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Guidelines: A Perspective From the United Kingdom
Editorial A Decade After the KDOQI CKD/Guidelines: A Perspective From the United Kingdom
I
n the past decade, the perception of renal medicine in the United Kingdom as complex, rare, and almost exclusively concerned with dialysis and transplantation has shifted to one of kidney disease being seen as common, linked with vascular risk, amenable to early intervention, and a subject that all health care practitioners need to know about. This followed the widespread acceptance of the KDOQI (Kidney Disease Outcomes Quality Initiative) chronic kidney disease (CKD) guidelines nomenclature, supported by the universal adoption of estimated glomerular filtration rate (eGFR) as the currency for kidney function reporting and the national implementation of primary care–based CKD registers to promote a chronic disease management model of care.1-3 In the wake of this paradigm shift, the political and public profile of kidney disease has increased dramatically, kidney research has expanded, care is being integrated across primary and secondary services,4-11 and shared decision making with every patient who has advanced CKD is a key goal for the UK kidney community. Two-thirds of the expected prevalent population with CKD stages 3-5 have now been entered into the primary care CKD register in the United Kingdom. During the same period, acceptance rates onto renal replacement therapy (RRT) programs have plateaued and pre-emptive live donor kidney transplantation rates are increasing.12 However, despite this, there are still wide variations in CKD ascertainment and blood pressure control and missed opportunities to prevent CKD progression. Physician preference continues to influence patient choice in determining RRT modality, diabetic kidney disease prevalence is increasing, acute kidney injury as a complication (and a cause) of CKD is not adequately recognized, and multimorbidity remains a major challenge. Within the UK National Health Service (NHS), which can be thought of as a closed managed care system, ⬎99% of the population are registered in primary care and 97% of the population are seen within a 5-year period.13 The founding principles of This editorial is part of a series in the November 2012 issue of AJKD that explores the impact of the KDOQI CKD guidelines a decade after publication. Address correspondence to Donal J. O’Donoghue, MB, ChB, FRCP, National Health Service Kidney Care, London, United Kingdom. E-mail: donal.o’[email protected] © 2012 by the National Kidney Foundation, Inc. 0272-6386/$36.00 http://dx.doi.org/10.1053/j.ajkd.2012.08.011 740
the NHS are consistent with structured delivery of health care for kidney disease patients that spans the entire system, beginning at the “at-risk” stage and reaching through to end-stage renal disease. However, in practice, professional, organizational, and institutional impediments exist to the coordination and delivery of care, and historically, kidney disease was not a priority area for the NHS. However, a quality and outcomes framework for primary care to systematically incentivize process measures such as computerization and chronic disease management by establishing practice-based disease registers was introduced in 2004. In April 2006, a CKD domain was added to this framework3 to coincide with the introduction of mandated eGFR reporting2 and constituted one element of a broader effort to identify people with CKD in primary care. To meet performance indicators, primary care practices had to prepare a register of adults with stages 3-5 CKD, record blood pressure and achieve levels ⬍140/85 mm Hg, and list the fraction of patients with CKD and hypertension who were treated with angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers. The indicators subsequently were updated to add proteinuria, and primary care offices now must record urine albumin-creatinine ratio in all patients included in the CKD register (Table 1). A national health check offered to all citizens aged 40-75 years that includes kidney disease was introduced in 2008.14 The National Policy initiatives were developed in parallel with professional guidelines,15 and the National Institute of Health and Clinical Excellence (NICE) was commissioned to systematically review the evidence base in order to prepare a clinical guideline covering early identification and management of adult patients with CKD in primary and secondary care.16 Awareness and education programs have been accompanied by a change to the primary care training curriculum and introduction of electronic learning for health CKD modules.17 The NHS has funded local networks to support coordination, greater patient involvement, quality improvement, research, and delivery of integrated CKD care. In the first year of the National CKD Programme, 3% of the adult population were identified and placed on CKD registers. Initially, there was up to a 50-fold difference from one practice to another in rates of CKD identification and registration, in some cases mirroring variances in age, ethnicity, and socioeconomic status, as well as spotlighting education deficiencies and system failure. This disparity in CKD detection and that of achieved Am J Kidney Dis. 2012;60(5):740-742
Editorial Table 1. Quality and Outcomes Framework CKD Indicators Indicator
Description
CKD 1
The practice can produce a register of patients aged 18 years and over with CKD (US National Kidney Foundation: stages 3 to 5 CKD). (R) The percentage of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months. (P) The percentage of patients on the CKD register in whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less. (IO) The percentage of patients on the CKD register with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker (unless a contraindication or side effects are recorded). (P-T-O) The percentage of patients on the CKD register whose notes have a record of a urine albumincreatinine ratio (or protein-creatinine ratio) test in the previous 15 months. (P)
CKD 2
CKD 3
CKD 5
CKD 6a
Abbreviations: CKD, chronic kidney disease; IO, intermediate outcome; P, process; P-T-O, process linked to outcome; R, register. Reproduced from the UK National Health Service Quality and Outcomes Framework3; re-used with the permission of the UK Health and Social Care Information Centre. a Introduced in 2009.
