1. Expert Systems in Renal Disease Kent Renal ServiceUniversity of KentSalford Hospital Chris Farmer Bernhard Klebe Jean IrvingDonal O’Donoghue Paul StevensRoger CooleyRachel Middleton Helen Hobbs

3. Referral Variance SD +2.0 0.0 -2.0 Referral variance Corrected for age, gender, ethnicity and population Extremal Quotient 52.72 Farmer C, Hobbs H, Klebe B, Stevens P

4. Referral Rates 2003-2006 2003200420052006

5. Proportion of Referrals Seen 20052006 Percentage

6. Outpatient Activity 623 forms assessed 623 forms assessed 53.2% Male 53.2% Male Median Age 59 (16-93) Median Age 59 (16-93) Median SCr 124  mol/L (35-832) Median SCr 124  mol/L (35-832) Median calculated GFR 50.4 (4.7>90) ml/min Median calculated GFR 50.4 (4.7>90) ml/min John RI, Farmer CK, Abbs I, Stevens PE

7. Intervention in the Last Year * * Denotes number of biopsies performed ever

8. Possible to identify patients who could be discharged based on: Possible to identify patients who could be discharged based on: Stable Chronic Kidney Disease Blood Pressure under 140/85 No alteration in treatment in the past year 29.8% of patients followed up

9. Possible to identify patients who could be discharged based on: Possible to identify patients who could be discharged based on: Stable Chronic Kidney Disease Blood Pressure under 140/85 No alteration in treatment in the past year 29.8% of patients followed up Provided there is a robust follow up arrangement

10. UK Referral Guidelines NEOERICA Per Million Action Stage 3 204712626 Other Tests Stable 18111 Refer Hb<11 27167 Refer BP >130/90 On 3 agents 2401480 Refer GFR falling Stage 4 45278 Another test then refer 960Refer Stage 5 536Refer

11. UK Referral Guidelines NEOERICA Per Million Action Stage 3 204712626 Other Tests Stable 18111 Refer Hb<11 27167 Refer BP >130/90 On 3 agents 2401480 Refer GFR falling Stage 4 45278 Another test then refer 960Refer Stage 5 536Refer 2558

12. Referral Rates 2003-2006 2003200420052006

13. Referral Rates 2003-2006 2003200420052006

15. ARF Stage 5 Stage 4 Unstable 3 Immunosuppressed Stage 4 (stable) Hypertension Stable Stage 3 Stage 1 or 2 At Risk Populations Intensive Management Hospital Based Care Community based care Increasing Level Of Care Needed Structured delivery of care

16. Expert System in Kidney Disease Identify patients requiring intensive management Identify patients requiring intensive management Facilitate robust follow up of patients discharged from hospital based care Facilitate robust follow up of patients discharged from hospital based care Provide patient specific guidance for further investigations of patients with CKD Provide patient specific guidance for further investigations of patients with CKD Manage stable chronic kidney disease in the community Manage stable chronic kidney disease in the community

17. General Practice Database Systems Data Extraction MIQUEST Database Reporting Tool Complete Database Study Data Patient Reports Decision Support Expert System

18. General Practice Database Systems Data Extraction MIQUEST Database Reporting Tool Complete Database Study Data Patient Reports Decision Support Expert System

20. General Practice Database Systems Data Extraction MIQUEST Database Reporting Tool Complete Database Study Data Patient Reports Decision Support Expert System

23. General Practice Database Systems Data Extraction MIQUEST Database Reporting Tool Complete Database Study Data Patient Reports Decision Support Expert System

24. Patient id varchar (20) pracid int sex varchar(6) dob date gp varchar(8) regDate date Creatinine id varchar (20) date date value int pracid int ReportedGfr id varchar (20) date date value float pracid int Bp id varchar (20) date date systolic int diastolic int pracid int Calcium id varchar (20) date date value float pracid int Hb id varchar (20) date date value float pracid int Phosphate id varchar (20) date date value float pracid int Potassium id varchar (20) date date value float pracid int Pth id varchar (20) date date value int pracid int Known id varchar (20) code varchar(30) date date pracid int Tables are linked by id and pracid to patient table. Tables created by SetupDatabase and filled by MiqReader. Result id varchar (20) date date stage int exitno int pracid int FurtherAction id varchar (20) date date actionid int pracid int done boolean Recommendations exitNo int recommendation varchar(500) Actions actionid int action varchar(30) Practice pracid int name varchar(30) KnownRubric code varchar(30) rubric varchar(30) Treatment id varchar (20) code varchar(30) date date pracid int type int Drug code varchar(30) rubric varchar(200) Category type int category varchar(30) Population pracid int population int date date Gfr id varchar (20) date date value float pracid int (may decide not to keep this – recalculable) Diabetic id varchar (20) code varchar(30) date date pracid int DiabeticRubric code varchar(30) rubric varchar(30) Glucose id varchar (20) date date value int pracid int HbA1c id varchar (20) date date value int pracid int Cholesterol id varchar (20) Code date date value int pracid int Proteinuria id varchar (20) Code date date value int pracid int Triglyceride id varchar (20) date date value int pracid int PCR id varchar (20) date date value int pracid int Proteinuria id varchar (20) Code date date value int pracid int GPDecision id varchar (20) date date pracid int decisionCode int Decisions decisionCode int rubric varchar(30) B12 id varchar (20) Code date date value int pracid int Referral id varchar (20) code varchar(30) date date referralType int pracid int Initially to indicate clinic attendance

25. General Practice Database Systems Data Extraction MIQUEST Database Reporting Tool Complete Database Study Data Patient Reports Decision Support Expert System

29. Development Recruitment of GP Surgeries Recruitment of GP Surgeries 8 Practices 8 Practices 100,000 people registered with their GP 100,000 people registered with their GP Development of decision support tool and secondary checking of outputs Development of decision support tool and secondary checking of outputs Development of “expert” areas such as rate of decline of renal function Development of “expert” areas such as rate of decline of renal function Implementation and checking in a second UK region Implementation and checking in a second UK region Cluster randomised controlled trial Cluster randomised controlled trial