47
10/21/2013 1 All Wales National Audit 2013 f ACKD Chris Brown SWW Renal Unit David Jackson Anke Hagemi ABMU HB North Wales Renal Unit Anaemia of CKD
10/21/2013 1
All Wales National Audit 2013 f ACKD
Chris Brown SWW Renal Unit
David Jackson Anke Hagemi ABMU HB North Wales Renal Unit
Anaemia of CKD
2
Governance: are reconfigured services robust?
Contractual: inform procurement obligations
Critical appraisal: what’s done well or not?
Defining National standards: registry shortfalls
Practice development: consider our treatment
approaches
Future opportunities: procurement & clinical
10/21/2013 3
Anaemia of Chronic Kidney Disease
Treated when HB consistently below 10g/dl with:
Iron repletion:
•Ferritin > 200 ng/ml TSAT >20%
ESAs
• Hb 10-12 g/dl
Treatment is effective BUT expensive AND also
labour intensive because of the need for tight target control
•HB: ‘too low’ is harmful & ‘too high’ harmful
• We need to use ESAs sparingly & with care
Set by the UK Renal
Association for:
Hb
Ferritin (shift 2011)
TSAT
Determined by the
Renal Registry for:
Hb
Ferritin
In HD and PD patients.
4
All Wales audit 2012:
Hb, Feritin, TSAT
In Pre-dialysis & Tx
Audit of routine monthly / quarterly bloods March 2013
Inclusion/exclusion criteria
Excel data proforma
N = ~ 3000 patients (~ 2700 after QC)
Analysis: compliance with national targets
Excel calculator developed for analysis
5 10/21/2013
10/21/2013 6
Study PERIOD
Study MONTH
January February March
ESA dose
Venofer
Cosmofer / Monofer / Ferinject / Rienso
Inclusion: Haemodialysis = All pts Peritoneal / Tx / Pre-dialysis = only ESA pts
Blood results = latest recorded
10/21/2013 7
10/21/2013 8
10/21/2013 9
= 2 x Month
= 1 x per day
1000
1000mg
1gm
1gms
1-gram
1g
1 g
10/21/2013 10
10/21/2013 11
Hospital No. Yes Yes yes
Unit Hub Yes Yes Yes
CKD Status Yes Yes Yes
Date dialysis initiated Yes Yes No
Incident vs Prevalent Yes Yes No
ESA Brand Yes Yes Yes
ESA Route Yes Yes Yes
Weekly ESA dose Yes Yes Yes
Freq of administration Yes Yes Yes
Monthly / Quart. Iron dose Yes Yes No
IV Iron brand Yes Yes No
Supp. oral Iron Yes Yes No
HB Yes Yes Yes
Ferritin Yes Yes Yes
TSAT Yes Yes N/A
CRP Yes Yes No
Pre and Post urea Yes Yes No
URR Yes Yes No
Vascular access Yes Yes No
10/21/2013 12
59.7%
56.2% 46.4%
56.0%
49.4%
55.1%
11.5 11.3 11.4
10.9
12.0
11.2
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
67 418 69 348 79 981
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All Wales
Mea
n H
b (
g/d
l)
Patient Numbers
% P
ati
ents
in
Hb
ra
ng
e
% above target (>12g/dl)
% in target (10-12g/dl)
% below target (<10g/dl)
Mean
10/21/2013 14
62.2%
56.4% 57.1%
60.9%
65.6% 59.2%
11.3 11.0
11.1 10.8 10.8 10.9
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
74 450 77 325 93 1019
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All Wales
Mea
n H
b (
g/d
l)
Patient numbers
% P
atie
nts
in H
b r
ange
% above target (>12g/dl)
% in target (10-12g/dl)
% below target (<10g/dl)
Mean
Bangor 74 100%
Cardiff 456 99%
Rhyl 77 100%
Swansea 325 100%
Wrexham 93 100%
All Wales 1025 99%
10/21/2013 16
Sw
an
sea
Ban
go
r
Rh
yl
Card
iff
Wre
x
Wale
s
61% 62% 57 % Wales 2013 56% 66% 59%
56% 60% 46 % Wales 2012 56% 50% 55%
