Optimal ESRD Starts: Moving Upstream Chronic Kidney Disease to Prevent or Delay End-Stage Renal Disease with Predictive Analytics

Abstracts from the Kaiser Permanente2018 National Quality Conference


Sophie Taylor, RN; Alvina Sundang; Leonid Pravoverov, MD;
Karen Ching, MD


From Colorado, Georgia, Hawaii, Mid-Atlantic States, Northern California, Northwest, Southern California, Washington, Program Offices, The Permanente Federation

Background: An Optimal End-Stage Renal Disease (ESRD) Start is defined as starting dialysis with a mature access such as arteriovenous fistula or graft, peritoneal dialysis catheter, or kidney transplant. Interventions in the earlier phases of chronic kidney disease (CKD) is the next frontier in quality management of this population. A methodology for screening patients for proteinuria and accurately staging their CKD has been developed by members of the Nephrology Inter-Regional Clinical Practice Group and Federation Analytics staff. Findings show that 32% of eligible patients were not screened for proteinuria or albuminuria, and 87% of eligible patients have ACE inhibitor (ACEI) or angiotensin II receptor blockers (ARBs) ordered.
Methods: Members with progressive CKD stages 1-5 reaching ESRD. CKD stages defined using Kidney Disease Improving Global Outcomes Staging (stages glomerular filtration rate into nine groups and divides proteinuria stages into seven groups). CKD stages are assigned by requiring 2 outpatient serum creatinine tests > 90 days apart used to estimate glomerular filtration rate according to the CKD-epidemiology equation. To determine members’ final CKD stage, a forward-looking algorithm is run until the algorithm reaches the most recent eGFR. Then, all Kaiser Permanente (KP) members are grouped using a standardized method across KP into distinct CKD groups, and this data becomes the foundation for tracking 2 metrics: Proteinuria Screening in CKD1-4 members and ACEI/ARB Treatment in hypertensive CKD1-4 members. The outcome measure will be to evaluate ESRD incidence over time.
Results: Of the 223,627 patients who met the criteria for screening of albuminuria/proteinuria, 32.38% did not receive screening. Of those meeting criteria for ACEI/ARB, 87.40% have ACEI or ARBs prescribed. Regional results for screening of albuminuria/proteinuria vary from 14% to 65%, and for ACEI or ARBs prescribed vary from 78% to 88%. Across the program, the estimated number of patients currently requiring albuminuria/proteinuria testing is approximately 72,000. The maximum for ACEI/ARB treatment is unknown but barring uncontrollable hyperkalemia, most nonallergic patients should be able to take one or the other. We believe 95% is attainable, and KP is currently at 87% nationally. Thus, there are about 4200 candidates for therapy.
Discussion: As the work on Optimal ESRD Starts continues, validation of the North-West Prediction Model in three Regions (Georgia, Northern California, and Hawaii) determined that the model performs very well. Further stratification of proteinuria screening-eligible candidates is needed to identify the most urgent patients at risk and to address this cohort first. Next steps include establishing workflows to screen, stage, and manage CKD patients in each Region.

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