blood pressure has begun to diminish and now 4.3% of the adult population are enrolled in a program of active management.3 The demystification of kidney disease through eGFR reporting and the concept of percentage of normal kidney function have been strengthened by adding proteinuria measurement as a requirement of CKD management in primary care. The latest UK Renal Registry Report numbers show that in end-stage renal disease, patients are referred late 19% of the time (down from 30%), and in the past 4 years, RRT acceptance rates have been stable at 109 per million population.12 Patients are starting RRT in a more planned fashion, evidenced by higher preemptive transplant listing rates, increased pre-emptive live donor transplantation, improved vascular access rates, and better biochemical control at initiation of dialysis therapy. Home hemodialysis rates are beginning to increase, although despite professional and NICE guidelines, peritoneal dialysis rates continue to decrease. Future service challenges include raising awareness among the public, more patient involvement in care and decisions, optimization of CKD management programs, identification and management of acute kidney injury risk, and integration of vascular management to encompass CKD, diabetes, and heart disease. Such integration will be necessary to transcend the limitations of the present tendency toward compartAm J Kidney Dis. 2012;60(5):740-742
mentalization of care and to achieve effective structured health care for the growing multimorbid population. Donal J. O’Donoghue, FRCP NHS Kidney Care London, United Kingdom Paul E. Stevens, FRCP Kent Kidney Research Group Canterbury, United Kingdom
ACKNOWLEDGEMENTS Dr O’Donoghue is National Clinical Director for Kidney Care, UK Department of Health. Financial Disclosure: The authors declare that they have no relevant financial interests.
REFERENCES 1. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2)(suppl 1):S1-S266. 2. Department of Health. Estimated glomerular filtration rate (eGFR) information for laboratories. http://webarchive.nationalarchives.gov.uk/⫹/ www.dh.gov.uk/en/Healthcare/Longtermconditions/Vascular/ Renal/RenalInformation/DH_4133073. Accessed March 8, 2012. 3. The Information Center. Quality and outcomes framework for GMS contract 2011/12: delivering investment in general practice. http://www.ic.nhs.uk/statistics-and-data-collections/auditsand-performance/the-quality-and-outcomes-framework. Accessed March 8, 2012. 4. Jones C, Roderick P, Harris S, Rogerson M. An evaluation of a shared primary and secondary care nephrology service for managing patients with moderate to advanced CKD. Am J Kidney Dis. 2006;47(1):103-114. 5. Jones C, Roderick P, Harris S, Rogerson M. Decline in kidney function before and after nephrology referral and the effect on survival in moderate to advanced chronic kidney disease. Nephrol Dial Transplant. 2006;21(8):2133-2143. 6. Richards N, Harris K, Whitfield M, et al. Primary care-based disease management of chronic kidney disease (CKD), based on estimated glomerular filtration rate (eGFR) reporting, improves patient outcomes. Nephrol Dial Transplant. 2008;23:549-555. 7. Phillips LA, Donovan KL, Phillips AO. Renal quality outcomes framework and eGFR: impact on secondary care. QJM. 2009;102(6):415-423. 8. Meran S, Don K, Shah N, Donovan K, Riley S, Phillips AO. Impact of chronic kidney disease management in primary care. QJM. 2011;104(1):27-34. 9. Rayner HC, Hollingworth L, Higgins R, Dodds S. Systematic kidney disease management in a population with diabetes mellitus: turning the tide of kidney failure. BMJ Qual Saf. 2011; 20(10):903-910. 10. Klebe B, Farmer C, Cooley R, et al. Kidney disease management in UK primary care: guidelines, incentives and information technology. Fam Pract. 2007;24(4):330-335. 11. Stoves J, Connolly J, Cheung CK, et al. Electronic consultation as an alternative to hospital referral for patients with chronic kidney disease: a novel application for networked electronic health records to improve the accessibility and efficiency of healthcare. Qual Saf Health Care. 2010;19(5):e54. 12. Gilg J, Castledine C, Fogarty T, Feest T. UK Renal Registry 13th Annual Report (December 2010): Chapter 1. UK RRT inci741
