One in 10 people in the UK have permanently-low kidney function, ‘Chronic Kidney Disease’ (CKD). Milder CKD often doesn’t cause symptoms, but is detected by blood and urine tests. Once detected, proper treatment, which includes use of specific drugs, and avoidance of others, can prevent complications from CKD, like kidney failure, heart attacks and strokes. This sometimes means attending a hospital specialist kidney clinic. However, not everyone with CKD is referred to kidney clinic, and getting to hospital clinics can be difficult. People with lower socioeconomic status are less likely to see a kidney specialist as early, and more likely to get complications.
Some new clinics identify people with CKD from General Practice notes, prompting kidney specialist referral. Then, instead of a hospital appointment, the specialist gives advice remotely. More research is needed to be certain that these ‘virtual clinics’ are beneficial, and don’t cause harm.
We want to develop a virtual CKD clinic and measure benefits and harms. . We are applying for funding for this research and want to use GP data from the Clinical Practice Research Datalink (CPRD) and Hospital data from Hospital Episodes Statistics (HES) to find out the number of people who have CKD and would normally need referral to a kidney specialist. We want to know how many of these people have already been referred, how many were offered appointments but didn’t attend, and some details of the medication being prescribed.
Our aim is to use this information to estimate the potential benefits of a virtual CKD clinic as part of our application for research funding.
Chronic Kidney Disease (CKD) affects 10-15% of the population, and its prevalence is increasing. Early detection and appropriate management of CKD (blood pressure control, Angiotensin Converting Enzyme (ACE) inhibitors and Angiotensin-2 receptor blockers, statins, aspirin and avoidance of potentially harmful drugs) reduces the risk of kidney failure and cardiovascular disease. Care is often delivered via hospital nephrology services, predominantly in face-to-face clinics. There is known socioeconomic inequity of access to these services. Although demand for hospital nephrology services is increasing, funding is reducing, reflecting NHS Improvement’s vision to ‘incentivise a change in the delivery of outpatient activity’ away from face-to-face clinics.
Some established virtual CKD (vCKD) services use technology to identify patients who meet criteria for hospital
referral, and deliver care virtually, through an electronic patient record. This has potential to improve access and reduce inequity, but no formal evaluation has been performed. The covid19 crisis has necessitated rapid adoption of remote clinics, but the implementation of unevaluated service changes risks unexpected harm to patients.
In preparation for a research funding application to develop and formally evaluate a vCKD service, supported by Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (BNSSG CCG) Research Capability Funding (£21,500) 2020-21, we propose a feasibility study to establish how well current hospital nephrology services meet the needs of the population. This will allow us to estimate the resources required to implement a vCKD model, and its potential impact.
We propose using the CPRD Aurum database to establish the number of people who meet NICE criteria for CKD referral within a sample of 50,000 patients in England over a 2 year period, the proportion of these with evidence of hospital nephrology referral (via CPRD-documented referral or HES outpatients (OP) record of nephrology clinic attendance), the rate of clinic non-attendance, and comparison of prescribing patterns between those whose care is delivered with or without secondary care input.
• Patients meeting National Institute for Health and Care Excellence NICE criteria for CKD secondary care referral: estimated Glomerular Filtration Rate (eGFR) <30ml/min/1.73m2, albumin:creatinine ratio >70mg/mmol or both;
• Of these, proportion referred to secondary care (CPRD referral file), and proportion with secondary care nephrology outpatient appointments (HES OP data) in order to define groups of patients managed with secondary care input vs managed in primary care alone;
• Of those offered secondary care nephrology appointments, proportion who did not attend (DNA).
• From patients who meet criteria for NICE referral, in each group (primary care alone vs secondary care input:
• The number with active prescription of renin-aldosterone-angiotensin system blockers (ACE inhibitors and ARBs), Aspirin, Statins, Non-steroidal anti-inflammatory drugs (NSAIDs)
• Evidence of active monitoring according to NICE guidance: blood pressure recording, eGFR and albuminuria measurement
• In those with recorded blood pressure readings, proportion who meet target blood pressure of below 140/90mmHg for all people with CKD, and below 130/80 in those with diabetes and CKD and those with CKD and an albumin:creatinine ratio above 70mg/mmol
Yoav Ben-Shlomo - Chief Investigator - University of Bristol
Dominic Taylor - Corresponding Applicant - North Bristol NHS Trust
Fergus Caskey - Collaborator - University of Bristol
Isaac Tseng - Collaborator - University of Bristol
Maria Pippias - Collaborator - University of Bristol
Sam Davies - Collaborator - WEST WALK SURGERY
Theresa Redaniel - Collaborator - University of Bristol
Tim Jones - Collaborator - University of Bristol
HES Outpatient