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Testing/Monitoring

Testing/Monitoring. Renal Group Risk group. +. **. +. No GFR 1. Risk - not tested. Renal - not tested. -. ** = will also be captured in group 1 or 3. +. Denominators. Numerator 1. GFR 1 >=60. no RF or RF coded <1 year prior to audit start. Patient not at risk

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Testing/Monitoring

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  1. Testing/Monitoring Renal Group Risk group + ** + No GFR1 Risk - not tested Renal - not tested - ** = will also be captured in group 1 or 3 + Denominators Numerator 1 GFR1 >=60 no RF or RF coded <1 year prior to audit start Patient not at risk Patients who became at risk within last year + Risk– no CKD3-5 - Practice population aged >18 * + - ** + - GFR1<60 and either (GFR2>=60 OR No GFR2) QOF CKD code or coded renal disease for > 1 year Risk– single low GFR Risk Group Renal Group Renal - tested - * + GFR1 and GFR2 <60 Risk – CKD3-5 unregistered * = will also be captured in group 2 Numerator 2 GFR1: Most recent eGFR within the last 12 months GFR2: eGFR prior to GFR1 where > 3months have elapsed between tests and is reported after 1/1/2008 + + lab ACR,/PCR or dipstick proteinuria code in last 12 months Risk - ACR tested Renal – ACR tested - Risk – no ACR Renal – no ACR

  2. Group 1 Coded CKD + Denominator Numerator No GFR1 Coded – no GFR past 2 year - Practice CKD QOF register, age >18 Practice CKD QOF register + GFR1 >=60 Coded – no CKD 3-5 based on last GFR - + No GFR2 OR GFR2>=60 Coded- single GFR GFR1: Most recent eGFR within the last 24 months GFR2: eGFR prior to GFR1 where > 3months have elapsed between tests and is reported after 1/1/2008 - Coded- CKD3-5

  3. Group 2Uncoded with CKD Uncoded patients Denominator Numerator + on QOF CKD register GFR1 <60 and either (No GFR2OR GFR2>=60) + Uncoded– single low GFR Patients with registered CKD 3-5 Practice population aged >18 - - + GFR1 and GFR2 <60 Uncoded patients Uncoded– CKD3-5 GFR1: Most recent eGFR within the last 24 months GFR2: eGFR prior to GFR1 where > 3months have elapsed between tests and is reported after 1/1/2008

  4. Group 3 Early CKD on QOF register or uncoded (group1 and 2) Denominator Numerators CKD captured elsewhere + Practice population aged >18 coded as CKD stage 1/ 2 + - Early – CKD coded + coded with renal disease code Early – non CKD coded

  5. Data extract for all cases (numerators and denominators)

  6. Risk Factors • Risk Factors (RFs): • Hypertension • Diabetes • Gout • IHD, congestive cardiac failure, atrial fibrillation • Cerebrovascular disease • Peripheral arterial disease • Kidney stones • Prostatic hypertrophy • Prescription of lithium last 1 year • Prescription of tacrolimus or cyclosporin last 1 year • Systemic lupus erythamatosis and connective tissue diorders • Agreed Exclusions (as to 29/5/13) • family history – inadequate data available to GPs • NSAIDs – inadequate coding (non-prescription use, prescription but no use) • Haematuria – impossible to interpret • Conditions with renal involvement which will be under the care of a hospital specialist: • sarcoid • amyloid • myeloma • TB

  7. Renal disease codes [This list needs populating from the meeting 29/5/13] Inclusions (agreed 29/5/13): DM with microalbuminuria Systemic disease coded only where nephritis/renal involvement is specified. Alports, Cystic disease, Fabry’s • Proteinuria Codes • This is both a code for proteinuria (as a renal condition) and codes for dipstick positive proteinuria (>1+). [Sally to update] • 467, 4672 to 4675, 4676 to 4678, 467A, 467E, 467H CKD stage 1/2 codes CKD stage 1 without proteinuria Heamaturia codes

  8. Staging Uncoded– CKD3-5 + Denominator Numerator GFR1 >=45 = + Confirmed CKD3-5 CKD 3a Coded- CKD3-5 - Confirmed CKD 3-5 + GFR1 >=30 CKD 3b - + GFR1 >=15 CKD 4 GFR1: Most recent eGFR within the last 24 months - CKD 5

  9. Monitoring This has now been incorporated into the testing algorithm (first slide). It therefore excludes patients with low GFR but without a QOF code or a renal disease code. [agreed 6 July]

