Friday, 14 December 2012

Alarming Diabetic Kidney Disease Data

The National Diabetes Audit published its latest report earlier in the week. It makes disquieting reading for clinicians, policy makers and most of all people with diabetes. It is over 10 years since the studies that showed how much we could do to prevent diabetic kidney disease were published and there is widespread knowledge about slowing the progression of kidney disease so the numbers of people affected are really starling. Less than a quarter of all people with diabetes in this, the largest national audit in the world, were found to be free of the kidney disease complications of diabetes. The fact that “only” 1.8% have advanced, CKD stage 4 and 5, kidney disease is no cause of complacency when nearly 50% of the whole population have macro or microproteinuria and nearly 20 % have stage 3 CKD giving them a massive risk of premature vascular events – heart attacks, atrial fibrillation, stroke, peripheral vascular disease as well as high risk of progression to kidney failure. We must not overlook the fact that in 10% of people with this common condition, a known high risk group in whom we have incontrovertible evidence based simple interventions that work we have no idea if they have early or even late kidney involvement because the routine blood and urine tests that are built into our payment system for primary care haven’t been done. Kidney disease is silent but deadly – we are failing a substantial proportion of our population.

The day before I had been reading about quality measures – “Metrics for quality must be acceptable to clinicians, collectable from management systems and understandable by the public. A simple triad that’s hard to reconcile” was the conclusion of Sir Liam Donaldson and Lord Darzi in their viewpoint article about quality measures comparing the US healthcare system to the NHS as it undergoes fundamental redesign to its structures and accountability mechanisms. Well, far be it from me to take issue with my esteemed erstwhile colleagues at the Department of Health  but these diabetic kidney disease quality measures are I think clinically credible, have been pulled from routine management systems and make sense to our public and patients – perhaps one of the exceptions that proves the rule.

Our former Chief Medical Officer and Minister of State for Health argued that no matter how often the language of quality and safety is spoken by those running the system, the true lingua  franca of healthcare in the United Kingdom is financial. They point to a perceived fundamental difference in the values of clinicians and patients on the one side and healthcare planners on the other. Often the absence of powerful data on quality of care, data that is universally believed and trusted further deepens this rife between managerial and clinical cultures.  Donaldson and Darzi argue cogently for a clinical culture of valuing collecting and working with quality data as a credible scientific endeavour on a par with clinical and molecular research in everyway. Well the future is here, but unevenly distributed!!!

If we are going to live up the rhetoric of “quality is the only organising principal of the NHS” as a credible scientific endeavour, we need to embrace clinical audit and quality improvement as a core component of good clinical practice. Rather than an activity that is tolerated because, management requires it. We have the audit data now we need the quality improvement. Renal replacement therapy is more common that retinopathy or amputation (major or minor ) and CKD is by far and away the most frequent and worrying vascular complication of diabetes affecting  20 times more people than those that have ischaemic heart disease. However, the point is not kidney disease is numerically larger than all the other complications put together rather it is these complications occur together – they are the same disease process - blood vessel injury and most importantly of all CKD is an early marker that we can both prevent and treat. The revised general practice contract with the addition of local quality improvement focused on particular disease pathways commissioned  by the NHS commissioning board through the Quality and Outcomes Framework provides a systematic mechanism for getting this right and avoiding these unnecessary heart breaking kidney  complications of diabetes. We should not go on missing these opportunities.

These qualities metric make sense to clinicians, patients and careers, managers and trust boards. It is time for action.

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