GFR Implementation CKD Program at Southern California Kaiser Permanente

1. GFR Implementation & CKD Program at Southern California Kaiser Permanente Peter Crooks, M.D. Physician Director, Renal Program Southern California Kaiser Permanente 4 October 2005

2. Kaiser PermanenteSouthern California Structure 3 legally independent entities Kaiser Health Plan (non-profit) Kaiser Foundation (np - owns facilities) Southern California Permanente Medical Group (for profit) Kaiser pays SCPMG PMPM SCPMG financially responsible for Medical Care, including care at non-Kaiser Facilities Some risk sharing for good or poor financial outcomes Kaiser Permanente (KP) is an example of a health care system with vertical integration, where the Kaiser Health Plan and the Permanente Medical Groups work together to directly provide most health care services. Kaiser Permanente Southern California (KPSC) has 11 full-service medical centers and many smaller facilities serving approximately 3 million members. There are over 3000 physicians, including 55 nephrologists. In addition to physician services, nearly all other medical services are provided at the medical centers and offices, including laboratory, diagnostic and pharmacy services. This setting is ideal for proactive disease management activities such as a CKD programKaiser Permanente (KP) is an example of a health care system with vertical integration, where the Kaiser Health Plan and the Permanente Medical Groups work together to directly provide most health care services. Kaiser Permanente Southern California (KPSC) has 11 full-service medical centers and many smaller facilities serving approximately 3 million members. There are over 3000 physicians, including 55 nephrologists. In addition to physician services, nearly all other medical services are provided at the medical centers and offices, including laboratory, diagnostic and pharmacy services. This setting is ideal for proactive disease management activities such as a CKD program

3. Kaiser PermanenteSouthern California (KPSC) 3,100,000 Members 90,000 CKD 1-5, 4500 ESRD 3300 Full-time Physicians 58 Nephrologists 12 Geographic Areas Bakersfield to San Diego 11 Medical Centers 100+ Medical Offices 1200 per diem Physicians 30,000 Employees Kaiser Permanente (KP) is an example of a health care system with vertical integration, where the Kaiser Health Plan and the Permanente Medical Groups work together to directly provide most health care services. Kaiser Permanente Southern California (KPSC) has 11 full-service medical centers and many smaller facilities serving approximately 3 million members. There are over 3000 physicians, including 55 nephrologists. In addition to physician services, nearly all other medical services are provided at the medical centers and offices, including laboratory, diagnostic and pharmacy services. This setting is ideal for proactive disease management activities such as a CKD programKaiser Permanente (KP) is an example of a health care system with vertical integration, where the Kaiser Health Plan and the Permanente Medical Groups work together to directly provide most health care services. Kaiser Permanente Southern California (KPSC) has 11 full-service medical centers and many smaller facilities serving approximately 3 million members. There are over 3000 physicians, including 55 nephrologists. In addition to physician services, nearly all other medical services are provided at the medical centers and offices, including laboratory, diagnostic and pharmacy services. This setting is ideal for proactive disease management activities such as a CKD program

4. Kaiser PermanenteSouthern California Structure Impact of Structure Linkage of payer and provider All in it together Drives integration of services Full-service Medical Centers/Hospitals Pharmacy & DME Lab & Imaging Consultative Services Drives internalization of care Drives information sharing & QI Drives proactive care Disease & population management Kaiser Permanente (KP) is an example of a health care system with vertical integration, where the Kaiser Health Plan and the Permanente Medical Groups work together to directly provide most health care services. Kaiser Permanente Southern California (KPSC) has 11 full-service medical centers and many smaller facilities serving approximately 3 million members. There are over 3000 physicians, including 55 nephrologists. In addition to physician services, nearly all other medical services are provided at the medical centers and offices, including laboratory, diagnostic and pharmacy services. This setting is ideal for proactive disease management activities such as a CKD programKaiser Permanente (KP) is an example of a health care system with vertical integration, where the Kaiser Health Plan and the Permanente Medical Groups work together to directly provide most health care services. Kaiser Permanente Southern California (KPSC) has 11 full-service medical centers and many smaller facilities serving approximately 3 million members. There are over 3000 physicians, including 55 nephrologists. In addition to physician services, nearly all other medical services are provided at the medical centers and offices, including laboratory, diagnostic and pharmacy services. This setting is ideal for proactive disease management activities such as a CKD program

