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

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

  1. 1. FLORIDA CKD Graphic by the American Association PROJECT of Kidney Patients Multi- Multi-Tasking GFR Results for CKD Detection: Tracking, Treatment and Patient Self- Self- Management Laura Gamba Chronic Kidney Disease Project Director, FMQAI Gwendolyn A. Williams Chronic Kidney Disease Project Coordinator, FMQAI The Medicare Quality Improvement Organization for Florida
  2. 2. FLORIDA CKD Objectives Graphic by the American Association PROJECT of Kidney Patients • 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 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) The Medicare Quality Improvement Organization for Florida 2
  3. 3. FLORIDA CKD Objectives Graphic by the American Association PROJECT of Kidney Patients • Explore a simple system change within the physician practice setting with potential to prevent progression from CKD to ESRD through: – Detailing of Kidney Disease Outcomes Quality Initiatives (KDOQI) Guideline #4/Estimation of Glomerular Filtration (eGFR)for CKD detection/diagnosis The Medicare Quality Improvement Organization for Florida 3
  4. 4. FLORIDA CKD Objectives Graphic by the American Association PROJECT 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 patient self-management during the office visit The Medicare Quality Improvement Organization for Florida 4
  5. 5. FLORIDA CKD CKD Project Graphic by the American Association PROJECT of Kidney Patients • Detect the incidence and decrease the progression of CKD • Improve care among Medicare beneficiaries 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 The Medicare Quality Improvement Organization for Florida 5
  6. 6. FLORIDA CKD Why? Graphic by the American Association PROJECT of Kidney Patients Medicare Savings to Improve beneficiaries Medicare for Quality of Cost to with CKD each patient Care for Medicare of account for who does not Medicare managing 16.5% of costs progress to Beneficiaries CKD is high. in the year the dialysis is through CKD disease is estimated at Project identified. $250,000. The Medicare Quality Improvement Organization for Florida 6
  7. 7. FLORIDA CKD Graphic by the Expenditures for CKD, by dataset PROJECT American Association of Kidney Patients Figure 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 The Medicare Quality Improvement Organization for Florida 7
  8. 8. FLORIDA CKD Annualized predicted costs for Medicare CKD Graphic by the American Association PROJECT of Kidney Patients patients (2007 CMS-HCC model), 2006 Figure 5.11 (Volume 1) 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. USRDS 2008 ADR The Medicare Quality Improvement Organization for Florida 8
  9. 9. FLORIDA CKD CKD stages as defined by old & new Graphic by the American Association PROJECT of Kidney Patients ICD- ICD-9-CM codes: Medicare 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. USRDS 2008 ADR The Medicare Quality Improvement Organization for Florida 9
  10. 10. FLORIDA CKD Graphic by the American Association PROJECT of Kidney Patients The Medicare Quality Improvement Organization for Florida 10
  11. 11. FLORIDA CKD Graphic by the American Association PROJECT of Kidney Patients The Medicare Quality Improvement Organization for Florida 11
  12. 12. FLORIDA CKD Likelihood of death vs. ESRD Graphic by the American Association PROJECT of Kidney Patients in the Medicare population 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. USRDS 2008 ADR The Medicare Quality Improvement Organization for Florida 12
  13. 13. FLORIDA CKD Background Graphic by the American Association PROJECT of Kidney Patients • In hypertensive patients with diabetes, treated with Angiotensin Converting Enzyme Inhibitor (ACEIs), the progression of kidney disease can be slowed by 50%. • Screening rates for patients with known risk factors for CKD are as low as 20%. Centers for Medicare & Medicaid Services The Medicare Quality Improvement Organization for Florida 13
  14. 14. FLORIDA CKD Florida Graphic by the American Association PROJECT of Kidney Patients Florida ranks 3rd in the incidence of CKD Nearly 26 million 9th leading cause adults are living with of death in the CKD and don’t know U.S. it. Screening rates For each patient who for patients with does not progress to known risk dialysis, Medicare factors for CKD saves $250,000. are as low as 20%. The Medicare Quality Improvement Organization for Florida 14
