Dr Ivan Benett explains how implementing the NICE quality standard on chronic kidney disease will help to reduce the number of individuals needing dialysis or renal replacement
  • The quality standard for CKD defines priorities for activity within primary care and commissioning objectives for secondary care
  • Improvement strategies will need to include an education programme on CKD for clinicians and managers based on the NICE guideline
  • At-risk groups should be offered testing for CKD
  • Achievement of the quality standard will result in better assessment of cardiovascular risk and interventions to reduce events, improved management of anaemia, a slower decline in renal function, and fewer people requiring dialysis or renal replacement
  • Implementing the quality standard will require local leadership, resources, and efficient data collection systems
  • An audit cycle for each quality statement needs to be established
  • Local performance targets need to be agreed.

The NICE guideline for chronic kidney disease (CKD) was published in 2008.1,2 Its development was driven by the expectation that if CKD could be identified early and managed optimally, the number of people needing expensive dialysis would fall, quality of life and longevity would improve, and the cost to the NHS would diminish. The NICE quality standard for CKD is based on key points from the guideline and provides a framework for quality improvement and commissioning.3

Prevalence

The age-adjusted prevalence of stages 3–5 CKD in the UK is approximately 8.5%.2,4 It rises steeply in people aged over 50 years to around 10% at 60 years and 40% at 80 years.2 At all ages, women have a higher prevalence of CKD than men.2 The prevalence among South-Asian and African-Caribbean populations is higher compared with Caucasians in the UK,5 and the disease also deteriorates more rapidly in these population groups.

Results from the 2010/11 quality and outcomes framework in England indicate a CKD prevalence of 4.3% on general practice registers.6 This suggests that the current detection of CKD is much lower than expected.

In a retrospective study of people with CKD, approximately 4% progressed to end-stage renal disease over 5.5 years while two-thirds died of other causes. Almost half of the latter were caused by cardiovascular disease (CVD).7 This burden of CVD compared with progression of renal disease has been confirmed in other observational studies.8,9 Deteriorating renal function is associated with increased CV events, particularly in the presence of proteinuria.9 Data from a US study suggest that CVD events rise from a baseline of about 2%–3% per 100 patient years to approximately 11% in people with stage 3B disease, 22% in those with stage 4, and 37% with stage 5 disease.9 There is a similar rise in hospital admissions and mortality with declining renal function.9

Quality standard for CKD

The NICE quality standard on CKD identifies the main implementation points from the related NICE guideline and consists of 15 statements. The first eight apply directly to primary care and the last seven statements relate more to secondary and tertiary care (see Table 1, see below).3

Table 1: NICE quality standard for chronic kidney disease3
No. Quality statements
1 People with risk factors for CKD are offered testing, and people with CKD are correctly identified.
2 People with CKD who may benefit from specialist care are referred for specialist assessment in accordance with NICE guidance.
3 People with CKD have a current agreed care plan appropriate to the stage and rate of progression of CKD.
4 People with CKD are assessed for cardiovascular risk.
5 People with higher levels of proteinuria, and people with diabetes and microalbuminuria, are enabled to safely maintain their systolic blood pressure within a target range 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
6 People with CKD are assessed for disease progression.
7 People with CKD who become acutely unwell have their medication reviewed, and receive an assessment of volume status and renal function.
8 People with anaemia of CKD have access to and receive anaemia treatment in accordance with NICE guidance.
9 People with progressive CKD whose eGFR is less than 20 ml/min/1.73m2, and/or who are likely to progress to established kidney failure within 12 months, receive unbiased personalised information on established kidney failure and renal replacement therapy options.
10 People with established renal failure have access to psychosocial support (which may include support with personal, family, financial, employment, and/or social needs) appropriate to their circumstances.
11 People with CKD are supported to receive a pre-emptive kidney transplant before they need dialysis, if they are medically suitable.
12 People with CKD on dialysis are supported to receive a kidney transplant, if they are medically suitable.
13 People with established kidney failure start dialysis with a functioning arteriovenous fistula or peritoneal dialysis catheter in situ.
14 People on long-term dialysis receive the best possible therapy, incorporating regular and frequent application of dialysis and ideally home-based or self-care dialysis.
15 People with CKD receiving haemodialysis or training for home therapies who are eligible for transport, have access to an effective and efficient transport service.
CKD=chronic kidney disease, eGFR=estimated glomerular filtration rate
National Institute for Health and Care Excellence website. Chronic kidney disease quality standard. Reproduced with kind permission. Available at: www.nice.org.uk/guidance/qualitystandards/chronickidneydisease/ckdqualitystandard.jsp (accessed 17 January 2012)

