Risk Group no RF or RF coded <1 year prior to audit start Testing/Monitoring Denominators Practice population aged >18 Numerator 1 Patient not at risk Patients who became at risk within last year QOF CKD code or coded renal disease for > 1 year Renal Group No GFR 1 Renal GroupRisk group Risk - not tested GFR 1 >=60 Risk– no CKD3-5 GFR 1 =60 OR No GFR 2 ) Risk– single low GFR GFR 1 and GFR 2 <60 Risk – CKD3-5 unregistered Renal - not tested + GFR 1 : Most recent eGFR within the last 12 months GFR 2 : eGFR prior to GFR 1 where > 3months have elapsed between tests and is reported after 1/1/ * * * = will also be captured in group 2 ** = will also be captured in group 1 or 3 ** Renal - tested ** Numerator 2 lab ACR,/PCR or dipstick proteinuria code in last 12 months Risk - ACR tested + Renal – ACR tested + - Risk – no ACR Renal – no ACR

No GFR 2 OR GFR 2 >=60 Group 1 Coded CKD Denominator Practice CKD QOF register, age >18 Numerator Coded – no CKD 3-5 based on last GFR GFR 1 >= Coded- single GFR - Coded- CKD3-5 GFR 1 : Most recent eGFR within the last 24 months GFR 2 : eGFR prior to GFR 1 where > 3months have elapsed between tests and is reported after 1/1/2008 Practice CKD QOF register Coded – no GFR past 2 year No GFR 1 + -

GFR 1 =60) Group 2 Uncoded with CKD Denominator Practice population aged >18 Numerator on QOF CKD register Patients with registered CKD 3-5 Uncoded patients Uncoded – single low GFR GFR 1 and GFR 2 <60 Uncoded – CKD GFR 1 : Most recent eGFR within the last 24 months GFR 2 : eGFR prior to GFR 1 where > 3months have elapsed between tests and is reported after 1/1/2008

coded with renal disease code coded as CKD stage 1/ 2 on QOF register or uncoded (group1 and 2) Group 3 Early CKD Denominator Practice population aged > CKD captured elsewhere + Early – CKD coded Early – non CKD coded + Numerators

Data extract practicedate of extraction NHS numberpostcode DOBNHS no. ageCan we identify nursing home residents? sexweight/bmi plus date ethnicitysmoking status plus date risk factors (appendix 1)date of risk factor first QOF CKD codedate of first QOF code most recent QOF CKD codedate of recent QOF code renal disease code (appendix 2)date of renal code CKD 1/2 code (appendix 3)date of CKD 1/2 code proteinuria/dipstick code (appendix 4)date of proteinuria code GFR 1 and GFR 2 (N.B. these values are different in the ‘testing’ algorithm from the ‘group’ algorithm date of GFR 1 and GFR 2 creatinine on same dates most recent ACR or PCRdate of ACR/PCR Data extract for all cases (numerators and denominators)

Risk Factors Risk Factors (RFs): Hypertension Diabetes Gout IHD, congestive cardiac failure, atrial fibrillation Cerebrovascular disease Peripheral arterial disease Kidney stones Prostatic hypertrophy Prescription of lithium last 1 year Prescription of tacrolimus or cyclosporin last 1 year Systemic lupus erythamatosis and connective tissue diorders Agreed Exclusions (as to 29/5/13) family history – inadequate data available to GPs NSAIDs – inadequate coding (non-prescription use, prescription but no use) Haematuria – impossible to interpret Conditions with renal involvement which will be under the care of a hospital specialist: sarcoid amyloid myeloma TB

Renal disease codes [This list needs populating from the meeting 29/5/13] Inclusions (agreed 29/5/13): DM with microalbuminuria Systemic disease coded only where nephritis/renal involvement is specified. Alports, Cystic disease, Fabry’s CKD stage 1/2 codes Proteinuria Codes This is both a code for proteinuria (as a renal condition) and codes for dipstick positive proteinuria (>1+). [Sally to update] 467, 4672 to 4675, 4676 to 4678, 467A, 467E, 467H CKD stage 1 without proteinuria Heamaturia codes

GFR 1 >=30 GFR 1 >=15 Staging Denominator Numerator CKD 3b CKD 4 - Coded- CKD3-5 GFR 1 : Most recent eGFR within the last 24 months Confirmed CKD 3-5 CKD 3a GFR 1 >= Uncoded – CKD3-5 Confirmed CKD3-5 = + CKD 5

Monitoring This has now been incorporated into the testing algorithm (first slide). It therefore excludes patients with low GFR but without a QOF code or a renal disease code. [agreed 6 July]

