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A Brief History of TimeSeries Graphs
Dr Hugh Rayner MD FRCP DipMedEd
Consultant NephrologistHeart of England NHS Foundation Trust
Birmingham
Pathology and renal services to c.900,000
Improving CKD outcomes
CKD 3 4 5 Dialysis
50 60 70Age 40
Age 70 80 90
Before:
Improving CKD outcomes
CKD 3 4 5 Dialysis
50 60
CKD 3 4 5 Trans-plant
Age 70 80 90
After:
70Age 40
Age 70 80 90
70Age 40 50 60
Before:
CKD management program
Start RRT
Slow progression
Identify patients at high risk
Primary care
Self care
How well are your kidneys
working now?
Reviewing U&E results
Date Creatinine eGFR15.01.2014 117 60.319.11.2013 91 81.415.08.2013 105 68.707.06.2013 113 63.013.05.2013 94 78.504.02.2013 106 68.1
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46 year old man, type I diabetes with nephropathy
eGFRml/min/1.73m2
Communication, partnership
and teamwork
• Give patients the information they want or need in a way they can understand
• Support patients in caring for themselves to improve and maintain their health
Population medicine
Secondary care
Declining eGFRor
Heavy proteinuria
Start RRT
Slow progression
Identify patients at high risk
Primary care
Self care
CKD registers
Pathology laboratory
Renal department
SQLdatabase
eGFR monitor
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2000 2002 2004 2006 2008 2010 2012
Follow-upvisits
First visits
Attendances at the diabetes-kidney clinic
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Incident RRTrate per millionpopulationaged over 14years
Numberstarting RRT
Patients starting RRT at Heart of England Foundation Trust
GP CKD QOF payments
Pre-ESRD team
eGFR reporting
Primary care education
Diabetes eGFR surveillance
Letters to patients
GP HT and diabetes QOF payments
Lowest rate of late presentation for chronic dialysis
HEFT % England, Wales & NI %
2009-10 9.9 20.6
2010-11 9.1 20.1
2011-12 7.4 19.5
2012-13 5.7 18.6
2013-14 4.9 18.0
4.9%
Percentage of patients presenting <90 days prior to starting RRT, 2013/2014
0.0
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Highest % rate of early presentation for chronic dialysis
Percentage of patients presenting > one year prior to starting RRT, 2012/2013(UK Renal Registry Report 2014)90.1%
Kennedy DM, Chatha K, Rayner HC
Laboratory database population surveillance
to improve detection of progressive chronic
kidney disease.
Journal of Renal Care 2013; 39 Suppl 2:23-9
“CKD Made Easy
– a guide for general practice”
Google: ‘CKD Made Easy’
Since 2012:
Laboratory
surveillance and
selective graphical
reports
Heart of England Kidney Function Monitor
Patient ZZC00261281
Date of Birth 17-Aug-1938 Sex M
Requesting
Clinician
Dr K Arora Location Perry Park 291 Walsall Rd
Date/Time of
Test
11-Apr-2012 04:13 Estimated
GFR
35 (ml/min)
0
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100
01/01/2008 01/01/2009 01/01/2010 01/01/2011 01/01/2012
Est GFR (ml/min) GFR if Afro Caribbean Marked as Inform Clinician Marked as Urgent
Other Tests From The Last 5 Years
Test Highest Date Latest Date
HbA1c 7.6 % 27/02/2012 7.6 % 27/02/2012
Serum K 5.1 mmol/l 11/04/2012 5.1 mmol/l 11/04/2012
Serum Na 144 mmol/l 15/09/2008 134 mmol/l 11/04/2012
Serum Urea 12.4 mmol/l 11/04/2012 12.4 mmol/l 11/04/2012
Urine Protein 0.27 g/l 15/09/2010 0.07 g/l 27/02/2012
Urine albumin:creatinine
ratio
30.5 mg/mmol 15/09/2010 1.7 mg/mmol 27/02/2012
Diabetic Status on Renal Database Not Diabetic
Dear Dr Arora,
This results for this patient have reviewed as part of our departments system for monitoring chronic kidney disease
using cumulative graphs of eGFR. Based on our criteria, agreed with the renal medicine department, this patient has
been identified as at increased risk of progression to end-stage kidney disease.
If you requirefurther advice or information for the management of this patient please contact Dr Hugh Rayner at
Birmingham Heartlands Hospital.
Email [email protected] for a copy of 'CKD Made Easy'.
Please quote this patient's NHS number.
GP feedback (n=36)
• 30% usually looked at only the last few results
• 74% found the graphical eGFR report useful
• 41% had changed patient management in response to the report
• Average ease of use of the graphs = 8 out of 10 (10 = easiest)
GP feedback
“I would be grateful for your advice regarding
the above 91 year old lady.
My query is in regards to her deteriorating eGFR
which has been made clear by a graph that had
been sent to me.”
UK
Prevalent population on RRTUK Heart of England Foundation Trust
0
100
200
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400
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700
199
71
998
199
92
000
200
12
002
200
32
004
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006
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008
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92
010
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12
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32
014
201
5
Total PD
Home HD
Centre HD
Transplant
UK
Prevalent population on RRTUK Heart of England Foundation Trust
0
100
200
300
400
500
600
700
199
71
998
199
92
000
200
12
002
200
32
004
200
52
006
200
72
008
200
92
010
201
12
012
201
32
014
201
5
Total PD
Home HD
Centre HD
Transplant
80 patients
£25,000
X 80
£2 million
Laboratory service 2016
• 1600 graphs reported to GPs per year
• Specialised services commissioning CQUIN income to HEFT = £361,812 per year
Summary of the benefits
Clinical
• Fewer patients reaching end-stage kidney failure
Financial • Cost of dialysis program stabilised
Environmental• Fewer patients attending hospital clinics
Social• Access to nephrology based upon health need regardless
of age, ethnicity and GP expertise in CKD
• Informed and shared decisions through better understanding of CKD by use of eGFR graphs
• Consultants in control of their workload
Free chapters on the
International Society
of Nephrology website:
www.theISN.org/Education
Search under Books
Chapter 1Kidney Anatomy and Physiology - The Basis of Clinical NephrologyChapter 2Measuring Kidney Function - Quantifying Glomerular Filtration from Laboratory TestsChapter 3 Plot All the Dots - Graphs Reveal the Progression of Kidney DiseaseChapter 17Make a Plan - When and How to Prepare for End-Stage Kidney Disease