O’Donoghue and Stevens dence in 2009: national and centre-specific analyses. Nephron Clin Pract. 2011;119(suppl 2):c1-c25. 13. Hippisley-Cox J, Vinogradova Y. Trends in consultation rates in general practice 1995 to 2008: analysis of the QResearch® database. http://www.ic.nhs.uk/webfiles/publications/gp/Trends_ in_Consultation_Rates_in_General_Practice_1995_2008.pdf. Accessed October 1, 2009. 14. Department of Health: NHS Check Programme, April 2008. Putting prevention first—NHS Health Check: Vascular risk assessment and management best practice guidance. http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_097489. Accessed May 18, 2008. 15. Joint Specialty Committee for Renal Disease Royal College of Physicians of London and the Renal Association. Chronic
742
kidney disease in adults: UK Guidelines for Identification, Management and Referral. Royal College of Physicians of London, 2006. http://www.renal.org/CKDguide/full/CKDprintedfullguide. pdf. Accessed April 1, 2006. 16. National Institute for health and Clinical Excellence (NICE). Chronic kidney disease. Clinical guideline 73. Chronic kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care. London; 2008. http://www.nice.org.uk/nicemedia/live/12069/42117/42117.pdf. Accessed July 22, 2012. 17. Royal College of General Practitioners. Kidney health in general practice. http//elearning.rcgp.org.uk/course/info.php?id⫽85. Accessed January 1, 2012.
Am J Kidney Dis. 2012;60(5):740-742
I
n the past decade, the perception of renal medicine in the United Kingdom as complex, rare, and almost exclusively concerned with dialysis and transplantation has shifted to one of kidney disease being seen as common, linked with vascular risk, amenable to early intervention, and a subject that all health care practitioners need to know about. This followed the widespread acceptance of the KDOQI (Kidney Disease Outcomes Quality Initiative) chronic kidney disease (CKD) guidelines nomenclature, supported by the universal adoption of estimated glomerular filtration rate (eGFR) as the currency for kidney function reporting and the national implementation of primary care–based CKD registers to promote a chronic disease management model of care.1-3 In the wake of this paradigm shift, the political and public profile of kidney disease has increased dramatically, kidney research has expanded, care is being integrated across primary and secondary services,4-11 and shared decision making with every patient who has advanced CKD is a key goal for the UK kidney community. Two-thirds of the expected prevalent population with CKD stages 3-5 have now been entered into the primary care CKD register in the United Kingdom. During the same period, acceptance rates onto renal replacement therapy (RRT) programs have plateaued and pre-emptive live donor kidney transplantation rates are increasing.12 However, despite this, there are still wide variations in CKD ascertainment and blood pressure control and missed opportunities to prevent CKD progression. Physician preference continues to influence patient choice in determining RRT modality, diabetic kidney disease prevalence is increasing, acute kidney injury as a complication (and a cause) of CKD is not adequately recognized, and multimorbidity remains a major challenge. Within the UK National Health Service (NHS), which can be thought of as a closed managed care system, ⬎99% of the population are registered in primary care and 97% of the population are seen within a 5-year period.13 The founding principles of This editorial is part of a series in the November 2012 issue of AJKD that explores the impact of the KDOQI CKD guidelines a decade after publication. Address correspondence to Donal J. O’Donoghue, MB, ChB, FRCP, National Health Service Kidney Care, London, United Kingdom. E-mail: donal.o’[email protected] © 2012 by the National Kidney Foundation, Inc. 0272-6386/$36.00 http://dx.doi.org/10.1053/j.ajkd.2012.08.011 740
the NHS are consistent with structured delivery of health care for kidney disease patients that spans the entire system, beginning at the “at-risk” stage and reaching through to end-stage renal disease. However, in practice, professional, organizational, and institutional impediments exist to the coordination and delivery of care, and historically, kidney disease was not a priority area for the NHS. However, a quality and outcomes framework for primary care to systematically incentivize process measures such as computerization and chronic disease management by establishing practice-based disease registers was introduced in 2004. In April 2006, a CKD domain was added to this framework3 to coincide with the introduction of mandated eGFR reporting2 and constituted one element of a broader effort to identify people with CKD in primary care. To meet performance indicators, primary care practices had to prepare a register of adults with stages 3-5 CKD, record blood pressure and achieve levels ⬍140/85 mm Hg, and