Chronic Kidney Disease Prevention and Control Current Situation and Prospect

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1 Chronic Kidney Disease Prevention and Control Current Situation and Prospect Adult and Elderly Health Division Bureau of Health Promotion, Department of Health, Executive Yuan

2 Analysis of Current Situation 2004 USRDS Data According to the dialysis registration system of the Taiwan Society of Nephrology, Taiwan s incidence rate of end stage renal disease (ESRD) in 2002 ranked number one in the world, ranking second in prevalence just after Japan. BNHI Statistics The nation s 40,000 ESRD patients make up 0.17% of the total number of insured in national health insurance (NHI), taking up more than 7% insurance costs, with dialysis costs in 2002 reaching as high as 24.5 billion dollars Database of Surveys on Three-Highs According to a calculation based on the MDRD formula: The nation s prevalence of chronic kidney disease (CKD) Stage III-V amongst those age 15 and over is as high as 6.43%.

3 Why do we have high prevalence of ESRD in Taiwan? Problem of aging population: Impact of NHI implementation in Taiwan: Change in the form of diseases and increase in chronic diseases: The public s lack of accurate knowledge and healthy behaviors towards kidney health maintenance: Unknown medications being widely accessible and medication misuse and abuse could all affect the health of people s kidneys:

4 CKD Prevention and Treatment Schemes Currently at Work Kidney Health Promotion Institutions Set up kidney health promotion institutions and quality supervision and control program (17 institutions) Case Management 1. Base-level Kidney Disease Case Management Trial Scheme (Kaohsiung City) 2. CKD Case Management Integration System Education, Training and Making of Teaching Materials Health Education Promotion 1. Kidney health maintenance, kidney disease care learning and teaching manuals 2. Community-based kidney disease healthcare promotion program 3. Prevention & Control Manual Kidney Health Month Activities (broadcasting plays, fairs), World Kidney Day

5 Summary of Promotional Works Conducted by the Kidney Health Promotion Institutions 2003 CKD prevention and control Pioneering Project 5 Kidney Health Promotion Institutions: Case Management 2004 Kidney Health Promotion Institution Setup Project 2005 Kidney Health Promotion Institution Setup & Guidance Project 2006 Kidney Health Promotion Institution Operation & Guidance Project 12 Kidney Health Promotion Institutions: Case Management, Health Education Promotion, Consultation and Referral 19 Kidney Health Promotion Institutions: Case Management, Health Education Promotion, Consultation and Referral, Interdisciplinary Integration 17 Kidney Health Promotion Institutions: Case Management, High Risk Group Screening, Consultation and Referral, Interdisciplinary Integration, Care Network

6 17 Kidney Health Promotion Institutions in 2006 Chang-Gung Memorial Hospital Linkou Branch Taipei Hospital, Department of Health Machay Memorial Hospital National Taiwan University Hospital Taipei Veterans General Hospital Taichung Veterans General Hospital Tung s Taichung MetroHarbor Hospital Sha Lu Branch Chunghua Christian Hospital China Medical University Hospital Cathay General Hospital Mennonite Christian Hospital National Taiwan University Hospital Yun-Lin Branch Chang-Gung Memorial Hospital Chiayi Branch Cheng Kung University Hospital Kaohsiung Veterans General Hospital Kaohsiung Medical University Hospital Kaohsiung Municipal Hsiao- Kang Hospital

7 Stage-by-stage Integrated Care Program for CKD Patients Draw up different treatment and care objectives in different phases and stages. Formulate different treatment and care strategies in different phases and stages. Administer different treatment and care methods in different phases and stages.

8 Stage-by-stage Integrated Care Program for CKD Patients ESRD Pre-ESRD Chronic Renal Failure (CRF) Quality medical treatment Return to society on one s autonomy Undergo dialysis treatment with thorough preparation and appropriate timing Delay progressing of kidney function Non-symptomatic and Normal Kidney Functioning Identify potential group with disease and proactively involve in their treatment

9 Formulae for Calculating the Stage of CKD (140-Age) Bwt 1.73 CC-GFR = 0.85 (if female) 72 Cr BSA BSA (Body Surface Area) = height (cm) weight (Kg) MDRD-GFR = 170 Scr Age (if female) (if black patient) SBUN A1b MDRD-S-GFR = 186 Scr Age (if female) (if black patient)

