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Widening the Circles of Inclusion. The National Renal Service Dr Donal ODonoghue 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: - PowerPoint PPT Presentation

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  • Widening the Circles of InclusionThe National Renal Service

    Dr Donal ODonoghueCo-Chair Renal Advisory Group4 July 2006

  • Standard one: A patient-centred serviceAim: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 serviceThe National Service Framework for Renal ServicesMarkers 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

  • Key FactsCKD > 5% of populationCo-morbidity : 90% HT, 40% CVD, 20% DMSMR 36 in unreferred < 60 yearsOptimal therapy 30%

    Potential savings US $18-60B / 10 yearsESRD Increasing at 6-8% paAcute 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)(Wanless)

  • The Epidemic of ESRF

  • Adapted from AM J Kidney Dis 2002; 39 (2,Suppl. 1): S17-S31Staging and Prevalence of CKD

  • CKD: A Typical GP Practice of 1000090460606380601530(GFR)Stage of Kidney Disease12345

  • Creating A National Kidney Care Service

  • Modernisation projects in renal servicesModernisation Agency Project : Birmingham, ExeterPatient View Project: Birmingham, Glasgow, LeedsSkills for Health Dialysis Project: Birmingham, Leicester, London, StevenageSkills for Health Transplant Project: Aberdeen, Canterbury, Cardiff, Gloucester, Hull, London, NewcastleLearning Sets Transport: Liverpool, MiddlesbroughLearning Sets Palliative Care: Birmingham, ManchesterLearning Sets CKD: Brighton, LeicesterABPILD Project Posts: Preston, WolverhamptonDo Once and Share - Leicester

  • NEOERICA: percentage recording of creatinine and prevalence of Stage 35 CKD by age 01020304050607080152425343544455455646574758485+Age groupsPatients (%)

    Authorised User - Permission to use may be required

  • %GFR 60 ml/minGFR
  • Go et al 2004CKD is a Major Health Burden

  • CKD Stage 1, 2, 3 Education Blood pressure Smoking cessation Lipid control Medicines Management Diet advice Exercise Psychosocial supportCKD Stage 4Anaemia Acidosis Bone disease Preparation/choiceCKD Stage 5HD Tp PD MCT

    Glycaemic control Complications eyes feet kidney Radiology Surgical interventionsAnti coagulation Anti arrhythmics Medical treatment of CHF+ DM+ CHDCardiac Kidney Diabetes

  • 304 pts referred to four renal centres in CanadaMean GFR 31 ml/minCVD 39%, DM 38%, dyslipidaemia 43%, smokers 27%, hypertension 80%

    BP > 140/9035%ACEI/ARB65%Aspirin27%Statin18%Tonelli M, AJKD 2001;37:484-489Modifiable Risk Factors - Reality

  • Relative risk Variable(95% CI)P valueNephropathy0.39 (0.17-0.87)0.003Retinopathy0.42 (0.21-0.86)0.02Autonomic0.37 (0.18-0.79)0.002 neuropathyPeripheral1.09 (0.54-2.22)0.66 neuropathy00.51.01.52.02.5Intensive therapy betterConventional therapy betterGaede et al, NEJM 2003;348:383-393STENO-2 Study

  • The CKD Domain of QOF

    PointsPaymentStagesCKD 1 A register of patients aged 18 years and over with CKD (Stage 3-5 CKD)6CKD 2 Percentage of patients with a record of blood pressure in the previous 15 months640-90%CKD 3 Percentage of patients with a BP of 140/85 or less1140-70%CKD 4: Percentage of patients who are treated with an ACEi and ARB (unless a contraindication)440-80%

  • Percentage late referrals (< 3 months) by centre 2002

  • Late Referral for RRT> 30% UK patients referred within
  • Pre-emptive & Live Donor TransplantationLiving Donor Kidney Transplants 1995-2003 (UKT)Unadjusted graft survival in 56,587 recipients of cadaveric transplants by length of dialysis treatment before transplant100908070605040302001224364860728496108120Months post-transplant% event free survivalPre-emptive06 months612 months1224 months24+ months

  • Demystifying and Managing Chronic Kidney DiseaseEducationEmpowermentEncouragementRegistrationRecallReviewKnowledgeManagement

    CfHIntegration Information Technology Information

    eGFR = % Kidney Function

  • The National Kidney Care Service158 Local Health Communities23 Renal Networks6 Transplant AlliancesWidening the Circles of Inclusion

  • Figure 2 from draft of primary nephrology paper (May 2005)