Microsoft PowerPoint - Multi-Tasking GFR Results for CKD ...

PROJECT

FLORIDA

CKD Graphic by the

American Association

of Kidney Patients

MultiMulti--Tasking GFR Results for Tasking GFR Results for CKD Detection: Tracking, CKD Detection: Tracking, Treatment and Patient SelfTreatment and Patient Self--

ManagementManagement

The Medicare Quality Improvement Organization for Florida

ManagementManagement

Laura GambaChronic Kidney Disease Project Director, FMQAI

Gwendolyn A. WilliamsChronic Kidney Disease Project Coordinator, FMQAI

PROJECT

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CKD Graphic by the


of Kidney Patients

ObjectivesObjectives

• Provide a brief overview of United States Renal

Data System (USRDS) 2008 Annual Data

Report (Precis and Chapters 3 & 4) highlighting

CKD’s prevalence, co-morbidities, cost and


CKD’s prevalence, co-morbidities, cost and

transition to end stage renal disease (ESRD)

• Discuss claims data diagnosis codes versus lab

values data for CKD detection (USRDS 2008,

Chapter 3, pp 38 and 43)

2

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CKD Graphic by the


of Kidney Patients


• Explore a simple system change within the

physician practice setting with potential to

prevent progression from CKD to ESRD

through:


through:

– Detailing of Kidney Disease Outcomes Quality

Initiatives (KDOQI) Guideline #4/Estimation of

Glomerular Filtration (eGFR)for CKD

detection/diagnosis

3

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CKD Graphic by the


of Kidney Patients


– Transforming eGFR lab values into actual GFR

at the time vital signs are assessed

– Transitioning GFR from numeric calculations

onto multi-functional tools for patient

tracking/trending tool, patient education and


tracking/trending tool, patient education and

patient self-management during the office visit

4

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of Kidney Patients

CKD ProjectCKD Project

• Detect the incidence and decrease the

progression of CKD

• Improve care among Medicare beneficiaries

through provider adoption of timely and


through provider adoption of timely and

effective quality of care interventions and

beneficiary education

• Key collaborations for system change at the

state and local level

5

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Why?Why?

Medicare Savings to

The Medicare Quality Improvement Organization for Florida 6

Improve Quality of Care for Medicare

Beneficiaries through CKD

Project

Cost to Medicare of managing

CKD is high.

Medicare beneficiaries with CKD account for

16.5% of costs in the year the

disease is identified.

Savings to Medicare for each patient

who does not progress to dialysis is

estimated at $250,000.

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FLORIDA

CKD Graphic by the


of Kidney PatientsExpenditures for CKD, by datasetFigure 5.2 (Volume 1)


Medicare: period prevalent general Medicare patients age 65 & older, with Medicare as primary payor, & not enrolled

in Medicare Advantage. Medstat: period prevalent patients age 50–64, enrolled in a fee-for-service plan. CHF, diabetes,

& CKD determined from claims.

USRDS 2008 ADR

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FLORIDA

CKD Graphic by the


of Kidney PatientsAnnualized predicted costs for Medicare CKD

patients (2007 CMS-HCC model), 2006Figure 5.11 (Volume 1)

The Medicare Quality Improvement Organization for Florida 8USRDS 2008 ADR

Prevalent general Medicare patients, not enrolled in an HMO, without ESRD, & surviving in 2005. Medicare payments

in 2006 include inpatient, skilled nursing, home health, outpatient, physician/supplier, & durable medical equipment.

Diagnosis groups based on M+C risk adjustment model (see www.cms.gov). Actual PPPM cost not weighted by follow

up time. Definitions for CKD, diabetes, & CHF are based on the CMS-HCC model, i.e., defined if there is any diagnosis

code. HCC: hierarchical condition category.

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of Kidney Patients

CKD stages as defined by old & new CKD stages as defined by old & new

ICDICD--99--CM codes: MedicareCM codes: MedicareFigure 2.2 (Volume 1)Figure 2.2 (Volume 1)


Point prevalent general Medicare patients age 65 & older, surviving all of

2006 with Medicare as primary payor & not enrolled in an HMO. ESRD

patients excluded. CKD & other comorbidities defined by diagnosis codes in

2006. In USRDS analyses, patients with ICD-9-CM code 585.6 are considered

to have code 585.5; see Appendix A for details.

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CKD Graphic by the


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CKD Graphic by the


of Kidney PatientsLikelihood of death vs. ESRD Likelihood of death vs. ESRD in the Medicare populationin the Medicare population

Figure 4.1 (Volume 1)Figure 4.1 (Volume 1)


1: non-CKD, NDM, non-CHF 2: CKD only (NDM, non-CHF) 3: CKD + DM 4: CKD + CHF 5: CKD + DM + CHF

Point prevalent general Medicare patients entering Medicare before January 1, 2004, alive & age 66 or older on

December 31, & followed for two years. Patients enrolled in an HMO, with Medicare as secondary payor, or diagnosed

with ESRD during the year are excluded. CKD, diabetes, & CHF defined during 2004. Comorbidity groups not

mutually exclusive.

