Title: QI Project: ASSIST-CKD East Midlands: Northampton clinical missioning group
Funder: Kidney Research UK

Abstract: We are leading a UK-wide project, supported by the Health Foundation, which involves over 20 renal units and pathology laboratories, and their surrounding GP practices covering an estimated population of around 11-12 million people across the UK. The project is known as ASSIST-CKD. Our aim is to provide better and safer patient care by identifying people with CKD who are at the greatest risk of disease progression. We want to ensure they are referred to secondary care at the right time, for the right treatment in the right care setting, to potentially reduce the rate of decline and so delay or even avoid the need for dialysis or a kidney transplant. Nearly 2 million people in the UK have been diagnosed with moderate-severe CKD by their GP but it is estimated that a further one million people remain undiagnosed as people with CKD often have little or no symptoms until the later stages of the disease. Patients also have an increased risk of cardiovascular disease and acute kidney injury (AKI). The project is based on a system that has been running successfully at the Heart of England Foundation Trust (HEFT) in Birmingham. It uses software to map data from routine blood tests (eGFR), creating graphs of kidney function over time. For patients with deteriorating kidney function, the participating sites send a report, including the graph, to the referring GP with a prompt that specialist advice may be needed. Another benefit is that patients with more stable CKD can be discharged back into primary care confident that their kidney function will continue to be monitored via these graphs. HEFT has had the lowest late presentation rate for dialysis in the UK since CKD graphical surveillance was introduced (delayed referral to specialist care as kidney function declines, makes it more difficult to prepare for dialysis or a kidney transplant and the outcomes for patients are not as good). Feedback from the primary care team has also been positive with 74% of local GPs finding the graph reports to be useful, and 41% having changed the management of their patients as a result. FROM WEBSITE - https://www.kidneyresearchuk.org/research/assist-ckd

Lay abstract: We are leading a UK-wide project, supported by the Health Foundation, which involves over 20 renal units and pathology laboratories, and their surrounding GP practices covering an estimated population of around 11-12 million people across the UK. The project is known as ASSIST-CKD. Our aim is to provide better and safer patient care by identifying people with CKD who are at the greatest risk of disease progression. We want to ensure they are referred to secondary care at the right time, for the right treatment in the right care setting, to potentially reduce the rate of decline and so delay or even avoid the need for dialysis or a kidney transplant. Nearly 2 million people in the UK have been diagnosed with moderate-severe CKD by their GP but it is estimated that a further one million people remain undiagnosed as people with CKD often have little or no symptoms until the later stages of the disease. Patients also have an increased risk of cardiovascular disease and acute kidney injury (AKI). The project is based on a system that has been running successfully at the Heart of England Foundation Trust (HEFT) in Birmingham. It uses software to map data from routine blood tests (eGFR), creating graphs of kidney function over time. For patients with deteriorating kidney function, the participating sites send a report, including the graph, to the referring GP with a prompt that specialist advice may be needed. Another benefit is that patients with more stable CKD can be discharged back into primary care confident that their kidney function will continue to be monitored via these graphs. HEFT has had the lowest late presentation rate for dialysis in the UK since CKD graphical surveillance was introduced (delayed referral to specialist care as kidney function declines, makes it more difficult to prepare for dialysis or a kidney transplant and the outcomes for patients are not as good). Feedback from the primary care team has also been positive with 74% of local GPs finding the graph reports to be useful, and 41% having changed the management of their patients as a result. FROM WEBSITE - https://www.kidneyresearchuk.org/research/assist-ckd

Research activity codes: 4.2 EVALUATION OF MARKERS AND TECHNOLOGIES
Health categories: RENAL AND UROGENITAL