10 CKD Health Education Instruction Contents(1) Stage1: (Follow-up every half a year) Stage2: (Follow-up every half a year) Stage3: (Follow-up every 3 months) Normal kidney function, abnormal urine (minute proteinuria ) GFR:>90 ml/min 1. Renal biopsy and pathological examination; 2. Treating idiopathic renal disease; 3. Observing the drug therapy plan; 4. Good control of blood pressure; 5. Importance of regular clinical follow-up. Mild chronic renal failure (CRF) GFR:60-89ml/min 1. Controlling blood pressure, lipids; reinforcing limits on smoking; encouraging exercise; 2. Appropriate diet adjustment and health education: Diets low in protein, potassium phosphate and oil; 3. Imparting correct perception of medical treatment; 4. Educating on the importance of regular clinical follow-up; 5. Discussing long-term treatment plan; 6. Preventing CRF complications; Moderate chronic renal failure (CRF) GFR:30-59ml/min 1. Preventing infection of related diseases; 2. Control and treatment by drugs; 3. Anemia care; 4. Reinforcing diet instructions (low protein and potassium phosphate; 5. Psychological construction for dialysis therapy in the future; 6. Preventing CRF complications; 7. Understanding timing of dialysis initiation; 8. Introducing renal replacement therapy.

11 CKD Health Education Instruction Contents(2) Stage4: (Follow-up every 3 months) Stage5: (Follow-up every 2-4 weeks) Advanced Pre-end Renal Disease GFR:15-29ml/min End Stage Renal Disease GFR:<15 ml/min 1. Anemia care; 2. Preventing CRF complications; 3. Continuing to understand the timing of dialysis and dialysis therapy; 4. Creating an arteriovenous fistula, peritoneal dialysis tube, or preparing for kidney transplant; 5. Dietary instructions; 6. Seizing the critical moment for treatment; Sharing experiences with patient support groups. 1. Dietary instructions; 2. Emergency treatment during the golden period; 3. Initiating dialysis therapy or kidney transplant; 4. Introducing various welfare measures; 5. Importance of psychological rehabilitation, returning to social life and normal work routines.

12 Procedures of CKD Case Acceptance Nephrologist Clinical Follow-up Stage I, II: Every 6 months Stage III, Stage IV: Every 3 months Stage V: Every 1-2 weeks or 1 month Reevaluating patients physiological and biochemical blood tests Outpatient acceptance Inpatient acceptance Evaluating patients physiological and biochemical blood tests Dietician Dietary instructions Designing dietary plans tailored to the individual CKD Health Education Nursing Staff Establish patients basic records Evaluate patients physiology Execute CKD comprehensive care

13 Team Work in Kidney Health Promotion Institutions General Practitioner Cardiologist Endocrinologist Orthopedist Kidney Transplantation Surgeon CKD Patient Peritoneal Dialysis Room Blood Purification Center Nephrologist Renal Health Dietician Pharmacist Social Worker

14 Implementation Results (up until Nov 30, 2005) 67.7% of patients are already using EPO to treat anemia conditions. 28.4% of patients underwent dialysis as outpatients, not through hospitalization. 46.5% of patients initiating dialysis did not use temporary catheter. CKD acceptance of all stages amounts to 6,733 people. The proportion of people in Stage 1-5 is respectively 6.40%, 9.25%, 32.07%, 27.36%,and 24.64%. 665 patients underwent dialysis therapy in 2005, amongst which 20.6% chose CAPD. 57.1% of the 508 patients who chose hemodialysis already had vascular access placement.

15 Research Evidence of the Effectiveness of Integrated CKD Care Program on the Treatment of Incident Hemodialysis Patients (Wei, 2006) Research Background: To evaluate the effectiveness of the Integrated CKD Care Program since its implementation in Research Aim: To explore in patients who did and did not accept intervention of integrated care: 1. Their distribution and difference in demographic features, primary diseases, other systemic diseases (complications); 2. Their condition and difference in the clinical results, quality, and depletion of the incident hemodialysis therapy; 3. Possible risk factors affecting the medical costs in the six months prior to and up including the day of dialysis initiation, and thus their prediction. Research Method: Incident hemodialysis patients of three hospitals in Kaohsiung City are the subjects of this research. Research data is based on relevant costs on the first day of and during the six months prior to dialysis, and information from various research variables. Data is collected from patients medical records, Dialysis Patient s File, and Outpatient Prescription and Treatment Specifications File, Inpatient Medical Claims File, and Physician Order File, where the last three are applicable to the Bureau of National Health Insurance. Quasi-experimental Group: 77 patients subject to the intervention program. Control Group: 117 patients not subject to the intervention program.