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CKD Graphic by the


of Kidney Patients

BackgroundBackground

• In hypertensive patients with diabetes,

treated with Angiotensin Converting

Enzyme Inhibitor (ACEIs), the

progression of kidney disease can be


progression of kidney disease can be

slowed by 50%.

• Screening rates for patients with known

risk factors for CKD are as low as 20%.

13

Centers for Medicare & Medicaid Services

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of Kidney Patients

FloridaFlorida

9th leading cause

of death in the

U.S.

Florida ranks 3rd

in the incidence

of CKD

Nearly 26 million

adults are living with

CKD and don’t know

it.


For each patient who

does not progress to

dialysis, Medicare

saves $250,000.

Screening rates

for patients with

known risk

factors for CKD

are as low as

20%.

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CKD Graphic by the


of Kidney Patients


African American/ Hispanic African American/ Hispanic

Beneficiaries in FloridaBeneficiaries in Florida

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of Kidney Patients


Medicare Diabetics in FloridaMedicare Diabetics in Florida

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of Kidney Patients


Chronic Kidney Disease Chronic Kidney Disease

in Floridain Florida

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of Kidney Patients

StrategyStrategy

• Multi-pronged approach

• Annual microalbumin testing

• Prescription of ACEIs/ARBs for diabetic patients

• Referral of patients to nephrologists for AVF counseling where appropriate

Physicians


appropriate

• Adoption of processes that target ESRD patients for AVF placement

Hospital

• Identification of priorities at the system level and development recommendations that can be implemented in all settings

CKD Coalition

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PROJECT

FLORIDA

CKD Graphic by the


of Kidney Patients

Definition & Definition & Classification Classification

• Kidney Disease Outcomes Quality Initiatives

(KDOQI)

– An effort to improve patient outcomes through the

development of clinical practice guidelines


About Chronic Kidney Disease

http://www.kidney.org/professionals/KLS/aboutCKD.cfm

development of clinical practice guidelines

– Defines Chronic Kidney Disease according to the

presence or absence of markers of kidney damage

and the level of kidney function, glomerular

filtration rate (GFR)

PROJECT

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CKD Graphic by the


of Kidney Patients

• Independent criteria for chronic kidney disease

– Kidney damage for ≥ 3 months as defined by structural or

functional abnormalities of the kidney, with or without

decreased GFR, manifested by either: pathological

abnormalities; or markers of kidney damage, including

Definition & Definition & Classification Classification




abnormalities; or markers of kidney damage, including

abnormalities in the composition of the blood or urine; or

abnormalities in imaging tests

– GFR < 60 mL/min/1.73m20 for ≥ 3 months, with or

without kidney damage

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Definition and Definition and ClassificationClassification

• GFR is the best overall index of kidney function

in health and disease

– Normal GFR varies according to age, sex and body size

– Young adults range from 120-130 mL/min/1.73 m2 and




decline with age

– GFR can be estimated from prediction equations, i.e., the

Modification of Diet in Renal Disease (MDRD) Study

equation recommend by KDOQI

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Stage DescriptionGFR mL/min/1.73 m2

(Kidney Function) Action

1Kidney damage with

Normal or ↑ GFR≥90

Diagnosis and treatment, treatment of co-

morbid conditions, slowing progression,

CVD risk reduction

CKD StagingCKD Staging

Stage is defined based on level of kidney function using GFR.

Higher CKD stages represent lower GFR levels.


CVD risk reduction

2 Kidney damage with

Mild ↓ GFR60-89 Estimating Progression

3 Moderate ↓ GFR 30-59 Evaluation and treating complications

4 Severe ↓ GFR 15-29Preparation for kidney replacement

therapy

5 Kidney failure

or Dialysis<15 (or dialysis) Replacement if uremia present

About Chronic Kidney Disease http://www.kidney.org/professionals/KLS/aboutCKD.cfm

PROJECT

FLORIDA

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of Kidney Patients

LaboratoriesLaboratorieseGFReGFR

• Early in 2008, 2 labs began providing

physicians with patients’ estimated

glomerular filtration rates (eGFR) taken from

the serum creatinine levels using either the


the serum creatinine levels using either the

Modification of Diet in Renal Disease Study

or the Cockcroft- Gault equations.

23

PROJECT

FLORIDA

CKD Graphic by the


of Kidney Patients

In the Physician In the Physician PracticePractice

So, let me get it right:• You want me to see my patients

• Order tests

• Review the results


• Review the results

• Track and Trend Progress

• Prescribe as appropriate

• Refer to specialists

What’s the catch.....

PROJECT

FLORIDA

CKD Graphic by the


of Kidney Patients

In the Physician In the Physician PracticePractice

No Catch!!• We want you to see your patients, like

you always do

• Order annual micro albumin testing for

your diabetic patients


your diabetic patients

• Track and Trend eGFR Progress on the

tracking tool

• Review the lab results with the patient

• Prescribe ACEIs/ARBs for diabetic

patients

• Refer patients to Nephrologists when

GFR begins approaching Stage 3.

