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Important Roles for Primary Care Providers in Treating Chronic Kidney Disease
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Important Roles for Primary Care Providers in Treating Chronic Kidney Disease

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Presentation of leading authorities for management of chronic kidney disease

Presentation of leading authorities for management of chronic kidney disease

Published in: Health & Medicine

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  • (In NHANES) prevalence of stage >3 is 8%, microalbuminuria almost 10%Conseq are..Goal, early referral to avoid consequences
  • Of the 341 responses regarding barriers (lack of evidence 33% vs. 6%, non adherence 2 vs. 11%) Other – 1. Not practically for international pediatric responders2. Specific guidelines impractical (albumin of 4, iPTH goals, phos goals.)3. KDIGO vs. KDOQI4. MD’s don’t follow5. bias 6 rigid
  • 5500 nephrologists have to take care of 2800 stage 3 pts50% want PCPs to do primary care in ESRD, stage 3 must be higher.Mythical practice of 2500, to rx 10 chronic diseases with recommended guidelines took an extra 3.5 hrs/day for stable pts, 10.5 for unstable Our carts are bigger than our horses, at least in the way we do things now.
  • Number of clicks, content is dense and links to tables that are often even more dense….
  • Transcript

    • 1. Chronic Kidney Disease:Important Roles for Primary CareProviders and Their Patients November 14th 2011
    • 2. Presenters Annette Eros, President and CEO The Kidney Trust Michael Choi, MD Vice Chair, Education National Kidney Foundation
    • 3. THE KIDNEY TRUSTCHRONIC KIDNEY DISEASEPresented by:Annette Eros, President & CEONovember 14, 2011
    • 4. THE KIDNEY TRUSTOUR MISSIONTo reduce the humanand economic costsof Chronic Kidney Disease(CKD) 4
    • 5. THE TRUTH ABOUT CKD 31 million adult Americans have CKD and 90% don’t know it Estimated annual growth rate of 8% 70 62 Million 60 Number of Americans with CKD 50 42 Million 40 31 Million 30 20 10 0 2011 2015 2020 5
    • 6. WHAT IS CHRONIC KIDNEY DISEASE (CKD)?  Normal kidney function • Remove waste products and excess fluid • Regulate body’s water, salts, chemicals in blood, remove drugs and toxins • Release hormones regulate blood pressure, make red blood cells and strong bones  CKD = decrease in kidney function, increase complications • High blood pressure, anemia, weak bones, malnutrition, nerve damage • Progresses to kidney failure • Dialysis or transplant 6
    • 7. EPIDEMIC AND GROWING Number of ESRD/Dialysis Patients 2,200,000 551,000 406,000 110,000 1985 2001 2010 2030 7
    • 8. COST TO TREAT ESRD Cost to Treat ESRD/Dialysis Patients $63 Billion $28 Billion $15 Billion $4 Billion 1985 2001 2010 2030 8
    • 9. REALITY OF DIALYSIS  Dialysis • Life-altering, time-consuming, expensive medical treatment • Average wait for a kidney transplant is two years  550,000 dialysis patients  95,000 on the kidney transplant waiting list  <20,000 transplants performed a year • Many will not receive a life-saving kidney transplant on time 9
    • 10. SILENT EPIDEMIC  No symptoms until late stage and kidneys begin to fail  Thousands of people have no advance warning  CKD is treatable if detected early 10
    • 11. WHO IS AT RISK? African High American Overweight Cholesterol or Obese Native Hispanic American Heart Disease Kidney Over Age 60 Disease Family History of Asian CKD Smoke Diabetes Tobacco High Blood Pacific Pressure Islander 11
    • 12. HIGH RISK  Not knowing may be riskiest of all 12