67% 59% 58 % RR 2011 55% 49% 59%
1.4% 2.5% 5.7% 3.3% 3.3% 2.7%
18.9%
14.3%
13.2% 17.6% 15.4%
55.4%
62.8%
71.4%
45.9% 41.8%
55.6%
27.0%
12.6% 11.7%
22.3% 26.4%
17.9%
13.5%
3.2% 2.6%
12.9% 11.0% 7.7%
516
352
397
461 465
413
200
250
300
350
400
450
500
550
600
650
700
74 438 77 318 91 998
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All Wales
Mea
n F
erri
tin
ng
/ml
Patient Numbers
% P
atie
nts
in f
erri
tin
ran
ge
% above target (>800ng/ml)
% above target (501-800ng/ml)
% in target (200-500ng/ml)
% below target (100-199ng/ml)
% below target (<100ng/ml)
Mean
Bangor 74 100%
Cardiff 456 96%
Rhyl 77 100%
Swansea 325 98%
Wrexham 93 98%
All Wales 1025 97%
10/21/2013 18
Ban
go
r
Card
iff
Sw
an
sea
Rh
yl
Wales 2012 99% 100% 97% 91% 95%
Wales 2013 99% 100% 97% 94% 97%
RR 2011 99% 97% 96% 91% 95%
Wale
s
Iron Dose mg mg mg mg
10/21/2013 19
Ban
go
r
Ca
rdif
f
Sw
an
sea
Rh
yl
57% 64% 54% 45% Wales 2012 54%
63% 71% 55% 46% Wales 2013 56 %
Wale
s
64% 63% 58% 50% RR 2011 59%
10/21/2013 20
Ban
go
r
Card
iff
Sw
an
sea
Rh
yl
2.9% 3% 7% 4.6% Wales 2012 5.2%
2.6% 14% 13% 3.2% Wales 2013 7.7%
Wale
s
0.0% 0.0%
19.5%
45.0%
14.4%
35.4%
0.0% 0.0%
80.5% 55.0% 85.6% 64.6%
30
22
36
26
0
10
20
30
40
50
60
0 0 77 322 90 489
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All-Wales
Mea
n T
SA
T %
Patient Number with test reult
% P
atie
nts
in T
SAT
ran
ge
% in target (>=20%
% below target (<20%)
Mean
Bangor 74 0%
Cardiff 456 0%
Rhyl 77 100%
Swansea 325 99%
Wrexham 93 97%
All-Wales 1025 48%
HB : Targets > UK benchmarks
Consistent across Wales
HB: Improvement from 2012
Ferritin: target > UK benchmarks
Appropriate iron strategies
Maintaining standards – 2013 RRR looks bright
Similarities: same outcomes
Differences: management strategies
10/21/2013 22
61.5%
38.9%
33.3% 56.0%
100.0%
49.4%
11.2
10.7 10.5
10.9 11.3
10.8
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
13 36 3 25 2 79
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All Wales
Mea
n H
b (
g/d
l)
Patient Number
% P
atie
nts
in H
b r
ange
% above target (>12g/dl)
% in target (10-12g/dl)
% below target (<10g/dl)
Mean
Bangor 13 100%
Cardiff 36 100%
Rhyl 3 100%
Swansea 25 100%
Wrexham 2 100%
All Wales 79 100%
7.7%
21.9%
12.0% 14.7%
15.4%
25.0%
20.0% 21.3%
61.5%
37.5%
100.0%
24.0%
50.0%
40.0%
15.4%
32.0%
18.7%
334
280
355
438
188
342
100
150
200
250
300
350
400
450
500
550
600
13 32 3 25 2 75
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All Wales
Mea
n F
erri
tin
ng
/ml
Patient Number
% P
atie
nts
in f
erri
tin
ran
ge
% above target (>800ng/ml)
% above target (501-800ng/ml)
% in target (200-500ng/ml)
% below target (100-199ng/ml)
% below target (<100ng/ml)
Mean
Bangor 13 100%
Cardiff 36 89%
Rhyl 3 100%
Swansea 25 100%
Wrexham 2 100%
All Wales 79 95%
0.0% 0.0%
100.0% 32.0% 0.0% 37.9%
34
20
15
21
0
10
20
30
40
50
60
70
80
0 0 3 25 1 29
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All-Wales
Mea
n T
SA
T %
Patient Numbers for test result
% P
atie
nts
in T
SAT
ran
ge
% in target (>=20%
% below target (<20%)
Mean
Bangor 13 0%
Cardiff 36 0%
Rhyl 3 100%
Swansea 25 100%
Wrexham 2 50%
All-Wales 79 37%
Surly more Home HD patients achieve target?