Identification—statement 1

This statement requires that people with risk factors for CKD are offered testing, and that individuals with the disease are correctly identified.3 In the context of general practice, this should be the registered list of patients for the practice or clinical commissioning group (CCG) population. At-risk groups should be identified from the practice register and testing for CKD should be offered to people with:1–3

  • diabetes
  • hypertension
  • CVD (ischaemic heart disease, chronic heart failure, peripheral vascular disease, and cerebral vascular disease)
  • structural renal tract disease, renal calculi, or prostatic hypertrophy
  • multisystem diseases with potential kidney involvement (systemic lupus erythematosus)
  • family history of stage 5 CKD or hereditary kidney disease.

If the estimated glomerular filtration rate (eGFR) is <60 ml/min/1.73 m2, the reading should be repeated within 2 weeks.3 If two readings have already been recorded, CKD should be staged according to NICE Clinical Guideline 73; an appropriate adjustment for ethnicity should be made. Significant proteinuria (albumin:creatinine ratio) should be confirmed by an early morning urine sample.1–3

Referral—statement 2

The quality standard defines when patients should be referred for specialist advice.3 The medical records of all people with CKD stage 3, 4, or 5 should be reviewed and those who fit the NICE criteria should be considered for referral. A review of the records of individuals who are currently under secondary care follow up should be performed and those who do not need to be seen in secondary care should be transferred back to primary care.

This statement will enable primary care clinicians and CCGs to be more confident about which patients they can manage on their own and which individuals require input from secondary care. The standards therefore also define the educational needs of primary care.

Care plan—statement 3

All people with CKD should have a care plan that is explicit in the patient records and which has been Read-coded. The care plan should include information on diagnosis and prognosis, multidisciplinary support, education, and provision of future care.3 The existence of care plans should be audited electronically every year.

Cardiovascular risk assessment—statement 4

The quality statement on assessing cardiovascular risk in people with CKD suggests a number of factors that should be recorded, such as angina and myocardial infarction, stroke and transient ischaemic attack, diabetes, and ethnicity. Healthy lifestyle factors should also be discussed with the patient.

An audit of all patients with CKD should be undertaken to establish whether they have had a risk assessment for CVD. Individuals who have not been assessed should receive one at their next clinic appointment. This process should be repeated every year.

Control of blood pressure—statement 5

Patients with CKD who have proteinuria or who have diabetes and microalbuminuria should have their blood pressure maintained within the following target range: systolic blood pressure between 120 and 129 mmHg and diastolic blood pressure below 80 mmHg.3 Electronic records should be audited at least yearly, and perhaps more frequently if necessary and patients whose blood pressure is not within the target range should be recalled.


Disease progression—statement 6

The quality statement on assessing the progression of CKD and functional decline is sometimes only discussed superficially, but is probably the most important in terms of identifying people who will require dialysis or renal replacement. Most individuals with CKD are older and have diabetes or hypertension. Their rate of renal decline is relatively slow and predictable. The, so called, ‘crash landers’ on the other hand, appear unexpectedly. They are often younger and have intrinsic inflammatory renal disease, and are also rare.

