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
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
Anaemia of Chronic Kidney Disease Treated when HB consistently below 10g/dl with: Iron repletion: Ferritin > 200 ng/ml TSAT >20% ESAs Hb 10-12 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
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
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
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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= 2 x Month 1000 1000mg 1gm 1gms = 1 x per day 1-gram 1g 1 g 10/21/2013 9
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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 10/21/2013 11
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% Patients in Hb range Mean Hb (g/dl) 100% Patient Numbers 67 418 69 348 79 981 16.0 90% 15.0 80% 14.0 70% 13.0 60% 50% 11.5 11.3 11.4 10.9 12.0 11.2 12.0 11.0 40% 10.0 30% 20% 56.2% 46.4% 56.0% 55.1% 9.0 8.0 % 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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% Patients in Hb range Mean Hb (g/dl) 100% 90% 80% 70% Patient numbers 74 450 77 325 93 1019 16.0 15.0 14.0 13.0 Bangor 74 100% Cardiff 456 99% Rhyl 77 100% Swansea 325 100% Wrexham 93 100% All Wales 1025 99% 60% 12.0 50% 11.3 11.0 11.1 10.8 10.8 10.9 11.0 40% 10.0 30% 20% 10% 62.2% 56.4% 57.1% 60.9% 65.6% 59.2% 9.0 8.0 7.0 % above target (>12g/dl) % in target (10-12g/dl) % below target (<10g/dl) 0% Bangor Cardiff Rhyl Swansea Wrexham All Wales 6.0 Mean
Swansea Bangor Rhyl Wales Cardiff Wrex 61% 62% 57 % Wales 2013 56% 66% 59% 56% 60% 46 % Wales 2012 56% 50% 55% 67% 59% 58 % RR 2011 55% 49% 59% 10/21/2013 16
% Patients in ferritin range Mean Ferritin ng/ml 100% 90% 80% 70% Patient Numbers 74 438 77 318 91 998 3.2% 2.6% 13.5% 12.6% 11.7% 12.9% 11.0% 7.7% 17.9% 27.0% 22.3% 26.4% 700 650 600 550 Bangor 74 100% Cardiff 456 96% Rhyl 77 100% Swansea 325 98% Wrexham 93 98% All Wales 1025 97% 60% 516 500 50% 461 465 450 40% 30% 20% 62.8% 352 71.4% 397 45.9% 41.8% 55.6% 413 400 350 300 % above target (>800ng/ml) % above target (501-800ng/ml) % in target (200-500ng/ml) % below target (100-199ng/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 250 200 % below target (<100ng/ml) Mean
Rhyl Cardiff Swansea Wales Bangor Wales 2013 99% 100% 97% 94% 97% Wales 2012 99% 100% 97% 91% 95% RR 2011 99% 97% 96% 91% 95% Iron Dose mg mg mg mg 10/21/2013 18
Cardiff Rhyl Bangor Swansea Wales 63% 71% 55% 46% Wales 2013 56 % 57% 64% 54% 45% Wales 2012 54% 64% 63% 58% 50% RR 2011 59% 10/21/2013 19
Rhyl Bangor Swansea Cardiff Wales 2.6% 14% 13% 3.2% Wales 2013 7.7% 2.9% 3% 7% 4.6% Wales 2012 5.2% 10/21/2013 20
% Patients in TSAT range Mean TSAT % 100% 90% 80% 70% 60% Patient Number with test reult 0 0 77 322 90 489 80.5% 55.0% 85.6% 64.6% 36 60 50 40 Bangor 74 0% Cardiff 456 0% Rhyl 77 100% Swansea 325 99% Wrexham 93 97% All-Wales 1025 48% 50% 40% 30% 30 22 26 30 20 % 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
