CKD/CRM Prevention
Purpose
We work together with our partners to transform CKD diagnosis and care across London and Surrey Heartlands. We strive to improve outcomes for people living with kidney disease through early identification, accurate coding, and optimising care to prevent progression thereby protecting the kidneys and saving lives.
LKN Leads
Andrew Frankel
Clinical Lead
Linda Tarm
Co-Clinical Lead
Prevention in London
There are ~86,000 adults living in London with undiagnosed Chronic Kidney Disease (CKD).
This exposes them to increased risk of cardiovascular events, worsening kidney function and end-stage kidney disease. These dire outcomes could be greatly reduced through early CKD identification, appropriate/consistent coding of CKD and effective evidence-based management strategies.
Early identification requires greater testing of Albumin Creatinine Ratio (ACR). The National Diabetes Audit (NDA) 2019/20 reported that across London, 71% of those with type 2 diabetes had received an ACR test, compared to 82% for those in the top performing decile.
Formal CKD diagnosis coding in primary care must be improved. In the national CVD-Prevent audit, ~34,000 of adults (registered with GPs) in London had evidence of CKD stage G3a to G5 but did not have a formal diagnosis of CKD.
We are in a new era of CKD treatment with multiple new agents established and in development, which could transform the outlook of people with CKD.
By investing in primary care, early identification tools/resources, teams and incentives to deliver effective interventions, there is an opportunity to deliver improved outcomes, including protecting the kidneys and heart, and a better patient experience.
Now is the time to act.
We have an opportunity to support GP practices to identify, code and manage CKD early to prevent or delay progression and protect the kidneys.
Aims and objectives of the group:
Aims:
- Use data to help ICSs understand and drive up their performance in CKD care
- Influence strategic commissioning across London ICSs to help ensure continued investment in CKD prevention
- Improve early identification in underserved populations across London through CKD community outreach programmes
- Each London sector has an effective programme to support people living with CKD stages 1-3 to understand and manage their condition
- CKD plans are aligned with a CRM approach to improve integrated CKD care
- To have a group of enthusiastic and committed people from across each ICS who will work together to help achieve improvements in CKD and CRM care in London
Objectives:
- Highlight and promote use of the LKN quarterly report that compares each ICSs CKD data.
- Create an automatically pulled 2nd generation CKD specific report for inclusion in the LKN ICS Dashboard and quarterly report
- Contribute towards developing an economic evaluation of the value of early detection and optimisation
- Develop practical guidelines i.e. a toolkit on setting up a CKD community outreach programme, based on the Hidden CKD model
- Communicate and share the toolkit with London ICSs to encourage consideration of similar programmes
- Develop and host 3 live and interactive educational webinars as exemplars for what could be delivered for people with CKD stages 1-3 living in London or Surrey Heartlands
- Co-create and share a ‘Medicines & Kidney’ resource
- Collaborate with 3rd sector organisations to develop further resources where needed
- Work collaboratively with the 3Ps renal evaluation team to help ensure successful delivery of the evaluation of the 3Ps CKD projects
- Work with the London diabetes and cardiac networks to co-develop and deliver appropriate resources that support ICSs in their endeavours to develop CRM models of care
- Collaborate with 3rd sector organisations when opportunities arise
- Establish a pool of people to facilitate regular communications and as a way to support the workstreams aims and objectives
Completed Work
Pathways
LKN CKD Early Identification Pathway
The Kidney Health Check for Adults Living with Diabetes or Hypertension – How to identify Chronic Kidney Disease early!
LKN CKD Optimisation Pathway
In adults with Type 2 diabetes and CKD (eGFR 20-90ml/min/1.73m2)
LKN CKD Optimisation Pathway
In adults without Type 2 diabetes, with CKD (eGFR 20-45ml/min/1.73m2 irrespective of the presence of albuminuria or eGFR 45-90ml/min/1.73m2 and uACR>22.6mg/mmol)
Guidance documents
Guidelines on CKD Coding in Primary Care
London Kidney Network Expert Consensus
Interpreting uACR & eGFR results
For clinicians
Other CKD Prevention Resources
Primary Care Resources Package
Helpful Patient Information Package
Sick Day Medication Guidance in CKD
Resources
Primary care patient searches and dashboard
Downloable searches that identify and create reports of your patients at risk of CKD or with CKD in SystmOne and EMIS
Information for people at risk of CKD or living with CKD
Educational leaflets and videos to help patients to understand their CKD diagnosis and how they can manage their condition
Primary care CKD review templates
Downloadable CKD templates available in SystmOne and EMIS that can be used to review patients with CKD
North West London Case Study
The North West London (NWL) consortium led a project with the London Kidney Network to identify and tackle the CKD related challenges facing primary care and patients. Click here to learn more about how the project was delivered and access the resources for patients and primary care.