Identifying people with serious renal pathology requires a careful evaluation of all individuals with CKD—this includes people at stage 1 and 2 and those with higher stages. These individuals may present with relatively mildly raised creatinine and can be missed. If intrinsic renal disease is suspected in the presence of mildly raised creatinine, then urine should be checked for the presence of blood as well as protein.

In people with a new finding of reduced eGFR, retest within 2 weeks to exclude causes of acute deterioration of GFR (e.g. acute kidney injury or initiation of angiotensin-converting enzyme [ACE] inhibitor/angiotensin-II receptor blocker [ARB] therapy). At least three separate eGFR measurements (over a period of not less than 90 days) need to be taken to establish the rate of decline.3 Progression is defined as a decline in eGFR of >5 ml/min/1.73 m2 within 1 year, or >10 ml/min/1.73 m2 within 5 years. There should be a particular focus on people in whom a decline of GFR continuing at the observed rate would lead to a need for renal replacement therapy within their lifetime, by extrapolating the current rate of decline.

Acute illness—statement 7

Patients with CKD who become acutely unwell should receive a medication review and assessment of volume status and renal function. Primary care clinicians should be particularly alert to patients who are elderly, who have hypertension or diabetes, or whose treatment includes a diuretic and/or ACE inhibitor or ARB.

Anaemia—statement 8

Anaemia contributes significantly to the symptom burden of CKD and is estimated to have an overall incidence of 12% in stages 3, 4, and 5.2 However, other causes of anaemia should be considered, especially in older people. The typical aspirational range for haemoglobin is 10–12 g/dl.10 Patients with CKD stage 3B–5 who present with symptoms of anaemia should have their haemoglobin and ferritin levels estimated and treated accordingly.3

Implementation of the quality standard

The quality standard for CKD is composed of statements that define the priorities for service improvement across the health community. Some apply to a whole population while others relate to individual care. The implication of the standards is that each health system should aspire to achieving the highest performance for their population. An ultimate aspiration would perhaps be 80%–100% achievement of quality standard criteria, although these would need to be agreed locally.

These statements should form the basis of audit criteria if national quality indicators do not exist, and can be used by emerging CCGs to establish current performance and to plan a cycle of improvement. The performance standards achieved for each criterion can also be compared with performance by other CCGs, or between practices or localities within a CCG. The quality statements that relate to secondary and tertiary care can be used by the CCGs for commissioning services and measuring contract performance. Where appropriate they can also be used to develop local Commissioning for Quality and Innovation payments (CQUINs).

The quality standard for CKD is challenging and will require local leadership, prioritisation of resources, and a system for gathering information and data that is practical. Where these elements are missing, implementation of the standard will be difficult to achieve. However, emerging CCGs have a significant stake in achieving high-quality care. They will have the mandate from practices in the group to implement changes, and will be seeking to minimise variation between practices.

As with any quality improvement, the baseline performance needs to be established, and new targets set. Improvement of standards will depend on individual circumstances and requirements of the practice or CCG. At the bare minimum, part of the cycle of change is likely to involve an education programme for its practitioners. Clinicians may need reminding about which people are at risk of CKD and how to stage the disease. These are defined in the NICE guideline on CKD, which should be used as the basis of an education programme and to support the implementation of the quality standard in general.

Implementation of the NICE quality standard for CKD will mean a more uniform assessment of cardiovascular risk, with appropriate intervention and a slower decline of renal function. The payoff in terms of productivity is that fewer patients will decline therefore reducing the need for renal replacement therapy.


Conclusion

The quality standard for CKD has now set a framework within which primary care and commissioners can build on existing work to raise the quality of care for people with the disease. By implementing the statements, the incidence of CVD events will be lowered, the decline in renal function will be reduced, and there will be better management of anaemia. Productivity will be improved as fewer patients will require dialysis or renal replacement. This standard, as with all quality improvements, will require the necessary resources, leadership, and educational input. They will enable commissioners to define performance indicators from providers of secondary and tertiary care confidently.

