QOF

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Chronic Kidney Disease, Aged 18 years and over

Includes latest code (with episode type 'First' or 'New' )(v30)

1Z12. Chronic kidney disease stage 3
1Z13. Chronic kidney disease stage 4
1Z14. Chronic kidney disease stage 5
1Z15. Chronic kidney disease stage 3A
1Z16. Chronic kidney disease stage 3B
1Z1B. Chronic kidney disease stage 3 with proteinuria
1Z1C. Chronic kidney disease stage 3 without proteinuria
1Z1D. Chronic kidney disease stage 3A with proteinuria
1Z1E. Chronic kidney disease stage 3A without proteinuria
1Z1F. Chronic kidney disease stage 3B with proteinuria
1Z1G. Chronic kidney disease stage 3B without proteinuria
1Z1H. Chronic kidney disease stage 4 with proteinuria
1Z1J. Chronic kidney disease stage 4 without proteinuria
1Z1K. Chronic kidney disease stage 5 with proteinuria
1Z1L. Chronic kidney disease stage 5 without proteinuria
K053. Chronic kidney disease stage 3
K054. Chronic kidney disease stage 4
K055. Chronic kidney disease stage 5

Excludes patients whose condition has improved with one of these as the latest code with episode type 'First' or 'New'

1Z10. Chronic kidney disease stage 1
1Z11. Chronic kidney disease stage 2
1Z17. Chronic kidney disease stage 1 with proteinuria
1Z18. Chronic kidney disease stage 1 without proteinuria
1Z19. Chronic kidney disease stage 2 with proteinuria
1Z1A. Chronic kidney disease stage 2 without proteinuria
K051. Chronic kidney disease stage 1
K052. Chronic kidney disease stage 2

Exception reporting codes added in the previous 12 months.

9hE1. Excepted from chronic kidney disease quality indicators: Informed dissent
9hE0. Excepted from chronic kidney disease quality indicators: Patient unsuitable

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Chronic kidney disease rationale for inclusion of indicator set

The international classification developed by the US National Kidney Foundation describes five stages of chronic kidney disease (CKD) using an estimated glomerular filtration rate (eGFR) to measure kidney function (table 1). People with CKD stages three to five have, by definition, less than 60 per cent of their kidney function. Stage three is a moderate decrease in GFR with or without other evidence of kidney damage. Several groups (NICE, SIGN, UK Consensus) have recommended splitting stage 3 into 3A and 3B (table 1). Stage four is a severe decrease in GFR with or without other evidence of kidney damage and stage five is established renal failure. The QOF indicator set refers to people with stage 3 to 5 CKD.

CKD is a long-term condition; the most recent population data from the National Health and Nutrition Examination Survey (NHANES 1999-2004) suggests that the age standardised prevalence of stage 3 to 5 CKD in the non-institionalised American population is approximately 6%. The prevalence in females was higher than in males (6.9 versus 4.9%). In the fully adjusted model, the prevalence of low GFR was strongly associated with diagnosed diabetes (OR, 1.54; 95% CI, 1.28-1.80) and hypertension (OR, 1.98; 95%CI, 1.73-2.67) as well as higher BMI (OR, 1.08; 95% CI, 1.02-1.15 per 5-unit increment of BMI).

In the UK the prevalence of CKD stage 35 was 8.5% and was higher in females, 10.6% in females versus 5.8% in males. The Association of Public Health Observatories has modelled the prevalence of CKD for England and Wales based on the results of the study by Stevens et al. and report a population prevalence of 8.9 per cent:

http://www.apho.org.uk/resource/item.aspx?RID=65647
http://www.apho.org.uk/resource/item.aspx?RID=63798

Table 1: Estimated glomerular filtration rate (eGFR) to measure kidney function

Stage
GFR*
Description
Included in QOF
1
90+
Normal kidney function but urine findings or structural abnormalities or genetic trait point to kidney disease
No
2
60-89
Mildly reduced kidney function, and other findings (as for stage 1) point to kidney disease
No
3
30-59
Moderately reduced kidney function. Subdivided into 3A (45 to 59) and 3B (30 to 44)
Yes
4
15-29
Severely reduced kidney function
Yes
5
<15
Very severe, or established kidney failure
Yes

* All GFR values are normalized to an average surface area (size) of 1.73m2

Further information
National service framework for Renal Services (2005).
https://www.gov.uk/government/publications/national-service-framework-kidneydisease

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This indicator set applies to people with stage three, four and five CKD (eGFR <60 mL/min/1.73m2 confirmed with at least two separate readings over a three month period).

CKD may be progressive; prevalence increase with age and female sex but progression increases with male sex, and South Asian and African Caribbean ethnicity. People of South Asian origin are particularly at risk of having both diabetes and CKD. Diabetes is more common in this community than in the population overall. People of African and African Caribbean origin have an increased risk of CKD progression linked to hypertension.

Only a minority of people with stage one or two CKD go on to develop more advanced disease and symptoms do not usually appear until stage four. Where eGFR has persistently been recorded below 60 (<60) the CKD (stage 3) label should continue to apply, even if future management may lead to an improvement in eGFR.

Early identification of CKD is important as it allows appropriate measures to be taken not only to slow or prevent the progression to more serious CKD but also to combat the major risk of illness or death due to cardiovascular disease. The presence of proteinuria is a key risk multiplier at all stages of CKD and CKD is an independent risk factor for cardiovascular disease and a multiplier of other risk factors

(Wali and Henrich. Cardiol Clin 2005; 23(3): 343-62)

Further information
NICE clinical guideline 73 (2008). Early identification and management of CKD in adults in primary and secondary care.
http://www.nice.org.uk/CG73

SIGN clinical guideline 103 (2008). Diagnosis and management of CKD in adults.
http://www.sign.ac.uk/guidelines/fulltext/103/index.html

These indicators reflect both of the guidance documents:

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Chronic kidney disease 001.1 Rationale

Patients aged18 years and over with a persistent estimate GFR or GFR of <60ml/min/1.73m2 should be included in the register. From 2006, eGFR has been reported automatically when serum creatinine concentration is measured.. Studies of general practice computerised medical records show that it is feasible to identify people with CKD (de Lusignan et al. Fam Pract 2005; 22(3): 234-41) and that computer records are a valid source of data (Anandarajah et al. Nephrol Dial Transplant 2005; 20(10): 2089-96).

The compilation of a register of people with CKD will enable appropriate advice, treatment and support for the patient to preserve kidney function and to reduce the risk of cardiovascular disease.

Eating a meal containing protein can elevate creatinine; therefore it is recommended that patients do not eat meat in the 12 hours before their creatinine is measured and eGFR estimated.

Chronic kidney disease 001.2: Reporting and verification

See indicator wording for requirement criteria.

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Prepared By Jean Keenan