HB, Ferritin and TSAT:
In target : Home HD < Unit HD
This must be because they over achieve target?
10/21/2013 26
70.0%
54.8%
75.0%
56.0%
75.0%
59.8%
11.3
10.3
11.1 10.9 10.9 10.7
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
10 42 8 50 12 122
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All Wales
Mea
n H
b (
g/d
l)
Patient
% P
atie
nts
in H
b r
ange
% above target (>12g/dl)
% in target (10-12g/dl)
% below target (<10g/dl)
Mean
Bangor 10 100%
Cardiff 43 98%
Rhyl 8 100%
Swansea 51 98%
Wrexham 12 100%
All Wales 124 98%
35.7% 7.0% 14.0%
0.0%
42.9%
14.3% 9.3%
16.7%
19.0% 70.0%
21.4%
71.4% 51.2% 66.7%
48.0%
20.9%
13.0%
10.0% 11.6% 6.0%
379
153
372
465
358 349
0
100
200
300
400
500
600
700
10 28 7 43 12 100
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All Wales
Mea
n F
erri
tin
ng
/ml
Patient Numbers
% P
atie
nts
in f
erri
tin r
ange
% above target (>800ng/ml)
% above target (501-800ng/ml)
% in target (200-500ng/ml)
% below target (100-199ng/ml)
% below target (<100ng/ml)
Mean
Bangor 10 100%
Cardiff 43 65%
Rhyl 8 88%
Swansea 51 84%
Wrexham 12 100%
All Wales 124 81%
36.2% 36.2%
0.0% 0.0% 0.0%
63.8%
0.0%
63.8%
23 23
0
5
10
15
20
25
30
35
40
0 0 0 47 0 47
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All-Wales
Mea
n T
SA
T %
Patient Numbers
% P
atie
nts
in T
SAT
ran
ge
% in target (>=20%
% below target (<20%)
Mean
Bangor 10 0%
Cardiff 43 0%
Rhyl 8 0%
Swansea 51 92%
Wrexham 12 0%
All-Wales 124 38%
HB : Targets > UK benchmarks
Less consistent across Wales (vs HD)
HB: similar to 2012
Ferritin: New target by authorities
Ferritin: target > UK benchmarks
Significant improvement to 2012
10/21/2013 30
10/21/2013 31
10/21/2013 32
10/21/2013 33
Why repatriated to a tertiary care service?
10/21/2013 34
1. Increasing prevalence & patient no.
Increasing recognition & referral
4. Increasing costs & need
to reduce expenditure
2. Tighter clinical targets
3. Increasing options &
complexity
10/21/2013 35
75.0%
59.3%
66.7%
60.9%
0.0%
60.7%
10.1
11.0
10.6 11.0 11.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
4 81 9 46 0 140
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All Wales
Mea
n H
b (
g/d
l)
Patient Numbers
% P
atie
nts
in H
b r
ange
% above target (>12g/dl)
% in target (10-12g/dl)
% below target (<10g/dl)
Mean
Bangor 4 100%
Cardiff 98 83%
Rhyl 9 100%
Swansea 46 100%
Wrexham 0 #DIV/0!
All Wales 157 89%
0.0%
33.9% 33.3%
10.0%
0.0%
24.5%
0.0%
23.2%
0.0%
35.0%
0.0%
25.5%
100.0%
23.2%
44.4%
35.0%
0.0%
30.2%
0.0%
10.7% 11.1%
10.0%
0.0%
10.4%
0.0%
8.9% 11.1% 10.0%
0.0%
9.4%
467
304
354 358
0
330
0
100
200
300
400
500
600
1 56 9 40 0 106
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All Wales
Mea
n F
erri
tin
ng
/ml
Patient Numbers
% P
atie
nts
in f
erri
tin
ran
ge
% above target (>800ng/ml)
% above target (501-800ng/ml)
% in target (200-500ng/ml)
% below target (100-199ng/ml)
% below target (<100ng/ml)
Mean
Bangor 4 25%
Cardiff 98 57%
Rhyl 9 100%
Swansea 46 87%
Wrexham 0 #DIV/0!
