen Alderson, Manchester Royal Infirmary Tracey Powell, Manchester Royal Infirmary Rasheeda Kholwadia, Manchester Royal Infirmary

4 1. INTRODUCTION & BACKGROUND This audit was undertaken to quantify regional kidney survival rate and also to compare take on rates in the North West region. The data was collected with reference to guidelines from the renal registry and KDOKI guidelines along with the DOPPS report. It is an important area because it highlights areas where improvements are needed to make sure all dialysis patients regardless of social status, sex, ethnicity, and co-morbidity receive the best possible outcome. 2. AIMS AND OBJECTIVES The aim of the audit is to work towards achieving equity of dialysis for patients of different social status, sex, ethnicity and co-morbidity. The objectives were to: Collect data over the course of 5 years ( ) Compare take on rate for each unit in terms of age, ethnicity and co-morbidity at start of renal replacement therapy (RRT). Quantify regional patient survival and record cause of death Compare outcomes to published national data from the renal registry 3. EVIDENCE BASE Renal Registry publishes survival on dialysis according to age at start of RRT. The DOPPS report KDOQI guidelines Page 2

5 4. STANDARDS There are currently no national guidelines or standards that relate specifically to dialysis mortality in the UK. Data is however, collected by the Renal Registry on mortality according to age at start of RRT. However there are recommendations which state that survival analysis must at least take account of age, gender, diabetes and co-morbidity. 5. METHODOLOGY All new renal dialysis patients who survive > 3 months. Data was collected prospectively from computer systems, and patient notes onto a standardised data collection sheet (excel format). Data was collated and analysed using standard Excel software by a member of the NW Renal Audit Team. Units that participated in this audit include MRI, Salford Royal and Aintree University Hospital. Off these units not all data was comparable for analysis purposes. Data collected varied through trusts. For MRI and SRFT it was collected over the period from January to December For AUH it covered the period from January 2009 to January Page 3

6 6. RESULTS SUMMARY 6.1 Demographics The data analysed here consist of 161 patients for MRI during 2009; 111 patients for Salford Royal Foundation Trust for 2009; and 75 patients for University Hospital Aintree. The data for MRI and SRFT covers the period January to December 2009; for AUH it covers a period from 2009 to January Aintree MRI SRH No. of patients Female Male Figure 6.1 Number of patients included in audit The demographic data overall was as expected with only marginal differences in the ratio between male and females across all the units. There was an approximate 50%/50% split between the number of patients commencing dialysis in the audit period who were <65 years old and those who were =/> 65 years old (Figure below) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Aintree -June 09 -Jan 11 MRI SRH <65 years old =/>65 years old Not stated Figure 6.1.1: Patients <65 years old and patients =/> 65 years old commencing dialysis during audit period Page 4

7 6.2 Aetiology of renal failure The most common causes of ESRF are diabetes (22%), obstruction (7.2%); hypertension (6.4%); ATN (6%), unknown or not stated (15%) (Table 6.2.1). These common causes of ESRF seem to be of a higher percentage of patients in AUH. Majority of the causes of ESRF seem to be likely from pre renal failure rather than post. Table 6.2.1: Causes of ESRF for MRI and AUH patients Cause of ESRF AUH patients % AUH MRI % MRI Total % ADPKD ATN (sepsis /hypotension) Amyloid Vasculitis Hypertension Diabetes Cholesterol emboli Chronic pyelonephritis Unknown cyclosporin toxicity Obstruction AKI post surgery FSGS Mesangiocapillary GN Unspecified GN Good Pasture Vasculitis Ig A nephropathy interstitial nephritis Ischaemic Nephropathy Membranous GN Membranoproliferative GN Myeloma Nephrectomy Renal Carcinoma Renal hypoplasia Renovascular Disease Sarcoid Scleroderma SLE Urate Nephropathy Not stated Totals % % 100% 6.3 Course of Renal Replacement Therapy This data was only available for MRI. Figure 6.3, below shows the course of RRT for MRI patients. The largest group of patients where those who started on HD and remained on it (33%). When analysing the RRT patients as a whole group there was no unusual findings this was also true of the split between male and female Page 5

