1. Remote Monitoring of Chronic Kidney Disease – Sheffield Experience Dr Arif Khwaja + Sister Sue Siddall Sheffield Kidney Institute

2. Talk Outline Background and local epidemiology Overview of design of service Clinical and environmental outcomes

3. Death – the key outcome in CKD 27,998 CKD patients – outcomes at 66 months Keith DS et al. Arch Intern Med. 2004;164:659-663 % patients

4. O'Hare, A. M. et al. J Am Soc Nephrol 2007;18 :2758-2765 Impact of age on outcomes in CKD 210,000 veterans 3.5 year follow up

7. Rationale for remote monitoring for CKD Management of CKD predominantly data driven – BP, laboratory results, medication, urinalysis In many cases telephone consultation could be adequate for assessment Strong drive from patients for ‘care closer to home’

8. Talk Outline Background and local epidemiology Overview of design of service Clinical and environmental outcomes

9. Chronic Kidney Disease – Disease Management Program (CKD-DMP) Aim: Identify and manage patients with CKD 3/4/5 who would be suitable for community care management. Focus on patients who would otherwise be managed in secondary care but unlikely to need renal replacement in 12 months

10. CKD-DMP - Process Patients identified using renal database based on stability of renal function and complexity of interventions. Secondary care generated care plan: specifying frequency of lab and BP monitoring and thresholds for action to be sent to primary care

11. CKD-DMP - Process CKD-Nurse Specialist to liase with practice/community nurses to ensure DMP implementation BP – monitored by patient or at surgery at intervals specified Blood results reviewed remotely by CKD nurse specialist CKD nurse specialist tele-consults with patient. Replaces the normal clinic visit

12. CKD-DMP – IT issues Results automatically downloaded onto Renal IT system (PROTON) Blood Pressure data – to be manually entered onto PROTON Medication changes – require liaison between CKD nurse specialist and practice nurse

13. CKD-DMP – Key people Patient CKD- Nurse Specialist Consultant Nephrologist Link Practice Nurse GPs

14. Where did we start from? The pilot commenced in the beginning of November 2011 in collaboration with Sheffield Central Consortium of GP practices Patients identified both within Sheffield Kidney Institute and also took direct referrals from GPs 77 CKD patients are on remote monitoring service

15. Overview of design of service Background and local epidemiology Overview of design of service Clinical and environmental outcomes

19. Environmental impact – on frequency of OPD attendance

20. Environmental impact – mode of transport for CKD monitoring Before Remote Monitoring Median distance travelled: 4 miles After Remote Monitoring Median distance travelled: 0.7 miles

21. Environmental impact – mode of transport for CKD monitoring

22. Environmental impact – frequency of clinical review Estimate 143 outpatient appointments avoided since pilot began Frequency of review% original forecast% of patients - actual 1 month5%2.6% 2 month5%6.4% 3 month50%25.6% 4 month25%23.1% 6 month10%37.2% Annually5%5.1%

23. Patient satisfaction data

24. Summary Remote chronic management of advanced CKD is: Deliverable Improves patient experience Is clinically safe in selected patients Likely to have positive environmental impact through reduced travelling Allows more appropriate use of primary and secondary care resource Maybe financially viable!

25. Any Questions??