Widening the circles of inclusion
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Widening the Circles of Inclusion. The National Renal Service Dr Donal O’Donoghue Co-Chair Renal Advisory Group. 4 July 2006. Standard one: A patient-centred service. Aim: To optimise the role that people with chronic kidney disease can take in the management of their care. Standard:

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Widening the Circles of Inclusion

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Widening the circles of inclusion

Widening the Circles of Inclusion

The National Renal Service

Dr Donal O’Donoghue

Co-Chair Renal Advisory Group

4 July 2006


Standard one a patient centred service

Standard one: A patient-centred service

Aim:

To optimise the role that people with chronic kidney disease can take in the management of their care.

Standard:

All people with chronic kidney disease are to have access to information to make informed decisions and encourage partnership with an agreed care plan.

The National Service Framework for Renal Service


Standard one a patient centred service1

Standard one: A patient-centred service

  • Markers of good practice

  • Provision of high quality, culturally appropriate and comprehensive information and education programmes

  • Education programmes tailored to the needs of the individual

  • Individual care plans, regularly audited, evaluated and reviewed

  • Access to a multi-skilled renal team whose members have the appropriate training, experience and skills

The National Service Framework for Renal Services


Key facts

CKD

> 5% of population

Co-morbidity : 90% HT, 40% CVD, 20% DM

SMR 36 in unreferred < 60 years

Optimal therapy 30%

Potential savings US $18-60B / 10 years

ESRD

Increasing at 6-8% pa

Acute Uraemic Emergencies 22-57%

Pre-emptive transplant listing 3-54%

Dialysis survival 1st year 75-93%

Cost £0.4B / year > £0.8B / year (2002/03) (2010/11)

Key Facts

(Wanless)


Widening the circles of inclusion

The Epidemic of ESRF


Widening the circles of inclusion

Staging and Prevalence of CKD

Adapted from AM J Kidney Dis 2002; 39 (2,Suppl. 1): S17-S31


Widening the circles of inclusion

CKD: A Typical GP Practice of 10000

5

6

15

4

60

Stage of Kidney Disease

30

(GFR)

380

3

60

2

460

90

1


Creating a national kidney care service

Creating A National Kidney Care Service


Widening the circles of inclusion

Modernisation projects in renal services

Modernisation Agency Project : Birmingham, Exeter

Patient View Project: Birmingham, Glasgow, Leeds

Skills for Health Dialysis Project: Birmingham, Leicester, London, Stevenage

Skills for Health Transplant Project: Aberdeen, Canterbury, Cardiff, Gloucester, Hull, London, Newcastle

Learning Sets – Transport: Liverpool, Middlesbrough

Learning Sets – Palliative Care: Birmingham, Manchester

Learning Sets – CKD: Brighton, Leicester

ABPILD Project Posts: Preston, Wolverhampton

Do Once and Share - Leicester


Neoerica percentage recording of creatinine and prevalence of stage 3 5 ckd by age

Recorded serum creatinine

Stage 3–5 CKD

NEOERICA: percentage recording of creatinine and prevalence of Stage 3–5 CKD by age

Patients (%)

80

70

60

50

40

30

20

10

0

15–24

25–34

35–44

45–54

55–64

65–74

75–84

85+

Age groups


Widening the circles of inclusion

Prevalence of Co-morbidity and Level of GFR

GFR <60 ml/min

GFR 60 ml/min

%

DM

Any CVD

IHD

CHF

Stroke/TIA

PVD


Widening the circles of inclusion

CKD is a Major Health Burden

Go et al 2004


Widening the circles of inclusion

Cardiac Kidney Diabetes

Anti coagulationAnti arrhythmicsMedical treatment of CHF

CKD Stage 4

AnaemiaAcidosisBone diseasePreparation/choice

CKD Stage 1, 2, 3EducationBlood pressureSmoking cessationLipid controlMedicines ManagementDiet adviceExercisePsychosocial support

Glycaemic control

+ DM

+ CHD

Complicationseyesfeetkidney

CKD Stage 5

HDTpPDMCT

RadiologySurgical interventions


Widening the circles of inclusion

Modifiable Risk Factors - Reality

  • 304 pts referred to four renal centres in Canada

  • Mean GFR 31 ml/min

  • CVD 39%, DM 38%, dyslipidaemia 43%, smokers 27%, hypertension 80%

    • BP > 140/9035%

    • ACEI/ARB65%

    • Aspirin27%

    • Statin18%

Tonelli M, AJKD 2001;37:484-489


Widening the circles of inclusion

STENO-2 Study

Relative riskVariable(95% CI)P value

Nephropathy0.39 (0.17-0.87)0.003

Retinopathy0.42 (0.21-0.86)0.02

Autonomic0.37 (0.18-0.79)0.002neuropathy

Peripheral1.09 (0.54-2.22)0.66neuropathy

00.51.01.52.02.5

Intensivetherapybetter

Conventionaltherapybetter

Gaede et al, NEJM 2003;348:383-393


Widening the circles of inclusion

The CKD Domain of QOF


Widening the circles of inclusion

60

50

40

% late referral

30

20

10

0

All

Extr

Leic

York

Hope

Bristl

Notts

Newc

Sheff

Prstn

Ports

Bangr

Mdlsbr

StJms

Renal Association

UK Renal Registry

Percentage late referrals

(< 3 months) by centre 2002


Late referral for rrt

Late Referral for RRT

  • > 30% UK patients referred within <4/12 of needing RRT

  • Higher mortality, morbidity, hospital stay, & cost (~£30k per case), due to poorer clinical state at presentation, lack of vascular access

  • No possibility of pre-emptive transplantation

Propensity score matched comparison, n=2078

Winkelmayer WC. J Am Soc Nephrol 2003; 14: 486-492.


Pre emptive live donor transplantation

Pre-emptive & Live Donor Transplantation

Living Donor Kidney Transplants 1995-2003 (UKT)

Unadjusted graft survival in 56,587 recipients of cadaveric transplants by length of dialysis treatment before transplant

% event free survival

Pre-emptive

0–6 months

6–12 months

12–24 months

24+ months

100

90

80

70

60

50

40

30

20

0

12

24

36

48

60

72

84

96

108

120

Months post-transplant


Demystifying and managing chronic kidney disease

Demystifying and Managing Chronic Kidney Disease

Education

Empowerment

Encouragement

Knowledge

Management

CfH

Integration Information Technology Information

Registration

Recall

Review

eGFR = % Kidney Function


The national kidney care service

The National Kidney Care Service

158 Local Health Communities

23 Renal Networks

6 Transplant Alliances

Widening the Circles of Inclusion


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