6. Why use an Estimated GFR? Medical evidence (EBG) Intervention can reduce ESRD and reduce CVD Permits Identification PCP recognition of CKD Permits patient to learn of condition, become educated and take action Permits Staging/Stratification Stage-specific intervention

7. Why use MDRD equation 7? Compromise of accuracy & ease of use Doesn�t require urine Only 4 variables Serum creatinine level, age, gender, black or non-black race Good fit with data at lower GFR Hope for better equation in future

9. Practical Implementation Issues Apply only to age > 18 If not provided by lab, GFR calculation not easy Report normal values as �> 90� Race is often not available in IT systems Report both B & NB result, clinician interprets GFR requires interpretation Acute vs. chronic renal insufficiency Age-adjusted interpretation Stage 2 in elderly Stage 3: GFR + 1/2AGE < 85 ? higher risk Accuracy of serum creatinine measurement

10. GFR Table Example

13. Comparison with Cleveland Clinic

14. Inter-Laboratory Comparison Testing for Creatinine (mg/dL)

15. CKD Staging Algorithm To automate CKD staging , need algorithm Compare recent GFR to GFR 3+ mos prior �Lock in� CKD Stage until two GFR >3 mos apart are both out of range in same direction q3mo GFR: 31, 35 (Stage 3), 29, 34, 26, 31, 22, 26 (Stage 4) Lag behind current GFR and provides �baseline� Urine ignored if GFR > 60 If GFR < 60, must decide urine and anatomic criteria (not simple) Need more than one abnormal urine result Focus on protein, ignore hematuria, etc.

16. CKD Staging Algorithm  Kaiser Permanente So California

17. CKD Staging AlgorithmAll Possible Outcomes Not determined - no serum creatinine available At Risk - age > 65, HTN, DM, Family History No CKD - 1 or more serum creatinine available, GFR > 90, U/A OK Chronically Reduced GFR stage 2 GFR 60-89 3+ mos, urine/anatomy normal Chronicity Unknown Reduced GFR 2 -5 low GFR not meeting 3+ mo criteria CKD Stage 1 CKD Stage 2 CKD Stage 3 High-risk ESRD/Low-risk ESRD CKD Stage 4 CKD Stage 5 Future renal replacement/No future renal replacement � CKD Stage 5 Hemodialysis CKD Stage 5 Peritoneal Dialysis CKD Stage 5 Transplant CKD substage 1-5

19. PERCENTAGES POPULATION GFR >90 or no CR 60-89 30-59 15-29 NHANES III 64% 31% 4.3% 0.2%

20. Modified Stage 3 High-risk if GFR + � Age < 85

21. CKD Staging Results Kaiser Permanente So California

24. Fax messages at point of careKaiser Permanente So California

27. CKD 4 & 5 (GFR < 30) unless other terminal disease/co-morbidity Nephrology Referralis strongly encouraged for all patients with...

28. For patients CKD 1-3,consider Nephrology referral if �. Proteinuria > 1000 mg/day ~random microalbumin 1000 especially if persists despite control of DM, HTN, and use ACE I/ARB Clarification of CKD diagnosis Very difficult to control Blood Pressure Suspected EPO-deficiency anemia Unexplained acute fall GFR > 25-50%

29. WHO ARE KP NEPHROLOGISTS SEEING?

31. CKD Education Kaiser Permanente So California Education: defined Classes Kidney Class: any CKD Stage Choices Class: Stage 4-5pre Group Visits Individual Counseling Social Worker, Care Manager, Nutritionist

33. Hospital Days, Nephrologist Visits& Modality EducationKaiser Permanente So California CKD 4 & 5pre: 4263 Patients

34. CKD and CVD CKD patients = highest CVD risk category CVD risk factors accelerate CKD CKD uniquely exacerbates CVD Most CKD patients die of CVD before ESRD Majority of new ESRD patients have CVD CKD need treatment for CVD risk reduction

35. CVD Risk vs. GFR in ARICManjunath et al. J Am Coll Cardiol 2003; 41: 47�55

36. When you see this...

37. GFR Implementation & CKD Program at Southern California Kaiser Permanente Thank you! And over to SCPMG colleague, James Dudl, M.D.