CME Slides Forum - P. Stevens

EARLY IDENTIFICATION OF CKD: THE PRIMARY CARE PHYSICIAN-NEPHROLOGIST INTERFACE

Paul Stevens, Canterbury, UK

Chair: Paul E. de Jong, Groningen, Netherlands

Eberhard Ritz, Heidelberg, Germany

stevens

Dr P. Stevens
Department of Renal Medicine
Kent and Canterbury Hospital
Canterbury, United Kingdom

Thank you Chairman, Ladies and Gentlemen and thank you to the organisers for inviting me to come to and talk to you today about early identification of chronic kidney disease, the primary care physician and nephrologist interface.

I’m going to approach this of course from the UK prospective from our health care system and I work here at Canterbury and for those of you who recognise it this is Canterbury Cathedral and Canterbury has been at the centre of the reformation over the years and we’re perhaps still at the centre of reformation of CKD in the UK and certainly many of our colleagues think that we’re heretics and that we’re executors but hopefully I’ll survive although I may not when Professor Ritz sees my last slide.

So, these then are the requirements for the optimal care of individuals with any disease and what we’re particularly concerned with today is the ability to identify the disease but also the ability to identify patients at risk.

We want to do this in primary care and in fact, we need to do it in primary care because certainly in our health care system primary care is where these patients are.
Primary care in the UK lends itself to these sorts of things because the average UK citizen consults his GP about 4 times a year. 82% of the population is seen each year and 97% we’re told within 5 years. But critically primary care in the UK is fully computerised and 97% of practices as at the end of last year receive their laboratory results electronically.

If we’re going though to identify these people we need to look at it in an integrated fashion.

And this is a slide that Adeera Levin’s lent me and these first three things; public awareness, professional education and policy influence can be underpinned by national initiatives to better identify.

These are the national initiatives that have been going on in the UK over the last 3-4 years. Starting with a National Service Framework then a number of different Guidelines, implementation of GFR reporting and the Quality and Outcomes framework and I’ll tell you a little bit about these very briefly as we go through.

Firstly the National Service Framework part 2 published in 2005 with 2 key quality requirements. Number 1: prevention and early detection of CKD. Number 2: minimising progression and consequences of CKD.

At the same time we were developing the UK CKD guidelines and they were published in 2005 and then we’ve had NICE anaemia and now drafted NICE CKD guidelines. They have one thing in common with each other and that is that they are weighty tones and primary care are not going to read these as they have a patient in front of them, so we need to do something and in fact we have with the UK CKD guidelines.

They’re condensed to an e-guide which you can get on the Renal Association Website with easy links to any part of the guideline that you want to go to.

Or alternatively you can do as we’ve done and others have done throughout the UK and that’s condense the UK guidelines down to one sheet of laminated paper with information on two sides, general information on one side.

And a sort of algorithmic approach on the other side to make it a lot easier for GPs.

On the 1st April 2006 we introduced eGFR reporting and renal indicators in the Quality Outcomes Framework for the first time. Critically again with the eGFR reporting this was a standardised approach.

So we chose to use the IDMS traceable MDRD equation but we use the National External Quality Assurance scheme to make sure that correction factors are supplied to each laboratory to correct their technique to the IDMS technique. So we have a standardised eGFR reporting.

Then we have renal indicators in the QOF that were introduced, as I said, at the same time.

And again critically it’s the first renal indicator that GPs are required to produce a register of patients aged 18 years and over with stage 3-5 CKD. Now admittedly this doesn’t address the question of proteinuria and we’re trying to do that and maybe next year we’ll get a little bit about proteinuria in this last indicator of the QOF but that remains to be seen.

There is, of course, no free lunch and when you start to introduce these sorts of things they do inevitably have consequences.

Before we look at the consequences it’s important for you to understand a little bit about UK demographics. So here we are. We’re a growing population; we’re growing older, we’re also growing bigger in a number of ways. Population has increased since 1971-2001 by 7.7 % and since 2001 by half a % per annum. We’re also getting a lot fatter and men are fatter than women. 67% of men in the UK are overweight 58% of women. We’re smoking less only 24% of people over the age of 16 are smokers but we’re older, a huge amount of the population is over 65 now, 16% of the population and we have comorbidity and you can see that for yourselves.

We’ve suggested from our work in Kent, Surrey and Greater Manchester that the adult age standardised prevalence of stage 3-5 CKD is around 8.5% and not surprisingly the prevalence rises with age partly in view of the way in which we predict prevalence. Again not surprisingly those people with a GFR less than 60 have a lot more hypertension, diabetes and cardiovascular disease than those with higher levels of GFR.

So this then is Quality and Outcomes Framework data of people who are now on the CKD register. This is just the first year that this QOF has been running. This is UK wide so down here are the various primary care trusts and there’s a range from just over 5% all the way down here to just over 1%.

