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PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
MultiMulti--Tasking GFR Results for Tasking GFR Results for CKD Detection: Tracking, CKD Detection: Tracking, Treatment and Patient SelfTreatment and Patient Self--
ManagementManagement
The Medicare Quality Improvement Organization for Florida
ManagementManagement
Laura GambaChronic Kidney Disease Project Director, FMQAI
Gwendolyn A. WilliamsChronic Kidney Disease Project Coordinator, FMQAI
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
ObjectivesObjectives
• Provide a brief overview of United States Renal
Data System (USRDS) 2008 Annual Data
Report (Precis and Chapters 3 & 4) highlighting
CKD’s prevalence, co-morbidities, cost and
The Medicare Quality Improvement Organization for Florida
CKD’s prevalence, co-morbidities, cost and
transition to end stage renal disease (ESRD)
• Discuss claims data diagnosis codes versus lab
values data for CKD detection (USRDS 2008,
Chapter 3, pp 38 and 43)
2
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
ObjectivesObjectives
• Explore a simple system change within the
physician practice setting with potential to
prevent progression from CKD to ESRD
through:
The Medicare Quality Improvement Organization for Florida
through:
– Detailing of Kidney Disease Outcomes Quality
Initiatives (KDOQI) Guideline #4/Estimation of
Glomerular Filtration (eGFR)for CKD
detection/diagnosis
3
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
ObjectivesObjectives
– Transforming eGFR lab values into actual GFR
at the time vital signs are assessed
– Transitioning GFR from numeric calculations
onto multi-functional tools for patient
tracking/trending tool, patient education and
The Medicare Quality Improvement Organization for Florida
tracking/trending tool, patient education and
patient self-management during the office visit
4
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
CKD ProjectCKD Project
• Detect the incidence and decrease the
progression of CKD
• Improve care among Medicare beneficiaries
through provider adoption of timely and
The Medicare Quality Improvement Organization for Florida
through provider adoption of timely and
effective quality of care interventions and
beneficiary education
• Key collaborations for system change at the
state and local level
5
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
Why?Why?
Medicare Savings to
The Medicare Quality Improvement Organization for Florida 6
Improve Quality of Care for Medicare
Beneficiaries through CKD
Project
Cost to Medicare of managing
CKD is high.
Medicare beneficiaries with CKD account for
16.5% of costs in the year the
disease is identified.
Savings to Medicare for each patient
who does not progress to dialysis is
estimated at $250,000.
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney PatientsExpenditures for CKD, by datasetFigure 5.2 (Volume 1)
The Medicare Quality Improvement Organization for Florida 7
Medicare: period prevalent general Medicare patients age 65 & older, with Medicare as primary payor, & not enrolled
in Medicare Advantage. Medstat: period prevalent patients age 50–64, enrolled in a fee-for-service plan. CHF, diabetes,
& CKD determined from claims.
USRDS 2008 ADR
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney PatientsAnnualized predicted costs for Medicare CKD
patients (2007 CMS-HCC model), 2006Figure 5.11 (Volume 1)
The Medicare Quality Improvement Organization for Florida 8USRDS 2008 ADR
Prevalent general Medicare patients, not enrolled in an HMO, without ESRD, & surviving in 2005. Medicare payments
in 2006 include inpatient, skilled nursing, home health, outpatient, physician/supplier, & durable medical equipment.
Diagnosis groups based on M+C risk adjustment model (see www.cms.gov). Actual PPPM cost not weighted by follow
up time. Definitions for CKD, diabetes, & CHF are based on the CMS-HCC model, i.e., defined if there is any diagnosis
code. HCC: hierarchical condition category.
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
CKD stages as defined by old & new CKD stages as defined by old & new
ICDICD--99--CM codes: MedicareCM codes: MedicareFigure 2.2 (Volume 1)Figure 2.2 (Volume 1)
The Medicare Quality Improvement Organization for Florida 99USRDS 2008 ADR
Point prevalent general Medicare patients age 65 & older, surviving all of
2006 with Medicare as primary payor & not enrolled in an HMO. ESRD
patients excluded. CKD & other comorbidities defined by diagnosis codes in
2006. In USRDS analyses, patients with ICD-9-CM code 585.6 are considered
to have code 585.5; see Appendix A for details.
