Kidney Research UK has reported some alarming statistics about chronic kidney disease (CKD)1:
- between 2005 and 2015 there was a 31.7% global increase in the number of people dying from CKD
- the burden of the disease increased by 19.6%
- estimates suggest that three million lives are at risk from CKD. As many as one million of these cases are undiagnosed
An early diagnosis helps GPs to manage and control cases. This means fewer patients are in a state of decline and fewer patients die early from the disease.
Introducing CKD Manager
The current NICE guidelines for managing CKD in general practice are comprehensive. They include identifying and managing patients with CKD as well as auditing the early identification and management of CKD patients.
We have built a collection of resources that includes reports, alerts and a template. We call this CKD Manager. Exact and efficient, it integrates with Vision, SystmOne and EMIS systems and helps GP practices to provide better care for CKD patients by improving register accuracy, optimising treatment and reducing the chance of further renal decline.
These are our recommended steps for managing and controlling chronic kidney disease with CKD Manager:
1. Identify patients with undiagnosed CKD
Use the practice reports to identify patients that may have the disease but are not on the register. You will see a count of patients meeting the diagnostic criteria for a specific CKD stage but have no CKD stage 3 (or above) Read code in their record.
You can then drill down into a list of patient names and add the appropriate Read codes to their records.
2. Improve CKD register accuracy
Before you start to use CKD Manager to control and manage care you should make sure your register is accurate. There are specific reports that help you to:
- remove patients that are on the register, but shouldn't be
- find patients on the register, but with an inaccurate CKD stage
- identify patients with a first GFR < 60 that may be overdue for a retest
3. Recall patients that need urgent reviews
GPs can see a list of patients where there is a clinical reason for an urgent record review, such as a large rise in Creatinine or a fall in GFR > 25%
Non-clinical staff can recall patients that need an urgent review for other reasons, such as overdue blood pressure checks. They can print invitation letters in bulk, but it's cheaper to do this with SMS text messages.
4. Routine reviews
It's quick and easy to identify cohorts of patients whose clinical record may need a review. CKD Manager suggests appropriate interventions and CKD Read coding. It will also show patients whose blood pressure is not on target.
You can bulk add Read codes by selecting patients within reports and then add one or more Read codes to them all.
5. Managing CKD for individual patients
CKD Manager includes an interactive template to help manage your CKD patients.
The template alerts clinicians when action relating to CKD may be beneficial during encounters. You can also access the template during consultations or from any of the CKD Manager reports.
Template highlights include:
- View the most recent and historical information that is relevant to the disease and current patient
- Add high quality data
- Add free text comments
- See the patient's latest and historical test results and investigations
- Record test requests
- Request repeat urine samples
- Smart Read coding: read codes are only available if the patient's CKD stage needs changing or you are adding a recent diagnosis to the register
- Document if the patient is aware of their diagnosis
- Record exceptions
The following links provide more detailed help and guidance for CKD Manager:
How to get started
An early diagnosis helps GPs to manage and control CKD cases. CKD Manager helps GPs to:
- Diagnose CKD earlier
- Avoid unnecessary renal decline
- Reduce the number of people dying early from CKD
CKD Manager is available centrally-funded on GPSoC as part of Outcomes Manager so there is no cost to GP practices in England. You can start using the software straight away and we will liaise with your CCG to organise the funding.
Population level case-finding
CCGs and health boards can use Outcomes Manager to case-find at scale across their entire population. It uses data from all practices, regardless of the clinical systems they use. This is then displayed within an interactive cloud-based reporting dashboard.
Greenwich CCG has achieved staggering results over a 12 month period. They used Outcomes Manger to identify 4,000 patients with undiagnosed long term conditions. You can download a case study to read more about this.
1Kidney Research UK, 7 October 2016: https://www.kidneyresearchuk.org/news/global-figures-show-staggering-increase-in-chronic-kidney-disease