RCH Clinical Chemistry & ASSIST-CKD

March 2016, SW SCN

Miss Anna Barton Principal Clinical Biochemist, Clinical Chemistry, Royal Cornwall Hospital, Truro

ASSIST CKD- Background

The aim is to improve the treatment and outcomes of patients who have chronic kidney disease (CKD)

Looking primarily at the long-term eGFR trend, by looking back up to five years

Also looks for short-term decline too

The project focuses on those patients who have declining kidney function and may ultimately require dialysis or a kidney transplant

Late Presentation for RRT

Message on the ACB Mailbase

With information on the ASSIST-CKD project

To cover 12-15 labs and at least 8 Renal Units

England, Wales, Scotland & N. Ireland

Funded for a year

Anyone interested?

How it started…November 2014

Increased Funding (due to high level of interest) Now up to March 2018 to sign-on more locations

Greatly increase statistical power & evidence base

Up to 20 main renal units

25 pathology laboratories

Estimated population of 11-12 million people

England, Wales, Scotland & N. Ireland

A year later……September 2015

4 Renal Units, 5 Labs

The Royal Cornwall Hospitals NHS Trust (Aug)

Doncaster & Bassetlaw Hospitals NHS Foundation Trust (Oct)

Wirral University Teaching Hospital (Oct)

Countess of Chester Hospital NHS Foundation Trust (Dec)

NHS Lanarkshire & Monklands Hospital, Airdrie (in final set-up phase)

Randomisation: July 2015, Group 1

IT

Installed the ASSIST-CKD eGFR program

Set up patient history: Uploaded all eGFR results on all adult patients reported in the last five years into the program (GP + in/out-patients)

Set-up weekly automatic download of latest eGFR results from Winpath, which could then be manually uploaded to ASSIST program

Setting-Up @ Truro

Information for the lab

Laboratory Information Pack

Written Guide to interpreting eGFR graphs

YouTube Guide to interpreting eGFR graphs

Competency assessment

Pack including 30 sample graphs & marking sheet

Setting-Up @ Truro

Information for GPs & KCCG

Factsheets explaining the new project from ASSIST-CKD sent to GPs & KCCG

Lab Med News

Dates of project starting & information on what will happen

Providing updates on the project and later Q&A feedback

Setting-Up @ Truro

Once a week Sunday- automated download of all of the previous

weeks reported eGFR (GP + in/out-patients) from Winpath into an excel file

New eGFR data manually uploaded into the ASSIST eGFR program by the Biochemist

Then Biochemist performs the patient searches, and reviews & reports on the eGFR graphs as per the ASSIST-CKD protocol

Reports printed sent to GP surgeries

What do we do in the laboratory?

Select eGFR reporting dates, GP patients only AND

Search A Max age 65 years with eGFR max 50 ml/min/1.73m2

Search B Min age 66 years, max 120 with eGFR max 40 ml/min/1.73m2

A list of patients fitting the criteria is produced

ASSIST-CKD program & searches

Graphs show all available eGFR results for the last FIVE years, giving a long term view of renal function

Who to report?

Don’t Report:

Horizontal trend

Rising trend-line

Not fit ‘report’ criteria

Previously marked as reported

No graph produced as only one data point available

Dialysis patients

Who to report?

Don’t Report:

Horizontal trend

Rising trend-line

Not fit ‘report’ criteria

Previously marked as reported

No graph produced as only one data point available

Dialysis patients

Who to report?

REPORT:

Decline greater than 5 ml/min/1.73m2/year

Decline <5 ml/min/1.73m2/year, however, patient will reach a GFR of 10 by the time they reach age 90

Recent drop >10ml/min/1.73m2 not consistent with previous trend

Change in the trend i.e. initially stable, before taking a downward trend which fits the above rules

Large variation in GFR reported

Previously marked as reported BUT new further steep decline/change in trend

Decline greater than 5 ml/min/1.73m2/year

Decline <5 ml/min/1.73m2/year, however, patient will reach a GFR of 10 by the time they reach age 90

Change in the trend i.e. initially stable, before taking a downward trend which fits the rules

Drop >10ml/min/1.73m2 in the last few months

Program Version 1

First date search 02/08/15 to 09/08/15

Had quite a few IT issues

Took >2 hours to review & report + print

Fed back problems to ASSIST-CKD

Suggested improvements

First run performed 10/08/15

Version 2, 2016

ASSIST-CKD took all our problems & suggestions on board and created a new version

Median 257 patients listed per week

88 reported (34%) per week

Time to perform patient reviews approx 60 -80 mins

We are far more familiar with the software & reporting

Many patients that are listed are already flagged

Streamlined processes within the lab

Version 2 aka ‘the Cornish version’

42% responded

96% liked the graph layout & found it clear

68% found the text information under the graph useful

Due to receiving an ASSIST-CKD graph 52% have consulted the RMS guidelines

50% have contacted the Renal team via email

13% have contacted the Renal team via phone

42% have referred a patient

63% have reviewed a patient earlier than planned

30% have shown a patient a graph & 56% found that useful

32% have altered the way they view long term changes in renal func

GP Questionnaire- mini snapshot Sent out Dec 2015 & again in Feb 2016 to non-responders

As of 17/03/16

100% would prefer electronic reporting 65% filled in the free text area “GPs feel the reports highlights the results in a way that stand out from

a simple set of numbers” “Please continue. Is a reassuring back-up to our own monitoring” “Prompt me to be certain that adequate care being given” “Reminds you to review patient but generally its already actioned” “Too late for me as have already dealt with results, but other drs may

not do the same and so it's a good prompt” “We review previous eGFR scores when filing results, so usually aware

of patient before report arrive” “Not helpful as out of date by the time we receive them, and just

another piece of paper for us to process” “None of the 3 GPs partners found the graphs helpful. We are already

are monitoring and referring our CKD3 patients very well”

GP Questionnaire- mini snapshot Sent out Dec 2015 & again in Feb 2016 to non-responders

Other

Biochem + Renal on Pirate2 Radio about ASSIST-CKD & CKD

Spoken at National & Local ASSIST-CKD events

ASSIST-CKD funding finishes end of July

We are placing a business case to the KCCG

Cover population approx. 470,000

RCHT Lab costs £4k/yr

RCHT IT costs £3k/yr

ASSIST-CKD Software costs £650/yr

Total £7,650 a year

But one years dialysis per patient is £25k + ancillary costs too

Future

Thank you