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
The Medicare Quality Improvement Organization for Florida 10
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
The Medicare Quality Improvement Organization for Florida 11
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney PatientsLikelihood of death vs. ESRD Likelihood of death vs. ESRD in the Medicare populationin the Medicare population
Figure 4.1 (Volume 1)Figure 4.1 (Volume 1)
The Medicare Quality Improvement Organization for Florida 121212USRDS 2008 ADR
1: non-CKD, NDM, non-CHF 2: CKD only (NDM, non-CHF) 3: CKD + DM 4: CKD + CHF 5: CKD + DM + CHF
Point prevalent general Medicare patients entering Medicare before January 1, 2004, alive & age 66 or older on
December 31, & followed for two years. Patients enrolled in an HMO, with Medicare as secondary payor, or diagnosed
with ESRD during the year are excluded. CKD, diabetes, & CHF defined during 2004. Comorbidity groups not
mutually exclusive.
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
BackgroundBackground
• In hypertensive patients with diabetes,
treated with Angiotensin Converting
Enzyme Inhibitor (ACEIs), the
progression of kidney disease can be
The Medicare Quality Improvement Organization for Florida
progression of kidney disease can be
slowed by 50%.
• Screening rates for patients with known
risk factors for CKD are as low as 20%.
13
Centers for Medicare & Medicaid Services
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
FloridaFlorida
9th leading cause
of death in the
U.S.
Florida ranks 3rd
in the incidence
of CKD
Nearly 26 million
adults are living with
CKD and don’t know
it.
The Medicare Quality Improvement Organization for Florida 14
For each patient who
does not progress to
dialysis, Medicare
saves $250,000.
Screening rates
for patients with
known risk
factors for CKD
are as low as
20%.
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
The Medicare Quality Improvement Organization for Florida 15
African American/ Hispanic African American/ Hispanic
Beneficiaries in FloridaBeneficiaries in Florida
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
The Medicare Quality Improvement Organization for Florida 16
Medicare Diabetics in FloridaMedicare Diabetics in Florida
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
The Medicare Quality Improvement Organization for Florida 17
Chronic Kidney Disease Chronic Kidney Disease
in Floridain Florida
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
StrategyStrategy
• Multi-pronged approach
• Annual microalbumin testing
• Prescription of ACEIs/ARBs for diabetic patients
• Referral of patients to nephrologists for AVF counseling where appropriate
Physicians
The Medicare Quality Improvement Organization for Florida
appropriate
• Adoption of processes that target ESRD patients for AVF placement
Hospital
• Identification of priorities at the system level and development recommendations that can be implemented in all settings
CKD Coalition
18
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
Definition & Definition & Classification Classification
• Kidney Disease Outcomes Quality Initiatives
(KDOQI)
– An effort to improve patient outcomes through the
development of clinical practice guidelines
The Medicare Quality Improvement Organization for Florida 19
About Chronic Kidney Disease
http://www.kidney.org/professionals/KLS/aboutCKD.cfm
development of clinical practice guidelines
– Defines Chronic Kidney Disease according to the
presence or absence of markers of kidney damage
and the level of kidney function, glomerular
filtration rate (GFR)
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
• Independent criteria for chronic kidney disease
– Kidney damage for ≥ 3 months as defined by structural or
functional abnormalities of the kidney, with or without
decreased GFR, manifested by either: pathological
abnormalities; or markers of kidney damage, including
Definition & Definition & Classification Classification
The Medicare Quality Improvement Organization for Florida 20
About Chronic Kidney Disease
http://www.kidney.org/professionals/KLS/aboutCKD.cfm
abnormalities; or markers of kidney damage, including
abnormalities in the composition of the blood or urine; or
abnormalities in imaging tests
– GFR < 60 mL/min/1.73m20 for ≥ 3 months, with or
without kidney damage
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
Definition and Definition and ClassificationClassification
• GFR is the best overall index of kidney function
in health and disease
– Normal GFR varies according to age, sex and body size
– Young adults range from 120-130 mL/min/1.73 m2 and
The Medicare Quality Improvement Organization for Florida 21
About Chronic Kidney Disease
http://www.kidney.org/professionals/KLS/aboutCKD.cfm
decline with age
– GFR can be estimated from prediction equations, i.e., the
Modification of Diet in Renal Disease (MDRD) Study
equation recommend by KDOQI
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
Stage DescriptionGFR mL/min/1.73 m2
(Kidney Function) Action
1Kidney damage with
Normal or ↑ GFR≥90
Diagnosis and treatment, treatment of co-
morbid conditions, slowing progression,
CVD risk reduction
CKD StagingCKD Staging
Stage is defined based on level of kidney function using GFR.