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 10/21/2013 22
% Patients in Hb range Mean Hb (g/dl) 100% 90% 80% 70% Patient Number 13 36 3 25 2 79 16.0 15.0 14.0 13.0 Bangor 13 100% Cardiff 36 100% Rhyl 3 100% Swansea 25 100% Wrexham 2 100% All Wales 79 100% 60% 12.0 50% 40% 11.2 38.9% 10.7 33.3% 10.5 56.0% 10.9 11.3 49.4% 10.8 11.0 10.0 30% 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
% Patients in ferritin range Mean Ferritin ng/ml 100% 90% 80% 70% Patient Number 13 32 3 25 2 75 15.4% 18.7% 32.0% 438 600 550 500 450 Bangor 13 100% Cardiff 36 89% Rhyl 3 100% Swansea 25 100% Wrexham 2 100% All Wales 79 95% 60% 400 50% 334 37.5% 355 50.0% 342 350 40% 30% 20% 10% 0% 61.5% 25.0% 280 40.0% 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 188 300 250 200 150 100 % above target (>800ng/ml) % above target (501-800ng/ml) % in target (200-500ng/ml) % below target (100-199ng/ml) % below target (<100ng/ml) Mean
% Patients in TSAT range Mean TSAT % 100% 90% 80% 70% Patient Numbers for test result 0 0 3 25 1 29 100.0% 32.0% 0.0% 37.9% 80 70 60 Bangor 13 0% Cardiff 36 0% Rhyl 3 100% Swansea 25 100% Wrexham 2 50% All-Wales 79 37% 60% 50 50% 40% 34 40 30 30% 20% 10% 20 15 21 20 10 % in target (>=20% % below target (<20%) 0% 0.0% 0.0% Bangor Cardiff Rhyl Swansea Wrexham All-Wales 0 Mean
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? 10/21/2013 26
% Patients in Hb range Mean Hb (g/dl) 100% 90% 80% 70% Patient 10 42 8 50 12 122 16.0 15.0 14.0 13.0 Bangor 10 100% Cardiff 43 98% Rhyl 8 100% Swansea 51 98% Wrexham 12 100% All Wales 124 98% 60% 12.0 50% 11.3 11.1 10.9 10.9 10.7 11.0 40% 54.8% 10.3 10.0 30% 56.0% 59.8% 9.0 % above target (>12g/dl) 20% 10% 70.0% 75.0% 75.0% 8.0 7.0 % in target (10-12g/dl) % below target (<10g/dl) 0% Bangor Cardiff Rhyl Swansea Wrexham All Wales 6.0 Mean
% Patients in ferritin range Mean Ferritin ng/ml 100% 90% 80% 70% Patient Numbers 10 28 7 43 12 100 10.0% 11.6% 6.0% 13.0% 21.4% 20.9% 465 700 600 500 Bangor 10 100% Cardiff 43 65% Rhyl 8 88% Swansea 51 84% Wrexham 12 100% All Wales 124 81% 60% 50% 379 372 358 349 400 40% 42.9% 48.0% 300 30% 20% 10% 0% 153 51.2% 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 200 100 0 % above target (>800ng/ml) % above target (501-800ng/ml) % in target (200-500ng/ml) % below target (100-199ng/ml) % below target (<100ng/ml) Mean
% Patients in TSAT range Mean TSAT % 100% 90% 80% 70% Patient Numbers 0 0 0 47 0 47 63.8% 63.8% 40 35 30 Bangor 10 0% Cardiff 43 0% Rhyl 8 0% Swansea 51 92% Wrexham 12 0% All-Wales 124 38% 60% 50% 23 23 25 20 40% 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
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 2012 10/21/2013 30
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Why repatriated to a tertiary care service? 10/21/2013 33
1. Increasing prevalence & patient no. Increasing recognition & referral 2. Tighter clinical targets 3. Increasing options & complexity 4. Increasing costs & need to reduce expenditure 10/21/2013 34