All Wales 157 68%
32.5% 31.7%
100.0%
0.0% 0.0%
67.5%
0.0%
68.3%
23 23
0
5
10
15
20
25
30
35
40
1 0 0 40 0 41
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All-Wales
Mea
n T
SA
T %
Patient Numbers
% P
atie
nts
in T
SAT
ran
ge
% in target (>=20%
% below target (<20%)
Mean
Bangor 4 25%
Cardiff 98 0%
Rhyl 9 0%
Swansea 46 87%
Wrexham 0 #DIV/0!
All-Wales 157 26%
66.3%
64.7%
73.2% 63.6%
65.2%
65.4%
10.9 10.8
11.0 11.3 11.4
11.1
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
98 411 138 445 204 1296
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All Wales
Mea
n H
b (
g/d
l)
Patient Numbers
% P
atie
nts
in H
b r
ange
% above target (>12g/dl)
% in target (10-12g/dl)
% below target (<10g/dl)
Mean
Bangor 100 98%
Cardiff 451 91%
Rhyl 138 100%
Swansea 459 97%
Wrexham 205 100%
All Wales 1353 96%
33.3%
26.3%
53.3%
39.0%
60.7%
40.3%
278
210
324
272 281
264
0
50
100
150
200
250
300
350
400
450
500
63 262 137 318 135 915
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All Wales
Mea
n F
erri
tin
ng
/ml
Patient Numbers
% P
atie
nts
in f
erri
tin
ran
ge
% above target (>800ng/ml)
% above target (501-800ng/ml)
% in target (200-500ng/ml)
% below target (100-199ng/ml)
% below target (<100ng/ml)
Mean
Bangor 100 63%
Cardiff 451 58%
Rhyl 138 99%
Swansea 459 69%
Wrexham 205 66%
All Wales 1353 68%
44.0%
13.0%
34.6%
77.8%
0.0%
77.9% 56.0% 87.0% 65.4%
25
0
28
21
30
24
0
5
10
15
20
25
30
35
40
9 0 68 334 100 511
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bangor Cardiff Rhyl Swansea Wrexham All-Wales
Mea
n T
SA
T %
Patient Numbers
% P
atie
nts
in T
SAT
ran
ge
% in target (>=20%
% below target (<20%)
Mean
Bangor 100 9%
Cardiff 451 0%
Rhyl 138 49%
Swansea 459 73%
Wrexham 205 49%
All-Wales 1353 38%
HB, Ferritin & TSAT:
Improvement on All Wales 2012 benchmarks
HB: consistent across Wales
New thinking : from ESA to Iron
10/21/2013 42
43
Share the results of our All-Wales audit of ESA for ACKD
Demonstrate the levels of target achievement in accordance
with current national standards & comparative benchmarks
Consider what we do with these results and how to make
best use of this information
How we go forward from here on an All Wales level
10/21/2013 44
% Pt on IV iron Venofer Cosmofer Monofer Ferinject Rienso
Bangor 14% 14% 7% 0% 79% 0%
Cardiff
Rhyl 31% 5% 0% 0% 95% 0%
Swansea 12% 96% 0% 4% 0% 0%
Wrexham 11% 96% 0% 0% 4% 0%
10/21/2013 45
10/21/2013 46
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CRP <10 CRP 10-39 CRP 40-79 CRP 80-99 CRP 100-199 CRP >200
% p
ati
ents
in
Hb
targ
et r
an
ge
Influeunce of CRP on Hb levels - Unit HD
Unit HD Hb > target
Unit HD Hb in target
Unit HD Hb < target
10/21/2013 47
‘The pessimist sees difficulties in every opportunity.
The optimist sees opportunities in every difficulty’
Winston Churchill
