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GMS Contract Guide - Kidney Disease

There are four quality indicators in the disease area of chronic kidney disease (CKD), worth a total of 27 points, producing a payment of £3,364 in 2007/8 for the practice with average list size and prevalence.

Kidney Disease: Clinical Indicators
Target (%)Points
Records
Register of patients aged 18 and over with chronic kidney diseaseRegister6
Initial management
Record of blood pressure in past 15 months906
Ongoing management
Last blood pressure reading (measured in past 15 months) 140/85 mmHg or less7011
Patients on ACE inhibitor or angiotensin II antagonist (unless contraindicated or side-effects recorded)804
Total 27

ACTION PLAN

Overview

  • This indicator set applies to patients with stages three, four and five CKD, using the classification developed by the US National Kidney Foundation.

  • Five per cent of the population have stage three to five CKD, according to the guidance. Prevalence increases with age, male gender and South Asian and African Caribbean ethnicity.

  • National prevalence rates for CKD according to QoF data for 2006/7 were 2.24 per cent in England and 2.3 per cent in Northern Ireland. However, experts believe this may under-represent the true level by more than half, partly because some practices did not have access to eGFR tests until well after the targets came into effect.

  • The guidance says early identification is important because it allows appropriate measures to be taken, not only to slow or prevent progression, but also to combat the major risk of illness or death owing to cardiovascular disease.

  • CKD is an independent risk factor for cardiovascular disease and a multiplier of other risk factors.


Step 1: Setting up the register


  • The register needs to include all patients aged 18 and over with stage three to five CKD.

  • The guidance defines those who need to be on the register as patients with a last estimated glomerular filtration rate (eGFR) of <60ml/min/1.73m2. This disease area is based on the premise that eGFR will be routinely reported data in 2006 and health departments wrote to pathology laboratories to underline this requirement.

  • Possible alternatives include the use of an online calculator (www.renal.org/eGFRcalc/GFR.pl) or your IT system suppliers may have created a program to go through your notes, find creatinine levels, calculate eGFRs and highlight abnormal ones.

  • A computer search on eGFR or creatinine levels should help to identify patients for the register. Ensure all patients are coded with the preferred Read code and new diagnoses are coded and added to the register.

  • Note that the diabetes disease area gives practices the option of reporting eGFR as an alternative to serum creatinine testing.

  • In 2006/7 many practices found that the use of the eGFR of <60ml/min/1.73m2 produced a disconcertingly large number of patients and that further work and repeat testing was needed to identify those who are appropriate to be on the CKD register.


Step 2: April to September


  • Decide how BP checks will be organised for this group of patients. It makes sense to try to do most of this work between April and September, which leaves the following six months to improve outcomes if necessary.

  • Use your hypertension register to help identify patients who also appear on the CKD register.

  • Patients with CKD who also suffer from hypertension need to be on an ACE inhibitor or angiotensin II antagonist. Those who are not need to be reviewed and a prescription issued, or exception coded where appropriate.

  • The guidance acknowledges that tight BP control will be difficult to achieve in this group but says the lower the BP achieved, the better for patient care and that 140/85 is taken as a pragmatic starting point for a new quality indicator. The indicator sets a target of 70 per cent.

  • Reduce the interval of repeat prescriptions for patients whose BP is above the target.


Step 3: September to March


  • Continue with work to improve therapy of poorly controlled patients.

  • Run searches to ensure new patients added to the register fall within the requirements of the rest of the indicators in this disease area and recall those who do not.


Useful Resources for Kidney Disease

National Service Framework for Renal Services

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