The National Quality Standards for Chronic Kidney Disease Dr Robert Lewis Chief of Service, Wessex Kidney Centre, Portsmouth Specialist Committee Member Quality Standard for Chronic Kidney Disease, NICE
Content An introduction to the New NICE Quality Standard for CKD Arriving at the quality indicators and what has changed Quality Statement 1: why is this important to outcomes?
Why should we be concerned about CKD?
NICE 2014: Diagnosis of CKD Two egfr estimations <60 ml/min/1.73 m 2 over a period not less than 90 days OR ACR >3 mg/mmol ACR=albumin:creatinine ratio; CKD=chronic kidney disease; egfr=estimated glomerular filtration rate. NICE (2014) Available at: https://www.nice.org.uk/cg182 (accessed 22.10.2014)
KDIGO guideline for management of CKD 2012
description and range Increasing risk Classification of CKD: NICE guidelines 2014 ACR categories (mg/mmol), description and range A1 (<3) Normal to mildly increased A2 (3 30) Moderately increased A3 (>30) Severely increased GFR categories (ml/min/1.73 m 2 ), G1 ( 90) Normal and high G2 (60 89) Mild reduction related to normal range for a young adult G3a (45 59) Mild moderate reduction G3b (30 44) Moderate severe reduction G4 (15 29) Severe reduction G5 (<15) Kidney failure ACR: albumin:creatinine ratio CKD: chronic kidney disease GFR: glomerular filtration rate. NICE (2014) Available at: https://www.nice.org.uk/cg182 Increasing risk
Projections of growth in expected number of people in England with CKD stage 3-5, 2011 2036 Chronic kidney disease prevalence model. Public Health England 2014
Summary of CKD stage 3-5 prevalence in England 2014 Chronic kidney disease prevalence model. Public Health England 2014
The effect of CKD on life expectancy A: egfr B: ACR The Lancet 2013 382, 339-352DOI: (10.1016/S0140-6736(13)60595-4
Estimated cost of CKD to the NHS (2010) The overall annual cost of CKD is estimated at 1.44 to 1.45 billion. This is equivalent to 795 for every person recorded with a diagnosis of CKD in the QOF. Estimating the financial cost of chronic kidney disease to the NHS in England Nephrol Dial Transplant. 2012;27(suppl_3):iii73-iii80. doi:10.1093/ndt/gfs269
What does good primary care for patients with CKD look like? Early diagnosis Early intervention to reduce risk Intelligent monitoring Appropriate referral to specialist services
Screening for CKD True positive Early diagnosis allows early intervention Early intervention in CKD may slow progression Lifestyle changes and CV risk reduction False positive Anxiety and medicalisation Unnecessary intervention Insurance premiums Is cost justified for: (1) population based screening? (2) targeted screening?
Adults at risk of CKD diabetes hypertension acute kidney injury cardiovascular disease structural renal tract disease, recurrent renal calculi or prostatic hypertrophy multisystem diseases with potential kidney involvement for example, systemic lupus erythematosus family history of end-stage kidney disease (GFR category G5) or hereditary kidney disease e.g. autosomal dominant polycystic kidney disease opportunistic detection of haematuria prescribed drugs that have an impact on kidney function e.g. calcineurin inhibitors, lithium and NSAIDs.
Pitfalls in diagnosis egfr MDRD vs CKD EPI Body habitus Dehydration Meat intake Drugs (e.g trimethoprim) ACR Exercise BP control
Early intervention Patient education and activation Accurate assessment of risk BP monitoring (patient?) CV risk assessment Rate of decline in egfr Quantification of proteinuria (frequency?) CV risk reduction Lifestyle adjustment Antiplatelet therapy Lipid management BP control (RAAS blockade?)
