1. Making life easier… Dr Michael Gordon GP Gleadless Medical Centre Sheffield michael.gordon@sheffield.ac.uk

2. Making life easier… Dr Michael Gordon Primary Care Lead Yorkshire & The Humber Renal Network

3. Making life easier… Dr Michael Gordon (emisWeb expert…not)

4. Making life easier… A Protocol for ACR interpretation

5. ACR measurement fiddly but important Measure albumin:creatinine ratio on a spot urine sample (preferably early morning) If the initial ACR is >30 and 70mg/mmol a repeat sample need not be tested In people without diabetes, clinically significant proteinuria is present when ACR >30mg/mmol. In people with diabetes microalbuminuria (ACR >2.5mg/ mmol in men and ACR >3.5mg/mmol in women) is clinically significant

6. The Challenges NICE output QOF requirements Remembering everything v knowing where to look Getting excited about niche areas – e.g. CKD Thinking hard when tired – Lab results.

7. Proteinuria predicts progression of CKD RR of progression Urine protein excretion (g/day) Ann Intern Med 2003;139:244-252

8. Proteinuria and CV mortality Muntner P et al JASN 2002;13:745

9. CVD the big killer

10. Traditional solution… The Wall Chart For Brighten the room Info at fingertips Promotes humility Against Clutter Get lost Undermine aura of omniscience Gathering data to check

13. When the ACR is 3 What do you need to know about the patient to make sense of the result? What else do you need to know to care for the patient optimally?

14. Facts (Concepts) Gender Diabetic? CKD already? Latest and previous eGFR Coded for microalbuminuria already Previous ACR readings BP – latest BP – appropriate target ACE/ARB use ACE/ARB allergy

15. emisWeb Protocols Check the facts (concepts) Follow user defined flowchart End in user specified output Applicable in a wide range of clinical situations

16. emis Web protocols – building blocks 1.Concepts – Something asked of the recorded data – e.g. gender, Lastest BP < 140/90, coding present 2.Questions – Posed to the operator – e.g. has the patient got specific symptoms 3.Outputs – Guidance for the operator – e.g. a text box saying repeat in 1 year

17. emisWeb protocols – construction process Pencil, paper rubber Build in emisWeb Whiteboard, post-it notes, peer scrutiny Attach to f12 key to run Engage colleagues to test

18. Mrs A Type 2 Diabetes Latest BP 140/82 Not coded for microalbuminuria/proteinuria No recent consultation with UTI symptoms 2 previous ACRs > 3.5 Allergic to ace/arb Latest ACR - 3.6

19. Mr B Type 2 Diabetes Latest eGFR 65 Latest BP 129/79 No recent symptoms of UTI On Ramipril Previous ACRs two > 2.5 No microalbuminuria coded Latest ACR - 25

20. Mr C Not diabetic Last eGFR 45 CKD stage 3 coded Latest BP 120/78 On Losartan No UTI symptoms Latest ACR - 35

21. Ms D Not diabetic CKD stage 3 coded Last eGFR 50 Latest BP 130/80 No UTI symptoms Latest ACR - 50

22. Acknowledgements NHS Kidney Care – How to Guides – Hosting videos and protocol to download Partners at Gleadless Medical