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FLORIDA

CKD Graphic by the


of Kidney Patients

Florida CKD Florida CKD Intervention Recipe Intervention Recipe

Slowing Kidney Disease before the Damage is Done

INGREDIENTS:

1. GFR calculator

2. Current lab work with serum creatine values


3. eGFR Trending tool

4. NKDEP “How well are your kidneys working?”

patient educational handout

5. (Optional) An RPA kidney report card

PROJECT

FLORIDA

CKD Graphic by the


of Kidney Patients

GFR CalculatorGFR Calculator

NationalNational

KidneyKidney

Disease Disease

Education Education


Education Education

ProgramProgram

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of Kidney Patients


NationalNational

KidneyKidney

FoundationFoundation


PROJECT

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CKD Graphic by the


of Kidney Patients


EpocratesEpocrates

MedToolsMedTools


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CKD Graphic by the


of Kidney Patients


Ortho Ortho

BioTechBioTech


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FLORIDA

CKD Graphic by the


of Kidney Patients


AmericanAmerican

College of College of

PhysiciansPhysicians


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of Kidney Patients

GFR Calculators for GFR Calculators for

the Technical Savvythe Technical Savvy

iPhoneiPhone

GFR GFR

Calculator Calculator

from DaVitafrom DaVita


FreewareFreeware

Pocket PCPocket PC

GFR GFR

CalculatorCalculator

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of Kidney Patients

Low Tech HandLow Tech Hand--held held



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of Kidney Patients

In the LabIn the Lab


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eGFReGFR Trending Trending ToolTool

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Graphic by the


of Kidney Patients

eGFR Trending Tool

Normal

THE

CKDCONNECTION

eGFRPatient:

Date:

FMQAI -- The Medicare Quality Improvement Organization for Florida

Stage II with mild �� in GFR

Estimating Progression

Annual Microalbumin

Urine Screen

<30 mg/G in green

>30 mg/G in red

ACEs & ARBs

First arm therapy


0

10

20

30

40

50

60

70

80

ESRD

CKD

Physician Office:

Estimating Progression

Identify risk factors

Stage III

Evaluation & Treatment

Referral to Nephrologist

Stage IV

Preparation for kidney

replacement therapy

Stage V

Renal placement as

symptoms progress

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of Kidney Patients


PROJECT

FLORIDA

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RPA Kidney RPA Kidney Report CardReport Card


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FLORIDA

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PROCEDURES:

Medical Assistant

1. Begin by rooming the patient, getting vitals.

2. Pull latest lab report. Locate the serum creatinine value and

calculate patient’s GFR.

3. Plot GFR result onto eGFR Trending tool in the patient’s


3. Plot GFR result onto eGFR Trending tool in the patient’s

chart.

4. Enter date of visit and GFR result onto to the NKDEP “How

well are your kidneys working?”

5. Place handout into the patient folder for physician’s

attention.

PROJECT

FLORIDA

CKD Graphic by the


of Kidney Patients


PROCEDURES:

Physician

1. Review consult sheet/chart, eGFR trending tool.

2. Pull/remove the NKDEP “How well are your kidneys

working?” patient educational handout for discussion with

patient.

3. Discuss relevant issues and treat accordingly (may order ACEIs


or ARBs, discuss lifestyle changes, blood pressure issues,

diabetes, etc.)

4. Refer, when appropriate, patient with evidence of kidney

disease (GFR falls below 30 ml/minute -- Stage 4 CKD -- for

nondiabetics or below 60 ml/minute -- Stage 3 CKD-- for

diabetics) to a Nephrologist.

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of Kidney Patients

Your TurnYour Turn


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Florida’sFlorida’sCKD TeamCKD Team

Laura Gamba, BA, CBAProject Director

800-564-7490 x 3920

[email protected]

Gwen Williams, BAProject Coordinator

800-564-7490 x. 3510

[email protected]

Laurie Ciannamea, MBA, CHCOProject Coordinator

800-564-7490 x. 3322

[email protected]

Kathleen Lightbourne, MPHProject Coordinator

800-564-7490 x. 3562

[email protected]


Vicki FarrellAdministrative Assistant

800.564.7490 x. 3632

[email protected]

Ferdinand Richards, MDMedical Director

800-564-7490 x. 3120

[email protected]

Candace Skelton, RN, CCTCProject Coordinator

800-564-7490 x. 3285

[email protected]

JiFeng Ma, PhDStatistician

800.564.7490 x. 3861

[email protected]

Mark Michelman, MD, MBAClinical Director

800-564-7490 x. 3540

[email protected]

This material was prepared by FMQAI, the Medicare Quality Improvement Organization (QIO) for Florida, under contract with the Centers for

Medicare & Medicaid Services, (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not

necessarily reflect CMS policy. FL20091AF73T1B0711066

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Microsoft PowerPoint - Multi-Tasking GFR Results for CKD ...

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