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% Patients in Hb range Mean Hb (g/dl) 100% 90% 80% 70% Patient Numbers 4 81 9 46 0 140 16.0 15.0 14.0 13.0 Bangor 4 100% Cardiff 98 83% Rhyl 9 100% Swansea 46 100% Wrexham 0 #DIV/0! All Wales 157 89% 60% 12.0 50% 40% 10.1 11.0 66.7% 10.6 11.0 11.0 11.0 10.0 30% 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
% 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 1 56 9 40 0 106 600 500 400 Bangor 4 25% Cardiff 98 57% Rhyl 9 100% Swansea 46 87% Wrexham 0 #DIV/0! All Wales 157 68% 60% 50% 23.2% 23.2% 304 44.4% 354 358 35.0% 30.2% 330 300 40% 30% 0.0% 35.0% 25.5% 200 20% 10% 0% 33.9% 33.3% 10.0% 100.0% 0.0% 0.0% 0.0% 0 24.5% Bangor Cardiff Rhyl Swansea Wrexham All Wales 100 0 % above target (>800ng/ml) % above target (501-800ng/ml) % in target (200-500ng/ml) % below target (100-199ng/ml) % below target (<100ng/ml) Mean
% Patients in TSAT range Mean TSAT % 100% 90% 80% 70% Patient Numbers 1 0 0 40 0 41 100.0% 67.5% 68.3% 40 35 30 Bangor 4 25% Cardiff 98 0% Rhyl 9 0% Swansea 46 87% Wrexham 0 #DIV/0! All-Wales 157 26% 60% 50% 23 23 25 20 40% 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
% Patients in Hb range Mean Hb (g/dl) 100% 90% 80% 70% Patient Numbers 98 411 138 445 204 1296 16.0 15.0 14.0 13.0 Bangor 100 98% Cardiff 451 91% Rhyl 138 100% Swansea 459 97% Wrexham 205 100% All Wales 1353 96% 60% 12.0 50% 10.9 10.8 11.0 11.3 11.4 11.1 11.0 40% 10.0 30% 64.7% 9.0 % above target (>12g/dl) 20% 10% 66.3% 73.2% 63.6% 65.2% 65.4% 8.0 7.0 % in target (10-12g/dl) % below target (<10g/dl) 0% Bangor Cardiff Rhyl Swansea Wrexham All Wales 6.0 Mean
% Patients in ferritin range Mean Ferritin ng/ml 100% 90% 80% 70% 60% 50% 63 262 137 318 135 915 33.3% 278 26.3% Patient Numbers 324 272 281 39.0% 40.3% 264 500 450 400 350 300 250 Bangor 100 63% Cardiff 451 58% Rhyl 138 99% Swansea 459 69% Wrexham 205 66% All Wales 1353 68% 40% 30% 210 53.3% 60.7% 200 150 % above target (>800ng/ml) % above target (501-800ng/ml) % in target (200-500ng/ml) 20% 100 % below target (100-199ng/ml) % below target (<100ng/ml) 10% 50 Mean 0% Bangor Cardiff Rhyl Swansea Wrexham All Wales 0
% Patients in TSAT range Mean TSAT % 100% 90% 80% 70% Patient Numbers 9 0 68 334 100 511 77.8% 77.9% 56.0% 87.0% 65.4% 30 28 40 35 30 Bangor 100 9% Cardiff 451 0% Rhyl 138 49% Swansea 459 73% Wrexham 205 49% All-Wales 1353 38% 60% 25 24 25 50% 21 20 40% 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
HB, Ferritin & TSAT: Improvement on All Wales 2012 benchmarks HB: consistent across Wales New thinking : from ESA to Iron 10/21/2013 42
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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% 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% 10/21/2013 45
% 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 10-39 CRP 40-79 CRP 80-99 CRP 100-199 CRP >200 10/21/2013 46
The pessimist sees difficulties in every opportunity. The optimist sees opportunities in every difficulty Winston Churchill 10/21/2013 47