GFR categories (ml/min/1.73 m 2 ), description and range Frequency of monitoring of GFR ACR categories (mg/mmol), description and range A1 <3 Normal to mildly increased A2 3 30 Moderately increased A3 >30 Severely increased G1 90 Normal and high G2 60 89 Mild reduction related to normal range for a young adult G3a 45 59 Mild moderate reduction G3b 30 44 Moderate severe reduction G4 15 29 Severe reduction G5 <15 Kidney failure 1 1 1 1 1 1 1 1 2 2 2 2 2 2 3 4 4 4 Abbreviations: GFR, glomerular filtration rate, ACR, albumin creatinine ratio Adapted with permission from Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group (2013) KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney International (Suppl. 3): 1 150
Appropriate monitoring Determined by: the underlying cause of CKD past patterns of egfr and ACR (but be aware that CKD progression is often non-linear) comorbidities, especially heart failure changes to their treatment (such as renin angiotensin aldosterone system [RAAS] antagonists, NSAIDs and diuretics) intercurrent illness whether they have chosen conservative management of CKD.
How do we know if we re doing well? Outcome data? Reiterative audit Benchmarking against best practice
QOF 2014/15 QOF indicator CKD005: The contractor establishes and maintains a register of patients aged 18 years or over with CKD with classification of categories G3a to G5 (previously stage 3 to 5). QOF indicator CKD004: The percentage of patients on the CKD register whose notes have a record of a urine albumin:creatinine ratio (or protein:creatinine ratio) test in the preceding 12 months. QOF indicator CKD002: The percentage of patients on the CKD register in whom the last blood pressure reading (measured in the preceding 12 months) is 140/90 mmhg or less. QOF indicator CKD003: The percentage of patients on the CKD register with hypertension and proteinuria who are currently treated with an ACE-I or ARB.
QOF 2016/17 QOF indicator CKD005: The contractor establishes and maintains a register of patients aged 18 years or over with CKD with classification of categories G3a to G5 (previously stage 3 to 5). QOF indicator CKD004: The percentage of patients on the CKD register whose notes have a record of a urine albumin:creatinine ratio (or protein:creatinine ratio) test in the preceding 12 months. QOF indicator CKD002: The percentage of patients on the CKD register in whom the last blood pressure reading (measured in the preceding 12 months) is 140/90 mmhg or less. QOF indicator CKD003: The percentage of patients on the CKD register with hypertension and proteinuria who are currently treated with an ACE-I or ARB.
Comparison of deaths between uncoded and coded patients with biochemical CKD stages 3-5 National Chronic Kidney Disease Audit - National Report (Part 2) December 2017
NICE quality standards Quality standards set out the priority areas for quality improvement covering: - areas where there is variation in care - topics across health and social care Each standard contains a set of statements to help improve quality. It also describes how to measure progress against the statement NICE quality standards are not guidelines, they sit alongside and complement guidelines
Process of identifying CKD Quality Standards 8 stake holders invited to suggest 5 areas for quality improvement during consultation period October-November 2016 British Kidney Patient Association Kidney Research UK NHS Improvement: patient safety Renal Psychologists Royal College of Nurses Specialist Committee Members UK Renal Association AstraZeneca NICE Quality Standards Committee: December 2016 Draft Quality Standards: consultation March 1st-28th 2017 Final Quality Standards: July 2017
NICE quality standards use in practice Support national frameworks Commissioning processes including incentives CQC inspection activities National audits Choices website Quality Accounts Patient/service users and representative organisations
NICE quality standards use at local level An assessment showing that a local service meets the quality standard, informed by readily available evidence, can: provide assurance to those involved in the governance of the services (governments, boards, regulators, insurers, consumers and service users) An assessment indicating areas that require quality improvement can: help inform local quality improvement programme planning identify priority areas for annual audit programmes inform local risk management planning
https://www.nice.org.uk/process/pmg30/chapter/introduction-and-background
CKD Quality Standards 2011 People with CKD who may benefit from specialist care are referred for specialist assessment in accordance with NICE guidance. People with CKD have a current agreed care plan appropriate to the stage and rate of progression of CKD. People with CKD are assessed for cardiovascular risk. People with CKD are assessed for disease progression. People with CKD who become acutely unwell have their medication reviewed, and receive an assessment of volume status and renal function. People with anaemia of CKD have access to and receive anaemia treatment in accordance with NICE guidance. People with progressive CKD whose egfr is less than 20 ml/min/1.73 m 2, and/or who are likely to progress to established kidney failure within 12 months, receive unbiased personalised information on established kidney failure and renal replacement therapy options. People with established renal failure have access to psychosocial support (which may include support with personal, family, financial, employment and/or social needs) appropriate to their circumstances.