  15. 15. FLORIDA CKD Graphic by the American Association PROJECT of Kidney Patients African American/ Hispanic Beneficiaries in Florida The Medicare Quality Improvement Organization for Florida 15
  16. 16. FLORIDA CKD Graphic by the American Association PROJECT of Kidney Patients Medicare Diabetics in Florida The Medicare Quality Improvement Organization for Florida 16
  17. 17. FLORIDA CKD Graphic by the American Association PROJECT of Kidney Patients Chronic Kidney Disease in Florida The Medicare Quality Improvement Organization for Florida 17
  18. 18. FLORIDA CKD Strategy Graphic by the American Association PROJECT of Kidney Patients • Multi-pronged approach Physicians • Annual microalbumin testing • Prescription of ACEIs/ARBs for diabetic patients • Referral of patients to nephrologists for AVF counseling where appropriate Hospital • Adoption of processes that target ESRD patients for AVF placement CKD Coalition • Identification of priorities at the system level and development recommendations that can be implemented in all settings The Medicare Quality Improvement Organization for Florida 18
  19. 19. FLORIDA CKD Definition & Graphic by the Classification American Association PROJECT of Kidney Patients • Kidney Disease Outcomes Quality Initiatives (KDOQI) – An effort to improve patient outcomes through the 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) About Chronic Kidney Disease http://www.kidney.org/professionals/KLS/aboutCKD.cfm The Medicare Quality Improvement Organization for Florida 19
  20. 20. FLORIDA CKD Definition & Graphic by the Classification American Association PROJECT 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 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 About Chronic Kidney Disease http://www.kidney.org/professionals/KLS/aboutCKD.cfm The Medicare Quality Improvement Organization for Florida 20
  21. 21. FLORIDA Definition and CKD Classification Graphic by the American Association PROJECT of Kidney Patients • 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 About Chronic Kidney Disease http://www.kidney.org/professionals/KLS/aboutCKD.cfm The Medicare Quality Improvement Organization for Florida 21
  22. 22. FLORIDA CKD CKD Staging Graphic by the American Association PROJECT of Kidney Patients Stage is defined based on level of kidney function using GFR. Higher CKD stages represent lower GFR levels. GFR mL/min/1.73 m2 Stage Description Action (Kidney Function) Diagnosis and treatment, treatment of co- Kidney damage with 1 ≥90 morbid conditions, slowing progression, Normal or ↑ GFR CVD risk reduction 2 Kidney damage with 60-89 Estimating Progression Mild ↓ GFR 3 Moderate ↓ GFR 30-59 Evaluation and treating complications Preparation for kidney replacement 4 Severe ↓ GFR 15-29 therapy 5 Kidney failure <15 (or dialysis) Replacement if uremia present or Dialysis About Chronic Kidney Disease http://www.kidney.org/professionals/KLS/aboutCKD.cfm The Medicare Quality Improvement Organization for Florida 22
  23. 23. FLORIDA Laboratories CKD eGFR Graphic by the American Association PROJECT of Kidney Patients • Early in 2008, 2 labs began providing physicians with patients’ estimated glomerular filtration rates (eGFR) taken from the serum creatinine levels using either the Modification of Diet in Renal Disease Study or the Cockcroft- Gault equations. The Medicare Quality Improvement Organization for Florida 23
  24. 24. In the Physician FLORIDA CKD Practice Graphic by the American Association PROJECT of Kidney Patients So, let me get it right: • You want me to see my patients • Order tests • Review the results • Track and Trend Progress • Prescribe as appropriate • Refer to specialists What’s the catch..... The Medicare Quality Improvement Organization for Florida 24
  25. 25. In the Physician FLORIDA CKD Practice Graphic by the American Association PROJECT of Kidney Patients No Catch!! • We want you to see your patients, like you always do • Order annual micro albumin testing for 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. The Medicare Quality Improvement Organization for Florida 25
  26. 26. FLORIDA Florida CKD CKD Intervention Recipe Graphic by the American Association PROJECT of Kidney Patients 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 The Medicare Quality Improvement Organization for Florida 26
  27. 27. FLORIDA CKD GFR Calculator Graphic by the American Association PROJECT of Kidney Patients National Kidney Disease Education Program The Medicare Quality Improvement Organization for Florida 27
