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IM proving P atient care and A wareness of K idney disease progression T ogether

IM proving P atient care and A wareness of K idney disease progression T ogether. May 2006. Does primary care intervention help the bulk of CKD patients???. NIHR CLAHRC Leicestershire, Northamptonshire and Rutland (LNR). A P rimary- S econdary Care P artnership to

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IM proving P atient care and A wareness of K idney disease progression T ogether

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  1. IMproving Patient care and Awareness of Kidney disease progression Together

  2. May 2006

  3. Does primary care intervention help the bulk of CKD patients???

  4. NIHRCLAHRC Leicestershire, Northamptonshire and Rutland (LNR) A Primary-Secondary Care Partnership to Prevent Adverse Outcomes in Chronic Kidney Disease A Cluster Randomised Clinical Trial

  5. NIHRCLAHRC Leicestershire, Northamptonshire and Rutland (LNR) Hypothesis “Intensive primary care led disease management programmes for CKD, supported by input from secondary care specialists will improve blood pressure control, slow progression of CKD and reduce cardiovascular events in patients on CKD registers”

  6. NIHRCLAHRC Leicestershire, Northamptonshire and Rutland (LNR) Other CLAHRC Aims Increase capacity for primary care research Involve new stakeholders Involve research naive practices Involve as any practices as possible

  7. NIHRCLAHRC Leicestershire, Northamptonshire and Rutland (LNR) How to test the hypothesis • take a number of general practices • identify all CKD patients • divide practices into 2 groups • 1 group continues to provide ‘normal’ CKD care • 1 group provides nurse led ‘intensified’ CKD care • team of CKD nurses supported by secondary care • compare CKD outcomes after an appropriate time period

  8. National average PCT CKD Prevalence figures (07-08 QoF) National Average 2.8%

  9. NIHRCLAHRC Leicestershire, Northamptonshire and Rutland (LNR) What do we need to do this? A robust data extraction tool applicable to all GP computer systems

  10. IMPAKT: IMproving Patient care and Awareness of Kidney disease progression Together A web based CKD data tool Based on MIQUEST search methodology Works with all GP IT systems

  11. A practice computer search tool find total population over 17 find those with eGFR <60 ml/min/1.73m2 ever find those with read code of renal impairment 2 OR 3 find in 4 those with RRT 4 NOT 5 to get the target population minus exclusions search 6 for the data needed

  12. Other data also extracted • Past medical history • Medication history • Blood pressure • Smoking history • BMI if recorded • Other blood biochemistry and haematology • Nurses keep reflective diaries of experiences

  13. What the tool does Register • Accuracy of existing coding of CKD • Identifies uncoded patients Risk • Identifies high risk of progression and CVD • Medicines managment Audit • Against NICE standards • Benchmarking Manage • Advice on BP, proteinuria, ACE/ARB • Referral • Medicines management – NSAIDs, metformin etc www.impakt.org.uk

  14. The CLAHRC LNR PSP-CKD Study

  15. The CLAHRC LNR PSP-CKD Study • In Northamptonshire: • 48 practices recruited • Total population >17yrs = 343,743 • 31,274 – most recent eGFR <60 ml/min • 20,383 – confirmed by 2nd value within 3 months • = confirmed CKD prevalence of 5.93%

  16. Outcomes • Primary outcome measure: • difference in mean CKD register patient eGFRs • between groups after 3.5 years of study • Secondary outcome measures: • - blood pressure control • - proteinuria • - incidence of cardiovascular events • - other biochemical parameters • - referrals to secondary care and hospitalisations • mortality • reflective experience of nurse intervention team

  17. www.impakt.org.uk

  18. IMPAKT does much more than this

  19. Haem/Biochemical/Urine variables albumin, B12, blood glucose, ferritin, haemoglobin, serum folate HbA1c, total cholesterol, serum triglycerides serum potassium, serum sodium, serum urea, serum bicarbonate, serum calcium, serum urate, serum phosphate, urine protein or albumin:creatinine ratio microhaematuria +/-

  20. Medications ACE inhibitor, ARB aspirin, other anti-platelet drugs beta/alpha-blocker Ca2+ channel blocker diuretic – thiazide/loop, K+ sparing diuretics other antihypertensive erythropoietin insulin statins lithium allopurinol metformin, sulfonylurea, other hypoglycaemic phosphate binders steroids vitamin D or its analogues NSAIDs

  21. Medical History anaemia, atrial fibrillation, cerebrovascular disease, heart failure, hypertension, ischaemic heart disease diabetes (type 1 and 2) , diabetic nephropathy glomerulonephritis malignant disease obesity peripheral vascular disease polycystic kidney disease prostatic hypertrophy renal artery stenosis CKD, urinary tract obstruction, recurrent UTI gout depression

  22. What’s Next? IMPAKT – Evolve In patients with LTCs maps: - short term alteration in patterns of primary care - fluctuations in lab variables inc. creatinine - alterations in key prescriptions Against: - clinical outcomes - hospital admissions - hospital lab data including AKI

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