GP commissioning take home message

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • Commissioners could begin their review of CKD by examining the QOF practice prevalence to ensure that patients are being identified
  • The QOF indicators for CKD (CKD1–CKD6) also provide information on the basic management of patients, particularly in relation to blood pressure control
  • Commissioners will need to secure, through contracts, best practice tariffs for effective care, including dialysis, for people with end-stage CKD
  • The quality standard for CKD is likely to form part of the national outcomes framework, which will judge the performance of commissioners and clinical commissioning groups and direct payments for quality premiums (subject to legislation)
  • Any focus on CKD is likely to increase detection and referral to secondary care—commissioners would be wise to agree local referral care pathways to prevent overwhelming secondary care and excessive tariff costs
  • Tariff prices for nephrology outpatient = £198 (new), £128 (follow up)a
CKD=chronic kidney disease; QOF=quality and outcomes framework
awww.dh.gov.uk/paymentbyresults/

  • Ask the audit question (i.e. are patients at risk of CKD being assessed?)
  • Set the audit criteria; for example, assess individuals in the following categories for CKD: diabetes, hypertension, CVD (ischaemic heart disease, chronic heart failure, peripheral vascular disease, and cerebral vascular disease), structural renal tract disease, renal calculi, prostatic hypertrophy, multisystem diseases with potential kidney involvement (systemic lupus erythematosus), family history of stage 5 CKD or hereditary kidney disease
  • Set a target performance for the first cycle of audit and aspirational performance (e.g. 60% at first cycle increasing to 90% in the first year)
  • Consider ways of improving performance at next medication review
    (e.g. check estimated glomerular filtration rate), or call patients in proactively for a blood test
  • Re-measure performance and continue the change cycle until aspirational performance is achieved.
  1. National Institute for Health and Care Excellence. Chronic kidney disease—early identification and management of chronic kidney disease in adults in primary and secondary care. Clinical Guideline 73. London: NICE 2008. Available at: www.nice.org.uk/Guidance/CG73
  2. National Collaborating Centre for Chronic Conditions. Chronic kidney disease: national clinical guideline for early identification and management in adults in primary and secondary care. London: Royal College of Physicians, 2008. Available at: www.rcplondon.ac.uk/pubs/brochure.aspx?e=257
  3. National Institute for Health and Care Excellence. Chronic kidney disease quality standard. www.nice.org.uk/guidance/qualitystandards/chronickidneydisease/ckdqualitystandard.jsp (accessed 15 December 2011).
  4. Stevens P, O’Donohue D, de Lusignan S et al. Chronic kidney disease management in the United Kingdom: NEOERICA project results. Kidney Int 2007; 72 (1): 92–99.
  5. Roderick P, Raleigh V, Hallam L, Mallick N. The need and demand for renal replacement therapy in ethnic minorities in England. J Epidemiol Community Health 1996; 50 (3): 334–339.
  6. The NHS Information Centre. Quality and outcomes framework achievement data 2010/11. The Health and Social Care Information Centre, 2010. Available at: www.ic.nhs.uk/statistics-and-data-collections/supporting- information/audits-and-performance/the-quality-and-outcomes-framework/qof-2010-11/qof-2010-11-bulletin
  7. Drey N, Roderick P, Mullee M, Rogerson M et al. A population-based study of the incidence and outcomes of diagnosed chronic kidney disease. Am J Kidney Dis 2003; 42 (4): 677–684.
  8. Keith D, Nichols G, Gullion C et al. Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization. Arch Intern Med 2004; 164 (6): 659–663.
  9. Go A, Chertow G, Fan D et al. Chronic kidney disease and the risk of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351 (13): 1296–1305.
  10. National Clinical Guideline Centre. Anaemia management in chronic kidney disease. Rapid update 2011. Clinical Guideline 114. London: NCGC, 2011. Available at: www.nice.org.uk/CG114G