list the fraction of patients with CKD and hypertension who were treated with angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers. The indicators subsequently were updated to add proteinuria, and primary care offices now must record urine albumin-creatinine ratio in all patients included in the CKD register (Table 1). A national health check offered to all citizens aged 40-75 years that includes kidney disease was introduced in 2008.14 The National Policy initiatives were developed in parallel with professional guidelines,15 and the National Institute of Health and Clinical Excellence (NICE) was commissioned to systematically review the evidence base in order to prepare a clinical guideline covering early identification and management of adult patients with CKD in primary and secondary care.16 Awareness and education programs have been accompanied by a change to the primary care training curriculum and introduction of electronic learning for health CKD modules.17 The NHS has funded local networks to support coordination, greater patient involvement, quality improvement, research, and delivery of integrated CKD care. In the first year of the National CKD Programme, 3% of the adult population were identified and placed on CKD registers. Initially, there was up to a 50-fold difference from one practice to another in rates of CKD identification and registration, in some cases mirroring variances in age, ethnicity, and socioeconomic status, as well as spotlighting education deficiencies and system failure. This disparity in CKD detection and that of achieved Am J Kidney Dis. 2012;60(5):740-742
Editorial Table 1. Quality and Outcomes Framework CKD Indicators Indicator
Description
CKD 1
The practice can produce a register of patients aged 18 years and over with CKD (US National Kidney Foundation: stages 3 to 5 CKD). (R) The percentage of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months. (P) The percentage of patients on the CKD register in whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less. (IO) The percentage of patients on the CKD register with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker (unless a contraindication or side effects are recorded). (P-T-O) The percentage of patients on the CKD register whose notes have a record of a urine albumincreatinine ratio (or protein-creatinine ratio) test in the previous 15 months. (P)
CKD 2
CKD 3
CKD 5
CKD 6a
Abbreviations: CKD, chronic kidney disease; IO, intermediate outcome; P, process; P-T-O, process linked to outcome; R, register. Reproduced from the UK National Health Service Quality and Outcomes Framework3; re-used with the permission of the UK Health and Social Care Information Centre. a Introduced in 2009.
blood pressure has begun to diminish and now 4.3% of the adult population are enrolled in a program of active management.3 The demystification of kidney disease through eGFR reporting and the concept of percentage of normal kidney function have been strengthened by adding proteinuria measurement as a requirement of CKD management in primary care. The latest UK Renal Registry Report numbers show that in end-stage renal disease, patients are referred late 19% of the time (down from 30%), and in the past 4 years, RRT acceptance rates have been stable at 109 per million population.12 Patients are starting RRT in a more planned fashion, evidenced by higher preemptive transplant listing rates, increased pre-emptive live donor transplantation, improved vascular access rates, and better biochemical control at initiation of dialysis therapy. Home hemodialysis rates are beginning to increase, although despite professional and NICE guidelines, peritoneal dialysis rates continue to decrease. Future service challenges include raising awareness among the public, more patient involvement in care and decisions, optimization of CKD management programs, identification and management of acute kidney injury risk, and integration of vascular management to encompass CKD, diabetes, and heart disease. Such integration will be necessary to transcend the limitations of the present tendency toward compartAm J Kidney Dis. 2012;60(5):740-742
mentalization of care and to achieve effective structured health care for the growing multimorbid population. Donal J. O’Donoghue, FRCP NHS Kidney Care London, United Kingdom Paul E. Stevens, FRCP Kent Kidney Research Group Canterbury, United Kingdom
ACKNOWLEDGEMENTS Dr O’Donoghue is National Clinical Director for Kidney Care, UK Department of Health. Financial Disclosure: The authors declare that they have no relevant financial interests.