NICE Quality statements 2017 Statement 1: Adults with, or at risk of, chronic kidney disease (CKD) have egfrcreatinine and albumin:creatinine ratio (ACR) testing at the frequency agreed with their healthcare professional. [2011, updated 2017] Statement 2: Adults with CKD have their blood pressure maintained within the recommended range. [2011, updated 2017] Statement 3: Adults with CKD are offered atorvastatin 20 mg. [new 2017]
NICE Quality statements 2017 Statement 1: Adults with, or at risk of, chronic kidney disease (CKD) have egfrcreatinine and albumin:creatinine ratio (ACR) testing at the frequency agreed with their healthcare professional. [2011, updated 2017] Statement 2: Adults with CKD have their blood pressure maintained within the recommended range. [2011, updated 2017] Statement 3: Adults with CKD are offered atorvastatin 20 mg. [new 2017]
Practice variation in percentage of people with coded CKD with annual repeat tests of egfr by diabetes status National Chronic Kidney Disease Audit - National Report (Part 1) January 2017
Practice variation in percentage with coded CKD stage 3-5 who have repeat urinary ACR tests stratified by diabetes National Chronic Kidney Disease Audit - National Report (Part 1) January 2017
Practice variation in percentage of patients at risk of CKD but not on the CKD 3-5 Register who are receiving recommended egfr testing (past year for diabetes and CNI/Li; past 5 years for others), by risk factor National Chronic Kidney Disease Audit - National Report (Part 1) January 2017
Practice variation in percentage of patients at risk of CKD but not on the CKD 3-5 Register who are receiving recommended urinary ACR testing (past year for diabetes; past 5 years for others), by risk factor National Chronic Kidney Disease Audit - National Report (Part 1) January 2017
Gathering data to assess Quality Standards Structure Process Outcomes
Structure Evidence of local systems that invite adults with, or at risk of, CKD to have egfrcreatinine and ACR testing. Data source: Local data collection, for example, through local protocols on appointment reminders.
Process Proportion of adults with CKD who had egfr testing in the past year. Numerator the number in the denominator who had egfrcreatinine testing in the past year. Denominator the number of adults with CKD. Data source: Local data collection, for example, audit of health records.
Process Proportion of adults at risk of CKD who had egfr testing at the frequency agreed with their healthcare professional. Numerator the number in the denominator who had egfrcreatinine testing at the frequency agreed with their healthcare professional. Denominator the number of adults at risk of CKD. Data source: Local data collection, for example, audit of health records.
Process Proportion of adults with CKD who had ACR testing at the frequency agreed with their healthcare professional. Numerator the number in the denominator who had ACR testing at the frequency agreed with their healthcare professional. Denominator the number of adults with CKD. Data source: Local data collection, for example, audit of health records.
Outcomes Prevalence of undiagnosed CKD. Data source: QOF vs CKD prevalence model Stage of CKD at diagnosis. Data source: Local data collection, for example, audit of health records
Summary CKD is associated with increased mortality and morbidity Early intervention and management improve outcomes CKD can be detected early and economically in at-risk populations (egfr and ACR) Management of CKD is no longer a QOF priority Measurement of the quality of early management of CKD (in primary care) remains desirable.
Quality Standards: Key learning points CKD Quality Standards are not guidelines CKD Quality statements aim for:- Simplicity in practice Measurability Impact (evidence base) CKD Quality Standards aim to drive quality.