Blood Pressure Collect: Antihypertensive medication classes Angiotensin Converting Enzyme Angiotensin Receptor Blocker Alpha Blocker Beta Blocker Calcium Channel Blocker Diuretic Aldosterone antagonists Other Antihypertensive Contraindication to ACE/ARB Group 1 Coded- CKD3-5 Group 2 Uncoded – CKD3-5 All CKD = + Denominator Last systolic BP Last diastolic BP Non-proteinuric CKD Proteinuric CKD/DM ACR>=30 (PCR>=50), proteinuria code or diabetes code Group 3 CKD1/2 + <=130 systolic and <=80 diastolic + + BP control BP subopt <=130 systolic and <=80 diastolic + BP control BP subopt - - -

Referral ACR>=70 (PCR>=100) and no diabetes in last 12 months All CKD Denominator Taking 4 antihypertensive classes (see previous) and last BP>140/90 in last 12 months eGFR 1 <30 (GFR 2 – GFR 1 ) >5 and GFR 1 is <45ml/min ACR>=30 (PCR>=50) and heamaturia code in last 12 months Referred or reviewed by nephrology/diabet es specialist in last 24 months Referred Coded genetic kidney disease – see renal disease codes GFR 1 : Most recent eGFR within the last 12 months GFR 2 : eGFR prior to GFR 1 where > 3months but <15months have elapsed between tests

CV risk All CKD No code for IHD, CCF, AF, PVD, cerebrovasc disease CV risk - primary collect: statin prescription contraindication to statin prescription exercise advice/weight loss advice stop smoking advice CV risk assessment e.g Q risk, framingham CV primary assessed CV risk - secondary additionally collect: aspirin prescription contraindication to aspirin prescription – eg GI bleeding/ulcer warfarin/clopidogrel prescription

CKD care plan Can only be ascertained by patient reported outcomes

Immunisation 1 Coded- CKD3-5 Uncoded – CKD3-5 Confirmed CKD3-5 = + Influenza immunisation in last 12 months Flu immunised

Immunisation 2 Coded- CKD4-5 Uncoded – CKD4-5 Confirmed CKD4-5 = + Hepatitis B immunisatio n in last 5 years Hep immunised Hepatitis HsAb in last 5 years Hep unknown Hep immune pos unknown neg yes Hep non-immunised n.b. this will depend on local practice – will need survey results to interpret these data

Immunisation 3 Coded- CKD4-5 Uncoded – CKD4-5 Confirmed CKD4-5 = + Pneumococus immunisation in last 5 years Pneumo immunised yes Pneumo non-immunised

Hb monitoring Coded- CKD3b-5 Uncoded – CKD3b-5 Confirmed CKD3b-5 = + Hb sample sent in last 12 months Hb monitored

BMD Coded- CKD4-5 Uncoded – CKD4-5 Confirmed CKD4-5 = + Bone metabolism (Ca/PO4/PTH/vit D level) checked in last 12 months BMD monitored Collect: Vitamin D preparations (long list) alphacalcidol ergocalciferol calcium tablets + variants sevalemer lanthanum aluminium hydroxide calcium acetate ‘dulwich mixture’/magnesium+calcium

The percentage of people with CKD who are assessed for kidney disease progression and related problems according to their disease stage [*, QS6] Based on eGFR/urine laboratory results/timing. For CKD 3B percentage that had Hb measured. The percentage of people with defined indicators for referral who were referred to secondary care [*, QS2] within 3 months of abnormal results eGFR/urine results and timing, high blood pressure despite 4 antihypertensive drug classes, read-codes for referral and/or renal ultrasound, pop-up box for GPs to fill in if phone or advice from specialistswas given The percentage of people with CKD who are assessed for cardiovascular risk [*, QS4] Management The percentage of people with CKD who have a current agreed care plan [QS3] by 1 year read-code on whether patients were informed about their diagnosis (once available), see 4.3. The percentage of people with CKD who have blood pressures in the NICE recommended target range by 1 year [*, QS5] Includes proportion of patients on renin-angiotensin blocking drugs according to proteinuria status The percentage of people with CKD who are treated with statins according to their cardiovascular risk by 1 year [*] Primary and secondary prevention as per updated NICE lipid guideline (once available) The percentage of people with CKD who had their medication reviewed whilst acutely unwell The percentage of people with CKD who were vaccinated for influenza (NICE TA158) For CKD stages 4 &5 this would also apply to pneumococcal virus and Hepatitis B if seronegative (KDIGO CKD guideline 2013). The percentage of people with CKD 4&5 who have phosphate and haemoglobin measurements on GP laboratory systems. [*] #