Capitation based funding of general practice is not fit for purpose

[First paragraph] I disagree with Majeed’s call for activity based funding for primary care, which would be a backwards step, ditching an important driver of cost effectiveness

Prescription Rates of Cardiovascular Medications in a Large UK Primary Care Chronic Kidney Disease Cohort

Background and Aims: Chronic kidney disease (CKD) is associated with increased cardiovascular (CV) risk. Guidelines have suggested the universal use of statins in CKD but aspirin's role is less well defined. The aim of this study was to determine prescription rates for statins and aspirin in a UK-based CKD cohort and to establish factors that influenced prescription rates. Methods: We used data from a UK primary care CKD cohort to study rates of prescription of statins and aspirin. Simple rates were initially calculated. Binary logistic regression was utilized with either statin or aspirin prescription as the outcome variable and covariates including demographic details and comorbidities. Results: There were 31,056 individuals in the cohort with at least one estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m², and 65.1% individuals had 2 eGFR results <60 ml/min/1.73 m² more than 3 months apart. Mean eGFR at baseline was 51.1 ml/min/1.73 m² (SD 9.1), and 64.9% had a diagnosis of hypertension (HTN), 18.8% had diabetes mellitus (DM) and 29.8% a history of CV disease. Statins were prescribed to 14,972 (48.2%) and aspirin to 11,023 (35.5%). The regression model suggested that CV disease, HTN and DM influenced the prescriptions of statins and aspirin but overall CKD stage, calculated by either eGFR or proteinuria, did not. Conclusions: Prescriptions of statins and aspirin in CKD is based more on the presence of comorbidities than the CKD severity. Further physician and patient education of the increased CV risk associated with CKD and its suitability for CV medication intervention is required

SCALE AND COSTS OF INTRODUCING CYSTATIN-C EGFR CALCULATIONS TO UK PRIMARY CARE

Introduction and Aims: The introduction of the CKD-EPI and cystatin-C testing has been recommended in recent CKD guidance. The cost impact of this has not been studied in a primary care CKD cohort. We evaluated the cost impact of these guideline changes for UK primary care. Methods: We analysed the baseline cohort of the PSP-CKD study, a large UK primary care CKD clinical trial. A laboratory calculated MDRD eGFR<60 ml/min/1.73m2 was the primary identifier for the cohort. Serum creatinine was also available. CKD-EPI (EPI) eGFR was recalculated from the serum creatinine. Costs were calculated using the criteria outlined in the 2014 NICE CKD guidance. Results: The records of 353,256 patients ≥18 years of age were analysed. 30,307 individuals had at least one MDRD eGFR3 months apart. Of those with a single MDRD eGFR60. Reclassification to EPI eGFR>60 was less likely in those with pre-existing second MDRD eGFR<60 (3.3% versus 11.1%, p<0.001).To assess the numbers eligible for cystatin-C assay, we further analysed the 20,166 individuals with confirmatory MDRD eGFR<60. 12,142 (60.2%) had EPI stage 3A CKD. Within the EPI 3A group 7,153 (58.9%) had stage A1 proteinuria and were therefore eligible for cystatin-C assessment. 3055 (25.2%) had not had a urinary protein assessment.Extrapolating nationally, ~2% of the adult population could be eligible for a cystatin-C assay. Assuming similar results across the UK’s adult population and at a conservative cost of £5.50 (€7.50) per test, the initial cost of implementing cystatin-C testing across the eligible CKD population would be £5.8 million (€7.9 million). This estimate does not include costs of interpretation and consequent changes to clinical management. Conclusions: Based on a large primary care CKD cohort, CKD stage reclassification using EPI is relatively infrequent, and occurs less often if a confirmatory MDRD eGFR is available. Up to 2% of the adult population and 60% of the stage 3A CKD population could require a cystatin-C measurement. Conservative cost estimates for this are high and further cost-benefit considerations of cystatin-C testing may be helpful. Table 1: Reclassification 1 MDRD<60 ≥2 MDRD<60 Whole Cohort EPI<60 8,689 18,909 27,598 EPI>60 1,086 (11.1%) 662 (3.3%) 1,748 (6.0%) No serum creatinine 366 595 961 Total 10,141 20,166 30,30

Making an IMPAKT; Improving care of Chronic Kidney Disease patients in the community through collaborative working and utilizing Information Technology.