8 Figure 6.3: a) Course of RRT (all patients) and b) course of RRT for males and females a) b) % Total patients PD - Transplant PD - Home - HD PD - HD - PD - HD PD - HD - Died PD - HD PD - Died PD HD - Transplant HD - recovered - HD - PD - HD HD - recovered - HD - died HD - recovered - HD - transplant HD - recovered - HD - died HD - recovered - died HD - recovered HD - PD - Transplant HD - PD - HD HD - PD - Died HD - PD HD - Home HD - Died HD 0% 5% 10% 15% 20% 25% 30% 35% PD - Transplant PD - Home - HD % Male PD - HD - PD - HD % Female PD - HD - Died PD - HD PD - Died PD HD - Transplant HD - recovered - HD - PD - HD HD - recovered - HD - transplant HD - recovered - HD - died HD - recovered - HD HD - recovered - died HD - recovered HD - PD - Transplant HD - PD - HD HD - PD - Died HD - PD HD - Home HD - Died HD 0% 5% 10% 15% 20% 25% 30% 35% 6.4 Co-morbidities The commonest co-morbidity at MRI was Ischaemic Heart Disease (HD), with a significantly higher percentage than those at AUH; together with a significantly higher percentage of patients with congestive cardiac failure. The proportion of other comorbidities in both AUH and MRI were broadly similar. When looking at the comorbidities data by age in fig6.4.1 it can be seen that at MRI there are significantly more patients who are 65> and are diagnosed with ischeamic heart disease that compared to Aintree. Comorbidities Ischaemic Heart Disease (IHD) Congestive Cardiac Failure Smoking in last 10 years COPD Cerebrovascular disease DM Malignancy Liver Disease PVD Aintree MRI Figure 6.4:1 Comorbidities by unit Page 6

9 Comorbidites by age Ischaemic Heart Disease (IHD) Congestive Cardiac Failure Smoking in last 10 years COPD Cerebrovascular disease DM Malignancy Liver Disease Aintree <65 Aintree =/>65 MRI <65 MRI =/>65 Figure 6.4.2: Comorbidities by unit and age 6.5 egfr at start of dialysis The results are similar across all the units, with the majority (>98%) of patients with an egfr of <15 at the start of ESRF. Majority of patients seem to start dialysis with a egfr of 5-7 in the region, where 58% of the patients commence dialysis with egfr of 5-7 =15 / > SRH MRI AH 5-7 < % of patients starting dialysis Figure 6.5.1: egfr at start of RRT Page 7

10 Percentage survival on dialysis % died w ithin 3 months % died w ithin 1 year % Survival over 1 year % Not Stated Aintree Hospital MRI SRH Figure 6.6: Percentage survival on dialysis Overall 1 year survival rate for the units were as follows it was 90% for Aintree 72.7% for MRI and 84.7% at SRH, comparing this to the renal registry which stands at 87.3%. Figure 6.7.1: Percentage survival by age Percentage survival by age <65 =/>65 <65 =/>65 <65 =/>65 Aintree Hospital MRI SRH % died within 3 months % died within 1 year % Survival over 1 year % Not Stated Figure 6.7.2: % survival by age compared against Renal Registry Unit <65 >65 Aintree 97.3% 83.3% MRI 82.9% 63.5% SRH 85.7% 83.3% Renal Registry Page 8

11 The percentage survival by age is more difficult to compare with the renal registry data as they are Kaplan M survival curves. As represented in table <65 s survival rate is bettering the northwest units to that compared with the renal registry data. In the >65 s however the data is true of the opposite specially for MRI, whose patients survival seem to be the worst at 63.5% to that of the renal registry of 91.9%. Figure 6.8: Deaths by age group Deaths by age Death =/< 3months Death >3 mths =/< 12 months Deaths =/> 12 months Death =/< 3months Death >3 mths =/< 12 months <65 years old =/>65 years old 1 Deaths =/> 12 months Aintree MRI SRH At MRI there seemed to be slight difference, an increase in the number of deaths in patients who were 65 or above and had been dialysing for less than 3 months. The reason for this could be due to the cohort of patients at MRI in comparison to the other units is more varied. Overall there was not a marked difference in the number of deaths in relation to age groups, just as expected the over 65 years old have a slightly higher death rate than those under 65 s Causes of death Figure 6.9: Causes of death by age group Causes of death by age <65 =/>65 years <65 =/>65 years Aintree MRI CRF Cerebral Haemorrhage Pneumonia Urospesis MI Lymphoma Cardiac Failure Bilateral PE Ischaemic Bowel / Bowel Perforation Discontinued treatment Stroke Cancer Myeloma Cardiovascular death Other Page 9

12 Regardless of age group, the overall main cause of death was CRF. In the over 65 s the main cause of death seemed to be due to pneumonia in both units. This correlates with the renal registry data. Cancer and myeloma also seemed to be factors for the cause of deaths in the over 65 population. Page 10