    • 13. KNOWING KIDNEY FUNCTION NUMBERS  Creatinine • Measures waste products in blood • Increase creatinine may mean some loss of kidney function • Normal creatinine ranges  Adult males: 0.8 – 1.4 mg/dL  Adult females: 0.6 – 1.1 mg/dL • Usually measured in blood tests as part of regular check ups 13
    • 14. KNOWING KIDNEY FUNCTION NUMBERS  Estimated Glomerular Filtration Rate (eGFR) • Uses creatinine score, age, race, and gender • More accurate and personalized 14
    • 15. eGFR SCORES  Estimated Glomerular Filtration Rate (eGFR) • ≥60 = no signs of kidney damage • 30-59 = May have moderate decrease in kidney functions  Should have further tests • 15-29 = May have severe decrease in kidney function  See doctor as soon as possible for further testing • ≤15 = May be in kidney failure  See a doctor immediately 15
    • 16. KIDNEY PROTECTION  Protecting kidneys • Control co-morbid conditions • Eat a balanced diet • Limit painkillers • Quit smoking • Learn about drug side effects • Protect during x-ray dye tests 16
    • 17. MOVING FORWARD  Take control of kidney health issues • Can no longer take a back seat • Need to remove the barriers to information and treatment 17
    • 18. Presenters Annette Eros, President and CEO The Kidney Trust Michael Choi, MD Vice Chair, Education National Kidney Foundation
    • 19. Integration of KDOQI and OtherChronic Kidney Disease (CKD)Guidelines in Clinical DecisionSupport Michael Choi, MD National Kidney Foundation 11/14/11
    • 20. OBJECTIVES1. Identify barriers to KDOQI*/CKD guideline implementation2. Describe optimal Clinical Decision Support strategies to implement CKD guidelines *Kidney Dialysis Outcome Quality Initiative 20
    • 21. Goals for CKD guideline implementationLevey AS Am J Kidney Dis 2009;53:S4-16
    • 22. CKD Stages GFR Prevalence Stage Description mL/min/1.73 m2 (×1000) Kidney damage with normal 1 ≥90 5900 GFR Kidney damage with mildly 2 60-89 5300 decreased GFR Moderately 3 30-59 7600 decreased GFR 4 Severely decreased GFR 15-29 400 5 Kidney failure <15 or on dialysis 300Adapted from: Coresh J, et al. Am J Kidney Dis. 2003;41:1-12.
    • 23. CKD Stages GFR Prevalence Stage Description mL/min/1.73 m2 (×1000) Kidney damage with normal 1 ≥90 5900 GFR Kidney damage with mildly 2 60-89 5300 decreased GFR Moderately 3 30-59 7600 decreased GFR 4 Severely decreased GFR 15-29 400 5 Kidney failure <15 or on dialysis 300Adapted from: Coresh J, et al. Am J Kidney Dis. 2003;41:1-12.
    • 24. C(KD)implications: Emphasis onEarly Recognition and Interdiction 100 80 Hypertension (%) Secondary HPT 60 Anemia (Hgb < 12 g/dl) Phosphorus > 4.5 mEq/L 40 Fail 1/4 mi walk 20 Hypoalbuminemia (Alb <3.5 g/dl) 0 1 2 3 4 CKD Stage 24
    • 25. Early referral avoids dialysis No Infection InfectionNo Infection Early Referral Late Referral 25
    • 26. Barriers to guideline implementation-lack of CKD knowledge• CKD knowledge – Older should be wiser • Only 35% of 301 docs (126 neph) were guideline adherent1 • Odds of adherence ↓ by 50% if practiced > 10 yrs• CKD knowledge – Younger means up to date2 • “When should a pt be referred to a nephrologist?” • 18.2% at <15 mls/min (stage 5) 1. Charles et al. AJKD 2009;54:227-237. 2.Agarwal V et al. AJKD 2008;52:1061-1069 26
    • 27. CKD knowledge gap will get worse• 6 million pages of medical literature published each year and literature is doubling every 20 years• A correct medication dose today factors in kidney and liver function + • indication, age, weight, height, other active meds, and allergies• Genomics, personalized medicine will increase the problem exponentially Covell DG, Uman GC, Manning PR. Ann Intern Med. 1985 Oct;103(4):596-9 Biomedical Computation Review 2010 27
    • 28. NKF Survey- Guideline implementation What are the barriers to implementation of KDOQI guidelines in daily practice? (n=341) Barriers * Proportion