Chronic kidney disease (CKD) is a serious long-term condition, which if left untreated causes significant cardiovascular sequele. It is well recognized management of modifiable risk factors, such as blood pressure (BP), can lead to improved long-term outcomes. A novel information technology (IT) solution presents a possible solution to help clinicians in the community identify and manage at risk patients more efficiently. The IMproving Patient care and Awareness of Kidney disease progression Together (IMPAKT) IT tool was used to identify patients with CKD and uncontrolled hypertension in the community. A CKD nurse utilized the tool at primary care practices to identify patients who warranted potential intervention and disseminated this information to clinical staff. Blood pressure management targets and incidence of coded CKD were used to evaluate the project. Altogether 48 practices participated in an 18 month project from April 2014, and data from 20 practices, with a total adult population of 121,362, was available for analysis. Two full consecutive QI (Quality Improvement) audit cycles were completed. There was an increase in the mean recorded prevalence of coded CKD patients over the course of the project. Similarly, there was an increase in the percentage of patients with BP been recorded and importantly there was an accompanying significant increase in CKD patients achieving BP targets. At the end of the project an additional 345 individuals with CKD achieved better blood pressure control. This could potentially prevent 9 cardiovascular events in the CKD group, translating to a cost saving of £320,000 for the 20 practices involved. The most significant change in clinical markers occurred during cycle 1 of the audit, the improvement was maintained throughout cycle 2 of the audit. Our results show the real-life clinical impact of a relatively simple and easy to implement QI project, to help improve outcomes in patients with CKD. This was achieved through more efficient working by targeting of high-risk groups, and improved communication between primary/secondary care. The project could be adapted for other chronic disease conditions. Despite the recorded improvements in blood pressure management, a large proportion of high-risk patients remained above ideal blood pressure, additional interventions in this area need to be explored. Through collaborative and multi-professional working and utilizing IT resources, we have shown it is possible to deliver measurable and sustainable improvements in blood pressure control for patients with CKD in a real life clinical setting

ASSESSMENT AND MANAGEMENT OF RISK FACTORS IN PEOPLE WITH CHRONIC KIDNEY DISEASE AND DIABETES MELLITUS MULTIMORBIDITY

Introduction and Aims: Chronic kidney disease (CKD) and diabetes mellitus (DM) are important risk factors for cardiovascular (CV) disease and are associated with increased CV events. Multimorbidity with both DM and CKD is increasing in prevalence. Appropriate monitoring and use of renin-angiotensin system antagonists, as well as optimising blood pressure and lipid levels, are important strategies in the management of people with CKD. Whether the presence or absence of DM influences the clinical assessment of CKD is unknown. We aimed to establish rates of other comorbidities and commonly used medication prescription rates. We also aimed to establish if DM affected the likelihood of confirmatory eGFR or urinary protein assessment being performed. Methods: We analysed the baseline cohort of the PSP-CKD study, a large United Kingdom primary care CKD clinical trial, to study a subgroup with DM. DM was defined using HbA1c, the use of DM medications or a Read code diagnosis of DM. Co-morbidities were based on Read codes and medications on prescription records. Comparison was made to members of the cohort with CKD but not known to have diabetes. Results: The DM subgroup consisted of 5,842 individuals, 55.6% of whom were female. Mean age was 74.1 years (standard deviation (SD) 10.5 years). Mean MDRD eGFR was 49.2 ml/min/1.73m2, 73.5% were CKD stage 3A. Individuals with DM, compared with those without DM, had a lower mean MDRD eGFR (49.4 ml/min/1.73m2 versus 54.4 ml/min/1.73m2, t-test p<0.001) and were more likely to have had a second confirmatory eGFR (76.1% versus 62.7%, Pearson Chi-squared p<0.001) and their urinary protein assessed (86.0% versus 66.5%, Pearson Chi-squared p<0.001). Of those with a urine assessment, 69.9% had stage A1 proteinuria. Mean HbA1c was 7.3% (SD 1.4%). Mean systolic blood pressure was 134.2 mmHg (SD 16.5 mmHg) and diastolic 73.1 mmHg (SD 10.2 mmHg). 76.4% were hypertensive and 38.9% had had a previous cardiovascular event. 74.3% were prescribed either an ACE inhibitor or ARB. 2.6% were prescribed both an ACE inhibitor and ARB, 74.2% were receiving a statin and 48.8% aspirin. Conclusions: Patients with CKD and DM have a significantly lower eGFR compared with patients with CKD alone. In addition, patients with CKD and DM were monitored more closely with confirmatory eGFR or urinary protein assessment compared to patients with CKD alone. RAS blockade medication and statins were prescribed to three quarters and aspirin to just under a half. Overall, the assessment and management of multimorbid patients with both CKD and DM is more thorough than those with CKD alone

Comorbidities and outcomes in South Asian individuals with chronic kidney disease: an observational primary care cohort.