REFERENCES 1. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2)(suppl 1):S1-S266. 2. Department of Health. Estimated glomerular filtration rate (eGFR) information for laboratories. http://webarchive.nationalarchives.gov.uk/⫹/ www.dh.gov.uk/en/Healthcare/Longtermconditions/Vascular/ Renal/RenalInformation/DH_4133073. Accessed March 8, 2012. 3. The Information Center. Quality and outcomes framework for GMS contract 2011/12: delivering investment in general practice. http://www.ic.nhs.uk/statistics-and-data-collections/auditsand-performance/the-quality-and-outcomes-framework. Accessed March 8, 2012. 4. Jones C, Roderick P, Harris S, Rogerson M. An evaluation of a shared primary and secondary care nephrology service for managing patients with moderate to advanced CKD. Am J Kidney Dis. 2006;47(1):103-114. 5. Jones C, Roderick P, Harris S, Rogerson M. Decline in kidney function before and after nephrology referral and the effect on survival in moderate to advanced chronic kidney disease. Nephrol Dial Transplant. 2006;21(8):2133-2143. 6. Richards N, Harris K, Whitfield M, et al. Primary care-based disease management of chronic kidney disease (CKD), based on estimated glomerular filtration rate (eGFR) reporting, improves patient outcomes. Nephrol Dial Transplant. 2008;23:549-555. 7. Phillips LA, Donovan KL, Phillips AO. Renal quality outcomes framework and eGFR: impact on secondary care. QJM. 2009;102(6):415-423. 8. Meran S, Don K, Shah N, Donovan K, Riley S, Phillips AO. Impact of chronic kidney disease management in primary care. QJM. 2011;104(1):27-34. 9. Rayner HC, Hollingworth L, Higgins R, Dodds S. Systematic kidney disease management in a population with diabetes mellitus: turning the tide of kidney failure. BMJ Qual Saf. 2011; 20(10):903-910. 10. Klebe B, Farmer C, Cooley R, et al. Kidney disease management in UK primary care: guidelines, incentives and information technology. Fam Pract. 2007;24(4):330-335. 11. Stoves J, Connolly J, Cheung CK, et al. Electronic consultation as an alternative to hospital referral for patients with chronic kidney disease: a novel application for networked electronic health records to improve the accessibility and efficiency of healthcare. Qual Saf Health Care. 2010;19(5):e54. 12. Gilg J, Castledine C, Fogarty T, Feest T. UK Renal Registry 13th Annual Report (December 2010): Chapter 1. UK RRT inci741
O’Donoghue and Stevens dence in 2009: national and centre-specific analyses. Nephron Clin Pract. 2011;119(suppl 2):c1-c25. 13. Hippisley-Cox J, Vinogradova Y. Trends in consultation rates in general practice 1995 to 2008: analysis of the QResearch® database. http://www.ic.nhs.uk/webfiles/publications/gp/Trends_ in_Consultation_Rates_in_General_Practice_1995_2008.pdf. Accessed October 1, 2009. 14. Department of Health: NHS Check Programme, April 2008. Putting prevention first—NHS Health Check: Vascular risk assessment and management best practice guidance. http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_097489. Accessed May 18, 2008. 15. Joint Specialty Committee for Renal Disease Royal College of Physicians of London and the Renal Association. Chronic
742
kidney disease in adults: UK Guidelines for Identification, Management and Referral. Royal College of Physicians of London, 2006. http://www.renal.org/CKDguide/full/CKDprintedfullguide. pdf. Accessed April 1, 2006. 16. National Institute for health and Clinical Excellence (NICE). Chronic kidney disease. Clinical guideline 73. Chronic kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care. London; 2008. http://www.nice.org.uk/nicemedia/live/12069/42117/42117.pdf. Accessed July 22, 2012. 17. Royal College of General Practitioners. Kidney health in general practice. http//elearning.rcgp.org.uk/course/info.php?id⫽85. Accessed January 1, 2012.
Am J Kidney Dis. 2012;60(5):740-742