Variability in testing exposing high risk patients to chronic kidney disease, national clinical audit finds

Published: 16 Jan 2017

Report calls for uniformity in testing and improved coding of patients, with blood pressure management, cholesterol treatment and vaccination use among recommendations

View full report, summary version and infographics

The national Chronic Kidney Disease (CKD) Audit, the first of its kind, has reported wide variations in diagnostic testing among patients at high risk of developing CKD, such as people with diabetes and heart disease.

CKD is a long-term irreversible deterioration in the function of the kidneys often found in people who also have diabetes and high blood pressure. It affects approximately 1 in 20 adults and is more common in the elderly. It can contribute to an increase in cardiovascular disease and acute kidney injury and while only a small number of cases progress to requirement for dialysis or a kidney transplant, the condition can be difficult for patients and families, and costly for the health economy.

CKD is often without symptoms until the very advanced stages and is only picked up by performing tests on blood and urine. The management of CKD is based on identifying patients at high risk, regular monitoring of their kidney function, avoidance of treatments that may further damage their kidneys and taking appropriate steps to protect their general health. This process of managing and safe prescribing for those with CKD is helped by GPs entering an appropriate diagnostic code for CKD onto the patient record. This audit was designed to help GPs improve coding and achieve these four goals.

The key findings of the audit were:

1.  NICE recommends both blood and urine tests are required for the appropriate risk management of CKD. While neither test is yet universally undertaken, the use of urine tests are underused.

2.  There remain a significant cohort of patients who have biochemical evidence of CKD but are not coded, and a smaller number of people coded with CKD when there is no biochemical evidence.

3.  For people with CKD, adherence to the NICE Guidance recommendations for management of their health; through blood pressure management, prescribing cholesterol lowering treatments and appropriate vaccinations; could be improved.

The report includes snapshot data from 911 practices in England and Wales collected in two phases, September 2014-February 2015 and March 2015-July 2016. The audit was commissioned by the Healthcare Quality Improvement Partnership (HQIP), as part of the National Clinical Audit Programme (NCA)*, and was carried out by Informatica systems in collaboration with London School of Hygiene and Tropical Medicine, University College London and Queen Mary (University of London).

Former National Clinical Director and Clinical Co-chair, Internal Medicine Programme of Care’ Dr Richard Fluck commented:

“Chronic kidney disease is important and whilst we have made significant progress in diagnosis and treatment over the last decade there is still unmet need in care.Historically, CKD was often not diagnosed in a timely way, reducing options to slow disease progression and prepare people for the possibility of kidney failure. This occurred in about 1 in 3 people starting dialysis over a decade ago and is now less than 1 in 5. That improvement is down principally to the skills of primary care in understanding the need to detect and manage CKD. However, we need to support GPs and their teams to continue that improvement, reducing avoidable variation in care in line with these findings. This first audit report – and its follow-up analysis – is a powerful tool in providing that support.”

Fiona Loud, Policy Director at the British Kidney Patient Association said

“There are some really important findings from this audit – the huge variation in identifying risk of kidney disease in those with diabetes and the even greater variation in checking for CKD in those with high blood pressure. This is despite the fact that diabetes and high blood pressure are the commonest causes of kidney disease. As patients we need primary care and rely on our doctors to look out for us; we hope that the audit will give further weight and encourage general practice to increase urine tests for those at risk.”

Summary of what the clinical audit asked

This report compared GP practice results in England and Wales against NICE quality standards, asking: Are people with risk factors being tested for CKD? Are people with CKD being correctly identified and given an appropriate code? And for people with CKD, are blood pressure targets being met, appropriate risk management being initiated, annual CKD reviews being performed and appropriate immunisations being given?

Summary of recommendations and results

Recommendation 1: For people at high risk of CKD, GPs should review practice to ensure they include both blood tests for estimated glomerular filtration rate (eGFR) and urinary testing for albumin to creatinine ratio (ACR).

Relevant audit findings:

  • On average GPs test 86% of people with diabetes for CKD (using annual blood tests), but only 54% have the relevant annual urine tests.
  • For other groups (such as those with hypertension), ACR rates are below 30%.
  • Whilst over 80% of those with CKD had had an eGFR test in the previous year, only 31% had a repeat ACR test.
  • For people without diabetes, where checking urine for albuminuria is not currently part of the Quality and Outcomes Framework Indicators, ACR testing rates are less than 15%

Recommendation 2: GPs should review practice to improve coding of patients with CKD

Relevant audit findings:

  • 70% of biochemically confirmed cases of CKD were given an appropriate Read code.
  • There is high variability in the accuracy of coding. The proportion of CKD cases that were uncoded ranged between 0% to 80%.
  • 11% of people given a CKD stage 3-5 Read code had biochemical evidence that they did not have CKD stage 3-5.
  • Computerised quality improvement tools, such as those used in this programme, can be used to improve CKD identification and to assist GPs with appropriate coding, which in turn supports improvements in management.

Recommendation 3: Having identified patients with CKD, efforts should be focused on regular reviews, management of high blood pressure, prescribing cholesterol lowering treatments, and performing vaccinations to improve health outcomes.

Relevant audit findings:

  • Over 80% of people with CKD had had an eGFR test in the previous year, but only 31% had a repeat ACR test. For people without diabetes, annual ACR testing rates are less than 15%.
  • Among groups with the highest risk of developing progressive CKD (i.e. those people with diabetes or an ACR >70mg/mmol) 70% had BP values above the recommended target range. Achievement of optimal blood pressure varied widely between practices.
  •  69% of people with identified CKD were prescribed statin medication in accordance with NICE guidelines. The lowest rates (40%) were among younger people without diabetes, a group that may have the most to gain from an informed offer of statin therapy for Cardiovascular Disease prevention.
  •  Whilst 75% of people with identified CKD had a flu vaccination in accordance with NICE Guidance only 23% of people with CKD stages 4 and 5 had the recommended pneumococcus vaccination.

Linking Secondary Care Data

The National CKD Audit is now working on linking the data to secondary care records and will provide part 2 of the report in Autumn 2017 analysing the outcomes for the patients with CKD.