BACKGROUND: South Asian (SA) individuals are more likely to develop end-stage renal disease (ESRD), but how chronic kidney disease (CKD) differs in relation to demographics, comorbidities and outcomes has not been studied. We aimed to study differences in SA individuals with CKD compared with White individuals. METHODS: This was an observational CKD cohort comparing SA with White individuals. Inclusion criteria were ≥18 years of age and two or more Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) eGFRs 3 months apart. Individuals with ESRD at baseline were excluded. Baseline characteristics, including eGFR formulae [CKD-EPI and CKD-EPI-Pakistan (CKD-EPI-PK)], were compared. Analysis using competing risk regression for cardiovascular (CV) and ESRD events and Cox proportional hazard model for mortality was performed. RESULTS: From an adult population of 277 248 individuals, 17 248 individuals had CKD, of whom 1990 (11.5%) were of SA ethnicity. Age-adjusted prevalence of CKD was similar between ethnicities. SA individuals were more likely to be male, younger and socioeconomically deprived, and to have diabetes mellitus, CV disease and advanced CKD. Mean CKD-EPI-PK eGFR was 6.5 mL/min/1.73 m2 lower (41.1 versus 47.6, 95% confidence interval for difference 6.47-6.56) than for CKD-EPI. During 5 years of follow-up, 5109 (29.6%) individuals died, 2072 (12.0%) had a CV and 156 (0.90%) an ESRD event. Risk for SA individuals was higher for ESRD, similar to CV events and lower for mortality. Each 1 mL/min/1.73 m2 decrease in CKD-EPI-PK was associated with a 13.1% increased ESRD risk (adjusted subdistribution hazard ratio 0.869, 95% confidence interval 0.841-0.898). CONCLUSIONS: SA individuals with CKD were younger and had more advanced disease than White individuals. Risk of ESRD was higher and CKD-EPI-PK was associated with ESRD risk in SA individuals. Specific CKD interventions, including the use of CKD-EPI-PK, should be considered in SA populations

Additional file 1: of Cluster randomised trial of a tailored intervention to improve the management of overweight and obesity in primary care in England

CONSORT checklist. (DOCX 24 kb

The association of blood pressure variability with adverse outcomes in a primary care chronic kidney disease cohort

Background: Hypertension is common in individuals with chronic kidney disease and both conditions are associated with adverse outcomes including cardiovascular morbidity. Therefore, it is clinically important to identify methods of risk prediction in individuals with chronic kidney disease. Blood pressure variability has recently emerged as a predictor of cardiovascular events and mortality in the general population, with growing evidence indicating that it may play a similar role in individuals with chronic kidney disease. However, there have been no large studies assessing blood pressure variability in individuals with chronic kidney disease in primary care, where the majority of these patients are managed.Method: Using a retrospective observational study design, we analyzed routinely collected blood pressure readings from 16 999 individuals in The Leicester and County Chronic Kidney Disease cohort. Standard deviation, coefficient of variation and average real variability of SBP were used to calculate blood pressure variability.Results: During a median follow-up of 5.0 (IQR 3.3--5.0) years, 2053 (12.1%) patients had cardiovascular events, death occurred in 5021 (29.6%) individuals and 156 (0.9%) individuals had endstage kidney disease events. In adjusted models, standard deviation and coefficient of variation were associated with cardiovascular events, all-cause mortality and endstage kidney disease. Average real variability was associated with all-cause mortality and cardiovascular events, but not endstage kidney disease.Conclusion: Blood pressure variability may be an accessible, routinely collected, noninvasive measure for stratifying the risk of adverse events in individuals with chronic kidney disease in a primary care setting.</div

Additional file 2: of Cluster randomised trial of a tailored intervention to improve the management of overweight and obesity in primary care in England

The NICE guideline recommendations for adults for primary care teams. (DOC 23 kb

The Primary-Secondary Care Partnership to Improve Outcomes in Chronic Kidney Disease (PSP-CKD) Study: A Cluster Randomized Trial in Primary Care

Background Most patients with CKD are managed in the community. Whether nurse-led CKD management programs improve outcomes in patients with CKD in primary care is unclear.Methods To assess the effect of such a program on the rate of renal function decline in patients with CKD (stages 3–5) in primary care in the United Kingdom, we conducted a cluster randomized trial, the Primary-Secondary Care Partnership to Improve Outcomes in Chronic Kidney Disease study. A software program designed for the study created a data file of patients with CKD in participating practices. In 23 intervention practices (11,651 patients), a CKD nurse practitioner worked with nominated practice leads to interpret the data file and implement guideline-based patient-level CKD management interventions. The 23 control practices (11,706 patients) received a data file but otherwise, continued usual CKD care. The primary outcome was defined at the cluster (practice) level as the change from baseline of the mean eGFR of the patients with CKD at 6-month intervals up to 42 months. Secondary outcomes included numbers of patients coded for CKD, mean BP, numbers of patients achieving National Institute for Health and Care Excellence BP targets for CKD, and proteinuria measurement.Results After 42 months, eGFR did not differ significantly between control and intervention groups. CKD- and proteinuria-related coding improved significantly along with the number of patients achieving BP targets in the intervention group versus usual care.Conclusions CKD management programs in primary care may not slow progression of CKD, but they may significantly improve processes of care and potentially decrease the cardiovascular disease burden in CKD and related costs.</div