Population approach to kidney care and the outcomes

I don’t often do bespoke blogs but here is one

I did a blog a few weeks ago on getting smarter about prevention from an NHS perspective. https://gregfellpublichealth.wordpress.com/2017/01/19/if-the-nhs-were-better-at-preventing-stuff-10-thoughts/

Point 8 was about population focused care.
 Someone asked me to unpack what I meant. 
Here goes
This is kidney focussed. Some years ago I was privileged to work with renal med. they openly let me into their world. It was fun
1)

Starting point – the data…….( I’m an epidemiologist at heart)

I obviously have to start with the Renal Registry. 

It’s stunningly amazing. As far as I can see has provided the template for all others to trail in its wake. 

The registry provides a rich vein of data and benchmarks on which to improve. It’s real life clinical data, not the (often useless) administrative data we normally have to rely on.

I still flick through it even though I go nowhere near this area of healthcare these days.

I was once privelidged to share a stage with Charlie Thompson where he set out to some SpRs the art and science of using data to drive improvement. Humbling. Many of tjose SpRs will now be consultants, hope they remembered what Charlie taught them

So….onto business…..The story I was alluding to was in the West Midlands 

Hugh Rayner is a consistent theme in the below

2)

Gotta get the labs sorted 

LABORATORY DATABASE POPULATION SURVEILLANCE TO IMPROVE DETECTION OF PROGRESSIVE CHRONIC KIDNEY DISEASE

https://www.ncbi.nlm.nih.gov/pubmed/23941701

Key points – lifted from th paper

Describes a population surveillance system using existing laboratory data to enable early detection of patients at high risk of ESKD by reviewing cumulative graphs of estimated glomerular filtration rate (eGFR).

The hypothesis is that earlier detection and intervention can halt or delay progression to end-stage kidney disease (ESKD).

Cumulative eGFR graphs containing up to five years of data are reviewed by clinical scientists for all primary care patients or out-patients with a low eGFR for their age. For those with a declining trend, a report containing the eGFR graph is sent to the requesting doctor.

Five patients (7%) with graphs flagged as high risk had a sustained >25% fall in eGFR without evidence of secondary care referral. 
This model developed a system for laboratory staff to review cumulative eGFR graphs for a large population and identify patients at highest risk of developing ESKD. 
 This study demonstrates the value of monitoring eGFR changes over time to enable better discrimination of patients with progressive CKD, who are at the highest risk of poor outcomes. 

 The cumulative eGFR graphs can be easily interpreted by community and practice- based nursing staff caring for patients in primary care. 

They aid in the decision of whether and when to refer patients for specialist care. 

The ‘safety net’ aspect of the system gives the nephrologists greater confidence to discharge patients from secondary care for monitoring in primary care. Multidisciplinary teams and kidney nurses can use the graphs as a visual tool to help patients understand the progressive nature of their kidney condition and enable them to be more actively involved in treatment decisions.

The authors note further research is needed to measure the impact of this service on patient outcomes.
Small numbers – leads me to think of the Brailsford aggregation of marginal gains theory ( seems to have done the job for British Cycling)
 

 

Paper 2)

Does community-wide chronic kidney disease management improve patient outcomes

https://academic.oup.com/ndt/article/29/3/644/1866444/Does-community-wide-chronic-kidney-disease

The programme was introduced in stages between 2003 and 2006 

Programme components are well described in the paper

  • primary care education and financial incentives, 
  • personal clinical reports written directly to patients following every consultation, 
  • routine laboratory estimated glomerular filtration rate (eGFR) reporting, 
  • eGFR graph surveillance to identify and monitor patients at risk (see above), 
  • multidisciplinary pre-RRT care 
  • conservative care. 

The group have got a decent handle on epidemiology and they obviously know the numbers and their population characteristics, as is evident from this paper
They also know conversation rates from state to state, and how conversion rates are changing over time

Results

  • The population-adjusted incident RRT rate peaked in 2005 and then declined; 
  • the proportion starting with transplant, peritoneal dialysis or haemodialysis by arterio-venous fistula increased to 63% by 2012 )
  • Fifty-two per cent of patients receiving planned conservative care without dialysis died out of hospital.

The paper concludes that following the introduction of a community-wide systematic CKD management programme:-

  • the population-adjusted incidence of RRT reduced, 
  • modality of initiation of RRT improved 
  • A majority of patients receiving planned conservative care without dialysis died out of hospital – i.e. Lower intensity care 

Some of the charts from the paper are worth a look
 

 

 3)

 The third paper in the trio was a QI paper focused in diabetes.

 Systematic kidney disease management in a population with diabetes mellitus: turning the tide of kidney failure

https://www.ncbi.nlm.nih.gov/pubmed/21719559

It focused in on the Identification of patients with low or deteriorating trend in eGFR from weekly database review, specialist diabetes-kidney clinic, self-management of blood pressure and transfer to multidisciplinary clinic >12 months before end-stage kidney disease.

RESULTS

  • New patients increased from 62 in 2003 to 132 in 2010; 
  • follow-ups fell from 251 to 174. 
  • Median eGFR at first clinic visit increased from 28.8 ml/min/1.73 m(2) (range 6.1-67.0) in 2000/2001 to 35.0 (11.1-147.5) in 2010 (p<0.006). 
  • In 2010, the number of patients starting KRT fell 30% below the projected activity using 1993-2003 data as baseline (p<0.003). 
  • The proportion starting KRT with either a kidney transplant, peritoneal dialysis or haemodialysis via an arteriovenous fistula increased from 26% in 2000 to 55% in 2010.

Key learning 
Systematic disease management across a large population significantly improves patient outcomes, increases the productivity of a specialist service and could reduce healthcare costs compared with the current model of care.

 

 4)

Other stuff 
a) E consultation 

Throw in John Stove’s and others amazing and groundbreaking work on e consultation

https://www.ncbi.nlm.nih.gov/pubmed/20554576

Increasing the appropriateness of referrals to renal med, reducing cost, reducing carbon (in those referral and appointments), improving the quality of primary care, patient experience. Everyone is a winner!

b) Shared care, home haemo

And then throw in the awesome work by Martin Wilkie and many others on shared decisions, person centred (a decade before it became the issue de jour), home haemo and bob is proverbially your uncle…. You’ve got a population based system

 
Concluding 

The above are three short reports (with some other stuff) that I have no doubt simplifies and belies vast effort by many people over a long time 

But….bingo ….there IS a Population approach to renal care. 

The acid test …. comes back to the renal registry…..does the registry say that the RRT /ESRD incident rate is declining faster in the West Midlands than other areas. This I don’t know, another reason to go and look at the registry report again.
Now…..obviously the challenge is to apply all this into a multi morbidity context! Gulp.

 

 

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