  28. 28. FLORIDA CKD GFR Calculator Graphic by the American Association PROJECT of Kidney Patients National Kidney Foundation The Medicare Quality Improvement Organization for Florida 28
  29. 29. FLORIDA CKD GFR Calculator Graphic by the American Association PROJECT of Kidney Patients Epocrates MedTools The Medicare Quality Improvement Organization for Florida 29
  30. 30. FLORIDA CKD GFR Calculator Graphic by the American Association PROJECT of Kidney Patients Ortho BioTech The Medicare Quality Improvement Organization for Florida 30
  31. 31. FLORIDA CKD GFR Calculator Graphic by the American Association PROJECT of Kidney Patients American College of Physicians The Medicare Quality Improvement Organization for Florida 31
  32. 32. FLORIDA GFR Calculators for CKD the Technical Savvy Graphic by the American Association PROJECT of Kidney Patients iPhone GFR Calculator from DaVita Freeware Pocket PC GFR Calculator The Medicare Quality Improvement Organization for Florida 32
  33. 33. FLORIDA Low Tech Hand-held Hand- CKD Graphic by the GFR Calculator American Association PROJECT of Kidney Patients The Medicare Quality Improvement Organization for Florida 33
  34. 34. FLORIDA CKD In the Lab Graphic by the American Association PROJECT of Kidney Patients The Medicare Quality Improvement Organization for Florida 34
  35. 35. eGFR Trending Tool FMQAI -- The Medicare Quality Improvement Organization for Florida THE FLORIDA eGFR Trending eGFR CKD CKD Tool Graphic by the Patient: Graphic by the American Association PCONNECTION ROJECT American Association of Kidney Patients Date: of Kidney Patients 10/1/2006 11/1/2006 12/1/2006 10/1/2007 11/1/2007 12/1/2007 10/1/2008 Annual Microalbumin 6/1/2006 7/1/2006 8/1/2006 9/1/2006 1/1/2007 2/1/2007 3/1/2007 4/1/2007 5/1/2007 6/1/2007 7/1/2007 8/1/2007 9/1/2007 1/1/2008 2/1/2008 3/1/2008 4/1/2008 5/1/2008 6/1/2008 7/1/2008 8/1/2008 9/1/2008 Urine Screen <30 mg/G in green >30 mg/G in red 120 110 ACEs & ARBs First arm therapy 100 Normal 90 Stage II with mild in GFR Estimating Progression 80 Identify risk factors 70 60 Stage III Evaluation & Treatment 50 Referral to Nephrologist 40 CKD Stage IV 30 Preparation for kidney 20 replacement therapy Stage V 10 ESRD Renal placement as symptoms progress 0 Physician Office: The Medicare Quality Improvement Organization for Florida 35
  36. 36. FLORIDA CKD Graphic by the American Association PROJECT of Kidney Patients The Medicare Quality Improvement Organization for Florida 36
  37. 37. FLORIDA RPA Kidney CKD Report Card Graphic by the American Association PROJECT of Kidney Patients The Medicare Quality Improvement Organization for Florida 37
  38. 38. FLORIDA Florida CKD CKD Intervention Recipe Graphic by the American Association PROJECT of Kidney Patients 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 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. The Medicare Quality Improvement Organization for Florida 38
  39. 39. FLORIDA Florida CKD CKD Intervention Recipe Graphic by the American Association PROJECT 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. The Medicare Quality Improvement Organization for Florida 39
  40. 40. FLORIDA CKD Your Turn Graphic by the American Association PROJECT of Kidney Patients The Medicare Quality Improvement Organization for Florida 40
  41. 41. FLORIDA CKD Graphic by the American Association PROJECT of Kidney Patients The Medicare Quality Improvement Organization for Florida 41
  42. 42. FLORIDA Florida’s CKD CKD Team Graphic by the American Association PROJECT of Kidney Patients Laura Gamba, BA, CBA Project Director 800-564-7490 x 3920 lgamba@flqio.sdps.org Gwen Williams, BA Laurie Ciannamea, MBA, CHCO Kathleen Lightbourne, MPH Project Coordinator Project Coordinator Project Coordinator 800-564-7490 x. 3510 800-564-7490 x. 3322 800-564-7490 x. 3562 gwilliams@flqio.sdps.org lciannamea@flqio.sdps.org klightbourne@flqio.sdps.org Vicki Farrell Candace Skelton, RN, CCTC JiFeng Ma, PhD Administrative Assistant Project Coordinator Statistician 800.564.7490 x. 3632 800-564-7490 x. 3285 800.564.7490 x. 3861 vfarrell@flqio.sdps.org cskelton@flqio.sdps.org jma@flqio.sdps.org Ferdinand Richards, MD Mark Michelman, MD, MBA Medical Director Clinical Director 800-564-7490 x. 3120 800-564-7490 x. 3540 frichards@flqio.sdps.org mmichelman@flqio.sdps.org 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 The Medicare Quality Improvement Organization for Florida 42
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