13 7. DISCUSSION Analysis of data contained within this report shows that: Demographics and survival are comparable across North west Regional survival comparable to national survival data Co-morbidities and death rate are highest amongst elderly Too few patients start dialysis with an AV fistula In some cases dialysis may be started too late The data set in this case was not uniform across the region which made it difficult to compare; also because it is an interim report the data was not truly comparable against the renal registry data set. The demographic data was not available in many cases to highlight areas. As stated, this was an interim audit which only contained 1 year of data so doesn t give a complete picture of dialysis comorbidity. The limitations of this audit was the lack of resources and difference in data collection at each unit, hence no data was collected in terms of postcode, ethnicity, social status etc. 8. RECOMMENDATIONS It is recommended that in future audits the following data should be included: Must ensure are comparing like for like across units when comparing mortality (postcode population data and demographics are important). Include number of pre-emptive transplants in data collection and analysis Include data on ethnicity and social status Further study on late starts and vascular access Other aspects to consider in future audit would be to separate out analysis of acute and chronic patients. This would be valuable as these are two distinct groups and co-morbidities are likely to be different between them. It is also important to carry out further studies to look at vascular access as there are no explanations as to why so many people start dialysis on a line. It would also be beneficial to include pre-emptive transplant, as this may be a significant group and could vastly alter the survival analysis when looking at all patients with ESRF. Regional guidelines are to be developed to ensure equity of dialysis that data collection and end dates should be the same in all units to avoid discrepancies due to time of months. Page 11

14 Action Plan In future audits choose a group of patients to concentrate on. Should consider starting GFR more closely with different modalities. Adjust data set so more comparable with the renal registry data. Page 12

15 PROJECT PLAN APPENDIX 1 NORTH WEST REGION RENAL AUDIT PROGRAMME PROJECT PLANNING GUIDE DIALYSIS MORTALITY AUDIT (FIVE YEAR STUDY) AUDIT PROJECT: Clinical Lead: Audit leads: Audit Facilitator: Type of audit: REASONS FOR CHOICE Aims and objectives: Proposed health benefits: Evidence base: Priority: METHODOLOGY Standards: Guidelines: Dr Iren Szeki Consultant Nephrologist, Manchester Royal Infirmary Angela Cooper - Arrowe Park Hospital Dr Sana Tahir - Aintree Hospital Dr Ching Cheung - Salford Royal Hospital tba - Royal Liverpool Hospital Iren Szeki - Manchester Royal Infirmary Tracey Powell Regional Renal Co-ordinator Individual Audit goals Compare take on rate for each unit in terms of age, ethnicity and co-morbidity at start of RTT Quantify regional kidney survival Equity of dialysis for patients of different social status, sex, ethnicity and co-morbidity. Renal Registry publishes survival on dialysis according to age at start of RRT. Regional It is recommended that survival analysis must at least take account of age, gender, diabetes and co-morbidity. Compare with Renal Registry data on mortality according to age at start of RTT. To be developed Patients: Methods: Health disciplines involved: All new renal dialysis patients who survive > 3 months. Data will be collected prospectively from computer systems, and patient notes onto a standardised data collection sheet (excel format). Data will be collated and analysed by a member of the NW Renal Audit Team. nurses Page 13

16 Timescale: ACTION Proposed date for audit presentation: physicians This audit is prospective and will run for a five year period. July June 2014 Interim presentation July 2011 REGISTRATION MRI Clinical Audit registration number: 2358 Page 14

17 GLOSSARY OF TERMS AND ABBREVIATIONS APPENDIX 2 AUH MRI SRH Aintree University Hospital Manchester Royal Infirmary Salford Royal Hospital KDOQI DOPPS The National Kidney Foundation Disease Outcomes Quality Initiative Dialysis Outcomes and Practice Patterns Study egfr ESRF IHD RRT estimated Glomerular Filtration Rate End Stage Renal Failure Ischaemic Heart Disease Renal Replacement Therapy Page 15

18 DATA PARAMETERS APPENDIX 3 NORTH WEST REGION RENAL AUDIT PROGRAMME DIALYSIS MORTALITY AUDIT Patient details Name Hospital Hospital No. DOB Gender Ethnicity egfr at dialysis commencement cause of ESRF date start dialysis smoking history >10 yrs angina MI within 3/12 prior to start of RRT previous MI > 3/12 after start of RRT CABG or coronary angioplasty congestive cardiac failure LVH cerebrovascular disease DM COPD liver disease PVD BMI>25 malignancy other Outcome date of death cause of death recovered R transplanted years with functioning graft death with functioning graft Page 16