The impact of population-based identification of chronic kidney disease using estimated glomerular filtration rate (eGFR) reporting.

BACKGROUND: The object of this study was to determine the impact of estimated glomerular filtration rate (eGFR) reporting, as part of a disease management programme (DMP), and clarify the prevalence of chronic kidney disease (CKD) and the level of un-met need in a UK Primary Care Trust. METHODS: Our approach was to prospectively identify patients with an eGFR <60 ml/min/1.73 m(2) using the four-variable MDRD equation in all patients from West Lincolnshire PCT (population 185 434 over the age of 15 years) having a routine estimation of serum creatinine. RESULTS: During the first 12 months of the programme 25.4% of the population had an eGFR reported. The likelihood of having an eGFR reported increased markedly with age. The prevalence of CKD stages 3-5 within primary care was 7.3%. Only 3.7% of patients with CKD stages 3-5 were under nephrology care compared to 13.7% in non-nephrology secondary care and 82.6% in primary care. There were marked differences in the male to female ratio between primary care and nephrology care, 1:1.9 versus 0.6:1, respectively (P < 0.001). The incidence of newly identified patients with CKD stages 4 and 5 was 0.16%. Initially there was a marked (up to 7-fold month on month) rise in nephrology referrals following institution of eGFR reporting which was reversed by the introduction of a referral management service as part of the DMP. Only 33% of patients with CKD stage 4 or 5, identified from within primary care, went on to have a nephrology referral in the subsequent 12 months compared with 44% and 78% respectively identified from non-nephrology secondary care (P < 0.001). CONCLUSIONS: The reporting of the eGFR in association with this DMP effectively identified patients with CKD. A referral assessment programme can effectively ensure appropriate nephrology referral and avoids exceeding the capacity of nephrology services. The vast majority of patients with CKD stages 3-5 are cared for within primary care. There are marked gender differences in the prevalence of CKD stages 3-5 that are not reflected by referral patterns to nephrology services. There are significant differences in referral practices between primary and secondary care. In a steady state the burden of incident patients with CKD stages 4-5 should not exceed the capacity of the local nephrology service.

Primary care-based disease management of chronic kidney disease (CKD), based on estimated glomerular filtration rate (eGFR) reporting, improves patient outcomes.

BACKGROUND: The majority of patients with chronic kidney disease (CKD) stages 3-5 are managed within primary care. We describe the effects, on patient outcomes, of the introduction of an algorithm-based, primary care disease management programme (DMP) for patients with CKD based on automated diagnosis using estimated glomerular filtration rate (eGFR) reporting. METHODS: Patients within West Lincolnshire Primary Care Trust, UK, population 223, 287 with CKD stage 4 or 5 were enrolled within the DMP between March 2005 and October 2006. We have analysed the performance against clinical targets looking at a change in renal function prior to and following joining the DMP and the proportion of patients achieving clinical targets for blood pressure control and lipid abnormalities. RESULTS: Four hundred and eighty-three patients with CKD stage 4 or 5 were enrolled in the programme. There were significant improvements in the following parameters, expressed as median values (interquartile range) after 9 months in the programme, compared to baseline and percentage values patients achieving target at 9 months: total cholesterol 4.2 (3.45-5.0) mmol/l versus 4.6 (3.9-5.4) mmol/l (P < 0.01), 75.0% versus 64.5% (P < 0.001); LDL 2.2 (1.6-2.8) mmol/l versus 2.5 (1.9-3.2) mmol/l (P < 0.01), 81.9% versus 69.2% (P < 0.05); systolic blood pressure 130 (125-145) mmHg versus 139 (124-154) mmHg (P < 0.05), 56.2% versus 37.1% (P < 0.05) and diastolic blood pressure 71 (65-79) mmHg versus 76 (69-84) mmHg (P < 0.01), 68.4% versus 90.3% (P < 0.01). The median fall (interquartile range) in eGFR in the 9 months prior to joining the programme was 3.69 (1.49-7.46) ml/min/1.73 m(2) compared to 0.32 (-2.61-3.12) ml/min/1.73 m(2) in the 12 months after enrolment (P < 0.001). One hundred and twenty-two patients experienced a fall in eGFR of > or = 5 ml/min/1.73 m(2), median 9.90 (6.55-12.36) ml/min/1.73 m(2) in the 9 months prior to joining the programme, whilst in the 12 months after enrolment, their median fall in eGFR was -1.70 (-6.41-1.64) ml/min/1.73 m(2) (P < 0.001). In the remaining patients, the median fall in eGFR was 1.92 (0.41-3.23) ml/min/1.73 m(2) prior to joining the programme and 0.86 (-1.03-3.53) ml/min/1.73 m(2) in the 12 months after enrolment (P = 0.082). CONCLUSIONS: These data suggest that chronic disease management in this form is an effective method of identifying and managing patients with CKD within the UK. The improvement in cardiovascular risk factors and reduction in the rate of decline of renal function potentially have significant health benefits for the patients and should result in cost savings for the health economy.