16 Research Results - Distribution of demographic features, primary diseases, types of complications has not yet revealed significant statistical variation. Clinical Results Hematocrit vs 22.78% p=0.018, and Albumin 3.28 vs 3.11 mg/dlp=0.032 revealed significant statistical variation, whilst other items have not revealed such variation. Results of Quality Grades 44 (59.46%) first graders (with arteriovenous fistula placement, matured usage, and undergoing initial dialysis as outpatients) of those who accepted the intervention exhibited significant variation of p<0.001 against 99 second to fourth graders (84.9%) of those who did not accept the intervention.

17 Implementation Results -Medical Costs Six Months before Dialysis Average outpatient and emergency cost per capita per month vs dollars, p=0.001; Total costs during the six months before dialysis per capita vs dollars, p=0.012; Average outpatient visits per capita per month: 1.58 vs visits; Total outpatient visits during the six months before dialysis per capita: 9.47 vs. 4.99, p<0.001; Initial Dialysis Total costs of initial dialysis (excluding cost of dialysis) vs dollars, p<0.001; Days of hospitalization for initial dialysis: 6.58 vs days, p<0.001; Total Medical Costs Total medical costs from during the six months before dialysis to initiation of dialysis (excluding cost of dialysis): vs dollars, p=0.006.

18 Current Status of Works on CKD Prevention and Control Kidney Health Promotion Institutions Set up kidney health promotion institutions Education and Training and Making of Teaching Materials Case Management Health Education Promotion 1. Publish learning and teaching manuals for kidney health maintenance and kidney disease care. 2. Community-based kidney disease care promotion program (seeded teachers workshop) 3. CKD Prevention & Control Manual 1. Base-level Kidney Disease Case Management Trail Scheme (Kaohsiung City) 2.CKD Case Management integration System Kidney Health Month Activities, Broadcasting plays

19 2005 National Health Survey Knowledge, attitude and action regarding kidney health maintenance in people aged 15 and over 3.8% prevalence in those whose kidney disease was confirmed by medical staff; The number of elderly aged 65 and over with a kidney disease (8.32%) is five times that of people aged (1.78%). Ratio of males to females is 1.2. Relationship between kidney disease and other diseases Higher risk of developing renal complications in those who suffer from high blood pressure, hyperlipidemia, coronary disease and hyperglycemia than those who do not. Do patients with kidney disease change related behaviors? Maintain blood pressure(49.3%), Maintain blood sugar(37.9%), Maintain cholesterol (44.8%), Low protein diets (32.7%), Low salt intake( 56.5%), etc. Compile the CKD Prevention & Control Manual 1. To provide a reference for the country s healthcare medical staff engaging in kidney disease prevention and care so as to establish uniformed service benchmarks; 2. To lead the public s understanding of kidney disease and promote their ability of kidney disease self-care.

20 Current Status of Works on CKD Prevention and Control Kidney Health Promotion Institutions Set up kidney health promotion institutions Education and Training and Making of Teaching Materials Case Management Health Education Promotion 1. Publish learning and teaching manuals for kidney health maintenance and kidney disease care. 2. Community-based kidney disease care promotion program (seeded teachers workshop) 3. Prevention & Control Manual 1. Base-level kidney disease case management trail scheme (Kaohsiung City) 2. CKD case management integration system Month of Kidney Health Activities, Broadcast plays

21 Base-level Kidney Disease Case Management Project Objectives Elderly Health Examination Adult Health Examination Community-based screening Integrate screening methods Public Health Centers Borough Warden s Offices Community Health-building Centers Kidney Health Promotion Institutions Establish an operational mechanism platform for base-level kidney health Education and training, Promotional Activities Provide correct knowledge on CKD to medical care workers and residents in the communities

22 Base-level Kidney Health Promotion Institutions Organization Structure Kaohsiung City Public Health Bureau Siao-Gang 1st & 2nd Health Centers Public Health Center of Sanmin District Community Health- Building Centers Kaohsiung MunicipleHsi ao-kang Hospital Kidney Health Promotion Institution Kaohsiung Medical University Hospital

23 Management Procedure for Base-level Kidney Disease Cases GFR(ml/min per 1.73m 2 ) Kidney Health Promotion Institutions, Other Medical Institutions Elderly Health Examination Adult Health Examination Community-based screening Public Health Centers Case Acceptance and Management GFR>60 Hyperglycemia Hypertension Case Closure 1.Moving elsewhere 2.Death

24 Future Directions Promote medical personnel s abilities of care of disease prevention and control Strengthen CKD patients self-care abilities Strengthen identification of CKD patients in current screening platforms Integrate resources to provide support systems

25 Thank you Feedback welcome