Presentation of leading authorities for management of chronic kidney disease

1. Chronic Kidney Disease:
Important Roles for Primary Care
Providers 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 TRUST
CHRONIC KIDNEY DISEASE
Presented by:
Annette Eros, President & CEO
November 14, 2011

4. THE KIDNEY TRUST
OUR MISSION
To reduce the human
and economic costs
of 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 Other
Chronic Kidney Disease (CKD)
Guidelines in Clinical Decision
Support
Michael Choi, MD
National Kidney
Foundation
11/14/11

20. OBJECTIVES
1. Identify barriers to KDOQI*/CKD guideline
implementation
2. Describe optimal Clinical Decision Support
strategies to implement CKD guidelines
*Kidney Dialysis Outcome Quality Initiative 20

21. Goals for CKD guideline implementation
Levey 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 300
Adapted 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 300
Adapted from: Coresh J, et al. Am J Kidney Dis. 2003;41:1-12.

24. C(KD)implications: Emphasis on
Early 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
Infection
No 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 pts2
1.http://www.therenalnetwork.org/home/resources/MD200
9NC_Wsh.pdf
2. Ostbye T et al. Am Fam Med 2005;3:209-214

30. NKF traditional tool for guideline
implementation – Clinical Action Plans
Problems include:
only 25% aware, # of clicks, dense content, not patient specific

31. Barriers to CKD/KDOQI Guideline
Implementation
Lack of CKD Guideline Recognition – should improve
Lack of CKD Knowledge – may worsen in the future
Guideline 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 well
Patwardhan MB et al. Clin J Am Soc Nephrol 2009;4:273-283 32

33. Optimal CKD CDSS –
Clinician-system interaction
Requirement 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 interaction
Ideally 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 content
Requirement 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 content
Requirement Example
• Generate feedback • Allows clinician to create on
performance reports demand reports
Patwardhan MB et al. CJASN 2009;4:273-283 Source Report: Patient Engagement Systems
36

37. Optimal CKD CDSS –
Clinician – Patient communication
Requirement Examples
• Facilitate pt-clinician,
• Transfer appropriate information
clinician-clinician
communication
Patwardhan MB et al. CJASN 2009;4:273-283 Source Report: Patient Engagement Systems
37

38. Summary
1. Lack of CKD guideline recognition
Integrate patient data, Risk screening recommendations
2. Lack of CKD knowledge
Algorithms incorporated into EHR
3. 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 remains
4. Workload for nephrologists, PCP
Time saver, generates documentation, pay for performance

39. Q&A

40. Thank You
For more information:
Jim Rose
Senior Vice President, Business Development
Email: jim.rose@ptengage.com
Telephone: (703) 537-5050