1. RCH Clinical Chemistry & ASSIST-CKD March 2016, SW SCN Miss Anna Barton Principal Clinical Biochemist, Clinical Chemistry, Royal Cornwall Hospital, Truro

2. ASSIST CKD- Background  The aim is to improve the treatment and outcomes of patients who have chronic kidney disease (CKD)  Looking primarily at the long-term eGFR trend, by looking back up to five years  Also looks for short-term decline too  The project focuses on those patients who have declining kidney function and may ultimately require dialysis or a kidney transplant

3. Late Presentation for RRT

4.  Message on the ACB Mailbase  With information on the ASSIST-CKD project  To cover 12-15 labs and at least 8 Renal Units  England, Wales, Scotland & N. Ireland  Funded for a year Anyone interested? How it started…November 2014

5.  Increased Funding (due to high level of interest)  Now up to March 2018 to sign-on more locations  Greatly increase statistical power & evidence base  Up to 20 main renal units  25 pathology laboratories  Estimated population of 11-12 million people  England, Wales, Scotland & N. Ireland A year later……September 2015

6. 4 Renal Units, 5 Labs  The Royal Cornwall Hospitals NHS Trust (Aug)  Doncaster & Bassetlaw Hospitals NHS Foundation Trust (Oct)  Wirral University Teaching Hospital (Oct)  Countess of Chester Hospital NHS Foundation Trust (Dec)  NHS Lanarkshire & Monklands Hospital, Airdrie (in final set-up phase) Randomisation: July 2015, Group 1

7. IT  Installed the ASSIST-CKD eGFR program  Set up patient history: Uploaded all eGFR results on all adult patients reported in the last five years into the program (GP + in/out-patients)  Set-up weekly automatic download of latest eGFR results from Winpath, which could then be manually uploaded to ASSIST program Setting-Up @ Truro

8. Information for the lab  Laboratory Information Pack  Written Guide to interpreting eGFR graphs  YouTube Guide to interpreting eGFR graphs Competency assessment  Pack including 30 sample graphs & marking sheet Setting-Up @ Truro

9. Information for GPs & KCCG  Factsheets explaining the new project from ASSIST-CKD sent to GPs & KCCG  Lab Med News  Dates of project starting & information on what will happen  Providing updates on the project and later Q&A feedback Setting-Up @ Truro

10. Once a week  Sunday- automated download of all of the previous weeks reported eGFR (GP + in/out-patients) from Winpath into an excel file  New eGFR data manually uploaded into the ASSIST eGFR program by the Biochemist  Then Biochemist performs the patient searches, and reviews & reports on the eGFR graphs as per the ASSIST-CKD protocol  Reports printed sent to GP surgeries What do we do in the laboratory?

11.  Select eGFR reporting dates, GP patients only AND  Search A  Max age 65 years with eGFR max 50 ml/min/1.73m2  Search B  Min age 66 years, max 120 with eGFR max 40 ml/min/1.73m2  A list of patients fitting the criteria is produced ASSIST-CKD program & searches

12. Graphs show all available eGFR results for the last FIVE years, giving a long term view of renal function

13. Who to report? Don’t Report:  Horizontal trend  Rising trend-line  Not fit ‘report’ criteria  Previously marked as reported  No graph produced as only one data point available  Dialysis patients

14. Who to report? Don’t Report:  Horizontal trend  Rising trend-line  Not fit ‘report’ criteria  Previously marked as reported  No graph produced as only one data point available  Dialysis patients

15. Who to report? REPORT:  Decline greater than 5 ml/min/1.73m 2 /year  Decline <5 ml/min/1.73m 2 /year, however, patient will reach a GFR of 10 by the time they reach age 90  Recent drop >10ml/min/1.73m 2 not consistent with previous trend  Change in the trend i.e. initially stable, before taking a downward trend which fits the above rules  Large variation in GFR reported  Previously marked as reported BUT new further steep decline/change in trend

16. Decline greater than 5 ml/min/1.73m 2 /year

17. Decline <5 ml/min/1.73m 2 /year, however, patient will reach a GFR of 10 by the time they reach age 90

18. Change in the trend i.e. initially stable, before taking a downward trend which fits the rules

19. Drop >10ml/min/1.73m 2 in the last few months

21. Program Version 1  First date search 02/08/15 to 09/08/15  Had quite a few IT issues  Took >2 hours to review & report + print  Fed back problems to ASSIST-CKD  Suggested improvements First run performed 10/08/15

22. Version 2, 2016  ASSIST-CKD took all our problems & suggestions on board and created a new version  Median 257 patients listed per week  88 reported (34%) per week  Time to perform patient reviews approx 60 -80 mins  We are far more familiar with the software & reporting  Many patients that are listed are already flagged  Streamlined processes within the lab Version 2 aka ‘the Cornish version’

23.  42% responded  96% liked the graph layout & found it clear  68% found the text information under the graph useful  Due to receiving an ASSIST-CKD graph  52% have consulted the RMS guidelines  50% have contacted the Renal team via email  13% have contacted the Renal team via phone  42% have referred a patient  63% have reviewed a patient earlier than planned  30% have shown a patient a graph & 56% found that useful  32% have altered the way they view long term changes in renal func GP Questionnaire- mini snapshot Sent out Dec 2015 & again in Feb 2016 to non-responders As of 17/03/16

24.  100% would prefer electronic reporting  65% filled in the free text area  “GPs feel the reports highlights the results in a way that stand out from a simple set of numbers”  “Please continue. Is a reassuring back-up to our own monitoring”  “Prompt me to be certain that adequate care being given”  “Reminds you to review patient but generally its already actioned”  “Too late for me as have already dealt with results, but other drs may not do the same and so it's a good prompt”  “We review previous eGFR scores when filing results, so usually aware of patient before report arrive”  “Not helpful as out of date by the time we receive them, and just another piece of paper for us to process”  “None of the 3 GPs partners found the graphs helpful. We are already are monitoring and referring our CKD3 patients very well” GP Questionnaire- mini snapshot Sent out Dec 2015 & again in Feb 2016 to non-responders

25. Other  Biochem + Renal on Pirate2 Radio about ASSIST-CKD & CKD  Spoken at National & Local ASSIST-CKD events

26.  ASSIST-CKD funding finishes end of July  We are placing a business case to the KCCG  Cover population approx. 470,000  RCHT Lab costs £4k/yr  RCHT IT costs £3k/yr  ASSIST-CKD Software costs £650/yr  Total £7,650 a year  But one years dialysis per patient is £25k + ancillary costs too Future

27. Thank you