Down in Kent our primary care trust that is closest to us is around the same sort of level as Stockport. So they’re running at around 2.3 and if you then dig into our primary care trusts and look at the practices within our local primary care trusts again there’s this wide variation from up here 6.5% all the way down to 0.

There’s also quite an impact on referral to nephrology services, of course and this is why we’re branded as heretics. This is 2004-2005 data prior to introduction of eGFR in the QOF and here’s 2006-2007 afterwards. Before introduction of these things we sent back about 11% of patients with an advice only letter. Since introduction of eGFR and the QOF, 26% sent back. More worryingly this is the number that if we followed CKD guidelines GPs should be referring to us and now clearly we don’t need to see all of these people so we’re going to have to look to some different strategies.

The other problem we have is the huge variation in what GPs do. So this is our area the bottom of Kent and the colour coding here is very simple, the redder the colour the higher the referral rate from GPs. The bluer the colour the lower the referral rate. This is referral corrected for age, gender, ethnicity and density of population. Despite a lot of education and introduction of all of these things there’s still a 50-fold variation in GP referral.

This slide here from my colleague Chris Farmer partly explains the problem that GPs have. This is live data from the last year, this is gleaned from a practice population of about 76.000 about 3% of whom have had a GFR and what you’re seeing is the number of GFR estimates by GFR level, by age. GPs have no problem with the lower slopes here because these are people with low GFRs who are young, quite happy with those. They’re quite happy with these who have high GFRs, are elderly, again have no problem. It’s the area in between that creates the uncertainty for them. So clearly there’s something else that we need to do.

When we implement these sorts of strategies what we need to put in place is a clear infrastructure so that the right people get treated in the right place, at the right time, with the right tools and get the right outcome. We can do this perhaps with CKD networks, networks of primary care, secondary care that involve public health and commissioners. We can also look to other things and in the last couple of minutes I just want to talk to you about a disease management programme and a clinical decision support.

Firstly the disease management programme. This was something that some of you may have seen in NDT published in two papers earlier this year and it comes from the West Lincolnshire area of the UK and it’s known as the Optimal Programme. It’s a disease management programme that relies on automatic patient identification through databases and then uses algorithm based referral and management as the disease management strategy.
Their aim was to improve performance against defined clinical targets in people with stage 4-5 CKD and also to reduce comorbidity, reduce resource utilisation and reduce cost.

West Lincs is a very rural area, it’s about a 200.000 population spread over quite a large area and they had a community based disease management programme team which consisted of nurses, dietician and social worker. What they’ve shown you can see here.

Over the first 9 months that they’re reporting on there’s a significant reduction in cholesterol and blood pressure and critically a decline in the rate of decline in GFR.

So this is quite promising and also what this shows quite a promising reduction in referral into nephrology. So when eGFR reporting comes in, it shoots up but as the disease management programme kicks in then that level’s coming down again. So that’s an encouraging strategy.

Here’s another one. This is our clinical decision support system that we have down in Kent. Here how it works. What happens is the GP initiates the test, that comes back electronically from the lab into the primary care database and that then triggers the system which then looks back into the primary care database to extract a whole host of information that it can gather using this morbidity information query and export syntax.

This picks up recoded or restructured data from GP systems. Then puts it through a knowledge base and the knowledge base consists of a whole host of these and I don’t expect you to read these.

These are rule-based decision matrices that form part of the knowledge base of the system and then the output in this case, we’re just looking at people with a GFR below 60, so they highlight these and give management recommendations.

So here’s what we’ve been doing over the last 12 months. In 6 primary care practices in Kent 76,000 about 23% as I said had had a creatinine. 3.000 of these have a GFR less than 60. But only 8%, 251 of them are actually known to us.

What the system does though is sort out the rest for us with a number of recommendations to GPs and on the right are the number of recommendations per 10.000 population which is a typical GP practice size in the UK. There are all sorts of recommendations but the point is that the number of things that the GP actually has to do over a period of 12 months are relatively few.

The system is structured so that not everyone is referred is through and we know that not everyone needs to be referred, not every single person with stage 4 CKD needs to see a nephrologist because we know that the majority of them are not only stable but they’re also having the right things done to them but what this system can do is actually make sure that they’re having the right things done to them and that they achieve the appropriate targets.

This is just one example. This is one of my favourite examples. This is when we switched the system on in August 2006 in practice and what it immediately does in this young diabetic is highlight the fact that this is really a highly inappropriate reduction in GFR and it has got nothing to do with the introduction of perindopril and on biopsy she turns out to have acute interstitial nephritis.

Just one example. What we’re trying to achieve though with both clinical decisions support and with the disease management programmes is a structured delivery of care for our patients with kidney disease and critically in this what we want is not only for patients to move into secondary care when there’s a requirement for us to see them but we also need to have the confidence that those patients can move back out into primary care, be appropriate followed up and be appropriately managed.