  10. BP control Blood Pressure + <=130 systolic and <=80 diastolic Group 2 Uncoded – CKD3-5 - BP subopt + Proteinuric CKD/DM Denominator ACR>=30 (PCR>=50), proteinuria code or diabetes code + BP control = All CKD + Group 1 Coded- CKD3-5 <=130 systolic and <=80 diastolic + - Non-proteinuric CKD Group 3 CKD1/2 - BP subopt Collect: Antihypertensive medication classes Angiotensin Converting Enzyme Angiotensin Receptor Blocker Alpha Blocker Beta Blocker Calcium Channel Blocker Diuretic Aldosterone antagonists Other Antihypertensive Contraindication to ACE/ARB Last systolic BP Last diastolic BP

  11. Referral Denominator Referred or reviewed by nephrology/diabetes specialist in last 24 months All CKD Referred GFR1: Most recent eGFR within the last 12 months GFR2: eGFR prior to GFR1 where > 3months but <15months have elapsed between tests eGFR1<30 (GFR2 – GFR1) >5 and GFR1 is <45ml/min Taking 4 antihypertensive classes (see previous) and last BP>140/90 in last 12 months ACR>=70 (PCR>=100) and no diabetes in last 12 months ACR>=30 (PCR>=50) and heamaturia code in last 12 months Coded genetic kidney disease – see renal disease codes

  12. CV risk No code for IHD, CCF, AF, PVD, cerebrovasc disease CV risk assessment e.g Q risk, framingham CV primary assessed CV risk - primary All CKD collect: statin prescription contraindication to statin prescription exercise advice/weight loss advice stop smoking advice CV risk - secondary additionally collect: aspirin prescription contraindication to aspirin prescription – eg GI bleeding/ulcer warfarin/clopidogrel prescription

  13. CKD care plan Can only be ascertained by patient reported outcomes

  14. Immunisation 1 Influenza immunisation in last 12 months Uncoded– CKD3-5 = + Confirmed CKD3-5 Flu immunised Coded- CKD3-5

  15. Immunisation 2 Hep immune pos neg Uncoded– CKD4-5 Hepatitis HsAb in last 5 years Hepatitis B immunisation in last 5 years yes = + Confirmed CKD4-5 Hep immunised Coded- CKD4-5 unknown Hep unknown Hep non-immunised n.b. this will depend on local practice – will need survey results to interpret these data

  16. Immunisation 3 Uncoded– CKD4-5 Pneumococus immunisation in last 5 years yes = + Confirmed CKD4-5 Pneumo immunised Coded- CKD4-5 Pneumo non-immunised

  17. Hb monitoring Hb sample sent in last 12 months Uncoded– CKD3b-5 = + Confirmed CKD3b-5 Hb monitored Coded- CKD3b-5

  18. BMD Bone metabolism (Ca/PO4/PTH/vit D level) checked in last 12 months Uncoded– CKD4-5 = + Confirmed CKD4-5 BMD monitored Coded- CKD4-5 Collect: Vitamin D preparations (long list) alphacalcidol ergocalciferol calcium tablets + variants sevalemer lanthanum aluminium hydroxide calcium acetate ‘dulwich mixture’/magnesium+calcium

  19. The percentage of people with CKD who are assessed for kidney disease progression and related problems according to their disease stage [*, QS6] • Based on eGFR/urine laboratory results/timing. For CKD 3B percentage that had Hb measured. • The percentage of people with defined indicators for referral who were referred to secondary care [*, QS2] within 3 months of abnormal results • eGFR/urine results and timing, high blood pressure despite 4 antihypertensive drug classes, read-codes for referral and/or renal ultrasound, pop-up box for GPs to fill in if phone or e-mail advice from specialistswas given • The percentage of people with CKD who are assessed for cardiovascular risk [*, QS4] • Management • The percentage of people with CKD who have a current agreed care plan [QS3] by 1 year • read-code on whether patients were informed about their diagnosis (once available), see 4.3. • The percentage of people with CKD who have blood pressures in the NICE recommended target range by 1 year [*, QS5] • Includes proportion of patients on renin-angiotensin blocking drugs according to proteinuria status • The percentage of people with CKD who are treated with statins according to their cardiovascular risk by 1 year [*] • Primary and secondary prevention as per updated NICE lipid guideline (once available) • The percentage of people with CKD who had their medication reviewed whilst acutely unwell • The percentage of people with CKD who were vaccinated for influenza (NICE TA158) • For CKD stages 4 &5 this would also apply to pneumococcal virus and Hepatitis B if seronegative (KDIGO CKD guideline 2013). • The percentage of people with CKD 4&5 who have phosphate and haemoglobin measurements on GP laboratory systems. [*]#

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