Higher CKD stages represent lower GFR levels.
The Medicare Quality Improvement Organization for Florida 22
CVD risk reduction
2 Kidney damage with
Mild ↓ GFR60-89 Estimating Progression
3 Moderate ↓ GFR 30-59 Evaluation and treating complications
4 Severe ↓ GFR 15-29Preparation for kidney replacement
therapy
5 Kidney failure
or Dialysis<15 (or dialysis) Replacement if uremia present
About Chronic Kidney Disease http://www.kidney.org/professionals/KLS/aboutCKD.cfm
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
LaboratoriesLaboratorieseGFReGFR
• Early in 2008, 2 labs began providing
physicians with patients’ estimated
glomerular filtration rates (eGFR) taken from
the serum creatinine levels using either the
The Medicare Quality Improvement Organization for Florida
the serum creatinine levels using either the
Modification of Diet in Renal Disease Study
or the Cockcroft- Gault equations.
23
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
In the Physician In the Physician PracticePractice
So, let me get it right:• You want me to see my patients
• Order tests
• Review the results
The Medicare Quality Improvement Organization for Florida 24
• Review the results
• Track and Trend Progress
• Prescribe as appropriate
• Refer to specialists
What’s the catch.....
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
In the Physician In the Physician PracticePractice
No Catch!!• We want you to see your patients, like
you always do
• Order annual micro albumin testing for
your diabetic patients
The Medicare Quality Improvement Organization for Florida 25
your diabetic patients
• Track and Trend eGFR Progress on the
tracking tool
• Review the lab results with the patient
• Prescribe ACEIs/ARBs for diabetic
patients
• Refer patients to Nephrologists when
GFR begins approaching Stage 3.
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
Florida CKD Florida CKD Intervention Recipe Intervention Recipe
Slowing Kidney Disease before the Damage is Done
INGREDIENTS:
1. GFR calculator
2. Current lab work with serum creatine values
The Medicare Quality Improvement Organization for Florida 26
3. eGFR Trending tool
4. NKDEP “How well are your kidneys working?”
patient educational handout
5. (Optional) An RPA kidney report card
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
GFR CalculatorGFR Calculator
NationalNational
KidneyKidney
Disease Disease
Education Education
The Medicare Quality Improvement Organization for Florida 27
Education Education
ProgramProgram
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
GFR CalculatorGFR Calculator
NationalNational
KidneyKidney
FoundationFoundation
The Medicare Quality Improvement Organization for Florida 28
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
GFR CalculatorGFR Calculator
EpocratesEpocrates
MedToolsMedTools
The Medicare Quality Improvement Organization for Florida 29
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
GFR CalculatorGFR Calculator
Ortho Ortho
BioTechBioTech
The Medicare Quality Improvement Organization for Florida 30
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
GFR CalculatorGFR Calculator
AmericanAmerican
College of College of
PhysiciansPhysicians
The Medicare Quality Improvement Organization for Florida 31
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
GFR Calculators for GFR Calculators for
the Technical Savvythe Technical Savvy
iPhoneiPhone
GFR GFR
Calculator Calculator
from DaVitafrom DaVita
The Medicare Quality Improvement Organization for Florida 32
FreewareFreeware
Pocket PCPocket PC
GFR GFR
CalculatorCalculator
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
Low Tech HandLow Tech Hand--held held
GFR CalculatorGFR Calculator
The Medicare Quality Improvement Organization for Florida 33
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
In the LabIn the Lab
The Medicare Quality Improvement Organization for Florida 34
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
eGFReGFR Trending Trending ToolTool
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8
Graphic by the
American Association
of Kidney Patients
eGFR Trending Tool
Normal
THE
CKDCONNECTION
eGFRPatient:
Date:
FMQAI -- The Medicare Quality Improvement Organization for Florida
Stage II with mild ���� in GFR
Estimating Progression
Annual Microalbumin
Urine Screen
<30 mg/G in green
>30 mg/G in red
ACEs & ARBs
First arm therapy
The Medicare Quality Improvement Organization for Florida 35
0
10
20
30
40
50
60
70
80
ESRD
CKD
Physician Office:
Estimating Progression
Identify risk factors
Stage III
Evaluation & Treatment
Referral to Nephrologist
Stage IV
Preparation for kidney
replacement therapy
Stage V
Renal placement as
symptoms progress
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
The Medicare Quality Improvement Organization for Florida 36
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
RPA Kidney RPA Kidney Report CardReport Card
The Medicare Quality Improvement Organization for Florida 37
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
Florida CKD Florida CKD Intervention Recipe Intervention Recipe
PROCEDURES:
Medical Assistant
1. Begin by rooming the patient, getting vitals.
2. Pull latest lab report. Locate the serum creatinine value and
calculate patient’s GFR.
3. Plot GFR result onto eGFR Trending tool in the patient’s
The Medicare Quality Improvement Organization for Florida 38
3. Plot GFR result onto eGFR Trending tool in the patient’s
chart.
4. Enter date of visit and GFR result onto to the NKDEP “How
well are your kidneys working?”
5. Place handout into the patient folder for physician’s
attention.
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
Florida CKD Florida CKD Intervention Recipe Intervention Recipe
PROCEDURES:
Physician
1. Review consult sheet/chart, eGFR trending tool.
2. Pull/remove the NKDEP “How well are your kidneys
working?” patient educational handout for discussion with
patient.
3. Discuss relevant issues and treat accordingly (may order ACEIs
The Medicare Quality Improvement Organization for Florida 39
or ARBs, discuss lifestyle changes, blood pressure issues,
diabetes, etc.)
4. Refer, when appropriate, patient with evidence of kidney
disease (GFR falls below 30 ml/minute -- Stage 4 CKD -- for
nondiabetics or below 60 ml/minute -- Stage 3 CKD-- for
diabetics) to a Nephrologist.
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
Your TurnYour Turn
The Medicare Quality Improvement Organization for Florida 40
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
The Medicare Quality Improvement Organization for Florida 41
PROJECT
FLORIDA
CKD Graphic by the
American Association
of Kidney Patients
Florida’sFlorida’sCKD TeamCKD Team
Laura Gamba, BA, CBAProject Director
800-564-7490 x 3920
Gwen Williams, BAProject Coordinator
800-564-7490 x. 3510
Laurie Ciannamea, MBA, CHCOProject Coordinator
800-564-7490 x. 3322
Kathleen Lightbourne, MPHProject Coordinator
800-564-7490 x. 3562
The Medicare Quality Improvement Organization for Florida
Vicki FarrellAdministrative Assistant
800.564.7490 x. 3632
Ferdinand Richards, MDMedical Director
800-564-7490 x. 3120
Candace Skelton, RN, CCTCProject Coordinator
800-564-7490 x. 3285
JiFeng Ma, PhDStatistician
800.564.7490 x. 3861
Mark Michelman, MD, MBAClinical Director
800-564-7490 x. 3540
This material was prepared by FMQAI, the Medicare Quality Improvement Organization (QIO) for Florida, under contract with the Centers for
Medicare & Medicaid Services, (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not
necessarily reflect CMS policy. FL20091AF73T1B0711066
42