    • 29. Guideline Implementation Barrier -Workload• Nephrologists can’t care for all CKD patients • Projection - 127 stage 4, 2818 stage 31 • Actual - 150 stage 4, but 200 stage 3• Primary Care Providers take care of stage 3 patients • To follow 10 chronic disease guidelines in a practice adds 3.5 hr/d for stable pts, 10.5 hr/d for unstable pts21.http://www.therenalnetwork.org/home/resources/MD2009NC_Wsh.pdf2. Ostbye T et al. Am Fam Med 2005;3:209-214
    • 30. NKF traditional tool for guidelineimplementation – Clinical Action Plans Problems include: only 25% aware, # of clicks, dense content, not patient specific
    • 31. Barriers to CKD/KDOQI GuidelineImplementation Lack of CKD Guideline Recognition – should improve Lack of CKD Knowledge – may worsen in the futureGuideline issues – want ↑evidence/updates, concise, tailored Workload for nephrologists and PCP – will worsen
    • 32. Knowledge needs for CKD management supported by Clinical Decision Support (CDS) • Identify and stage patients with CKD • Establish a co-management plan with PCP • Manage co-morbidities (HTN, lipids) • Monitor CKD progression • Plan permanent dialysis access • Establish a patient education plan • Identify reasons for patient non-adherence Provider as wellPatwardhan MB et al. Clin J Am Soc Nephrol 2009;4:273-283 32
    • 33. Optimal CKD CDSS –Clinician-system interactionRequirement Example• Decision support • CKD recommendations within automatically as part of summary screen workflow • Longitudinal trends Albuminuria present. Confirm the patient is on an ACE inhibitor or Angiotensin receptor blocker. Patwardhan MB et al. CJASN 2009;4:273-283 Source Report: Patient Engagement Systems 33
    • 34. Optimal CKD CDSS –Clinician-system interactionIdeally integrate medication treatment history in the EMR Pravastatin 10 mg a day (4/28/09) (Goal HCO3 22) Sodium Bicarbonate 650 mg twice a day (1/2/08)Patwardhan MB et al. CJASN 2009;4:273-283 Source Report: Patient Engagement Systems 34
    • 35. Optimal CKD CDSS –Clinician communication contentRequirement Examples• Identify which clinician or • Assign hypertension to the practice is responsible for referring PCP/other specialist given aspect of care or nephrologist• Prioritize care needs at a • Identify dialysis access visit planning as most important issue to address during a visit• Provide recommendations which don’t conflict with • Stage 4/5 + heart failure – others in the system Spironolactone vs. ↑blood • How about outside the potassium system?Patwardhan MB et al. CJASN 2009;4:273-283 35
    • 36. Optimal CKD CDSS –Clinician communication contentRequirement Example• Generate feedback • Allows clinician to create on performance reports demand reportsPatwardhan MB et al. CJASN 2009;4:273-283 Source Report: Patient Engagement Systems 36
    • 37. Optimal CKD CDSS –Clinician – Patient communicationRequirement Examples• Facilitate pt-clinician, • Transfer appropriate information clinician-clinician communicationPatwardhan MB et al. CJASN 2009;4:273-283 Source Report: Patient Engagement Systems 37
    • 38. Summary1. Lack of CKD guideline recognition Integrate patient data, Risk screening recommendations2. Lack of CKD knowledge Algorithms incorporated into EHR3. Guideline issues- Ideally want more evidence/updates, more concise, and specific for patients Tailor algorithms and suggestions at patient visit Ideal recommendations(?),update time, complexity remains4. Workload for nephrologists, PCP Time saver, generates documentation, pay for performance
    • 39. Q&A
    • 40. Thank YouFor more information:Jim RoseSenior Vice President, Business DevelopmentEmail: jim.rose@ptengage.comTelephone: (703) 537-5050