So this is where Professor Ritz will probably kill me, early identification of CKD is achievable. Strategies enabling early identification must be targeted at primary care and these strategies must be supported by a robust infrastructure to effect a sustained improvement.

In closing I just want to acknowledge my colleagues Chris Farmer, Helen Hobbs, Jean Irving, Ian John, Edmund Lamb in Canterbury and Donald O’Donoghue our National Director of Kidney Care who’s our key collaborator from Salford.

Chairman: Thank you Doctor Stevens there is room for questions. If I don’t see at once, oh yes there on the left side please.

Question: Thank you very much for your informative talk. My question is very practical. I’m a practicing physician my name is Gordana Kavric and I’m a practicing physician in Botswana, an African country with a high incidence of HIV, over 30% of population is HIV infected. Fortunately – has a programme and has a very good infrastructure. So I’m asking from a practical point of view where you don’t have primary care physicians but you have family nurse practitioners do you see or are you aware of any studies being done in developing countries where actually you can utilise family nurse practitioners and do a simple test as proteinuria or just checking the blood pressure and serum cholesterol and use it as an initiation of referral system? Because by the time I see the patient, the patient is already in uraemia. The other thing which I noticed and I don’t know whether the others will agree with me, the current WHO system of classification of renal illnesses is actually very misleading because simply when we do a register of illnesses and you register patients in CKD, they fall under urogenital diseases and especially in the resource limited settings, developing countries, I’m sure we are missing a number of patients with complicated malarias, now with emerging HIV nephropathies with toxicity, nephrotoxicity of ARV drugs and do you see the need for something to be reformed along that line? Thank you.

Dr Stevens: Right. Developing countries and nurse practitioner programmes, I guess in the UK we call America a developing country and I don’t know of any developing countries but I heard of one recently reported in the States at the National Kidney Foundation Meeting which was a nurse practitioner hypertension programme which was of interest because the patients who were referred to the programme were referred from nephrologists and the patients were nearly 90% Afro-Caribbean already on a significant number of antihypertensives but despite that the nurse practitioner-based programme had an improvement of 16% in blood pressure control in this difficult to control population. So that’s one example but we know that nurses following algorithm-based practice do things far better than the nephrologist because a nephrologist always he thinks he knows better than the evidence base on which the protocol he writes is based. Second question was about urogenital classification. I share your frustrations because actually in mice they use exactly the same thing. So if you want to find anaemia management guidelines or CKD management guidelines on the nice website, you have to go into urogenital. Any of us who work closely with urologists will know just how frustrating that is. I don’t know how to fix the WHO classification I’m afraid, maybe Professor Ritz does.

Prof Ritz: No I have no question but I wanted to have your thoughts upon a problem. I think patient psychology is as important as his medical status. I’m very unhappy about the adoption of the terminology chronic kidney disease and I will illustrate this with one example. Chris Reynolds told me the story that he had talked a husband into donating his kidney to his wife. He was told ‘your kidneys are perfectly fine’. After ¾ of a year he comes back hopping mad showing the laboratory report that he has CKD 3 because as an elderly gentlemen his GFR is now in the range of chronic kidney disease. I think we do probably create as much concern and unnecessary fear in the patient than we do good by monitoring for progression and for cardiovascular risk using this terminology. What are your thoughts about it?

Dr Stevens: Well, I quite agree and we’ve had the term disease visited upon us. We all know that really it should be chronic renal risk or chronic kidney risk or whatever you want to call it but disease clouds the issue. Maybe going back to the slide that Adeera lent me public awareness and not just awareness of what kidney disease is but also awareness of what the terminology means and why actually when you’re perfectly ok yesterday and now today when you have a GFR less than 60 you’ve suddenly got a disease while that perhaps isn’t quite the case but I should look upon it as we do just in terms of risk.

Dr Stevens: But maybe I could add to that discussion. Isn’t that indeed in the presence of signs of kidney damage which also is in the formula or indeed the MDRD criteria that it’s not only the level of GFR although in the stage 3 below 60 it is still only eGFR but that we preferably should add and you emphasised it also already albuminuria or some other signs of renal damage before we conclude that a person of elderly age with a GFR of 50 has CKD indeed.

Question: Yes I think also what one should do is actually do a proper study and look at what people’s attitudes and perceptions of CKD are in the general public. Because Chris’s story is great and I’ve heard that story as well but it is an anecdote. We don’t accept anecdotes in any other area of the science in which we practice.

Dr Stevens: I couldn’t more agree, we walk not on one leg but on two legs and our diagnosis should not walk only on the leg of creatinine, it should also walk on the leg of albuminuria, no question about it. But I’m concerned about the impact of such diagnoses on the patients and I think we should think about finding a more patient-friendly terminology.