Zin: Patient Arts/medisch team Maatschappij

Transcriptie

1

2 Zin: Patient Arts/medisch team Maatschappij

3 Zin: Patient Betere overleving Betere gezondheid Betere zorg (Cure? Of Care?) Financiele winst

4 Zin: Patient Betere overleving Betere gezondheid Betere zorg (Cure? Of Care?) Financiele winst Arts/medisch team Betere geneeskunde (cure of care?) Meer patienten

5 Zin: Patient Betere overleving Betere gezondheid Betere zorg (Cure? Of Care?) Financiele winst Arts/medisch team Betere geneeskunde (cure of care?) Meer patienten Meer tevreden patienten

6 Zin: Patient Betere overleving Betere gezondheid Betere zorg (Cure? Of Care?) Financiele winst Arts/medisch team Betere geneeskunde (cure of care?) Meer patienten Meer tevreden patienten Betere gezondheid in de ons toevertrouwde populatie Maatschappij

7 Zorgtraject Definitie: het zorgtraject is het traject van instellingen en organisaties met de daarbij betrokken disciplines dat de patiënt doorloopt tijdens het doormaken van zijn (chronische) ziekte Veronderstelt dus de juiste maat van zorg op het geschikte ogenblik door het geschikte echelon

8 Overgang eerste lijnsniveau naar specialistisch niveau Andere spelers, vb huisarts, andere specialisten, thuisverpleging, dietiste orgaanspecialist huisarts specialisten

9 Should everybody be treated by a nephrologist? Lee, B. J et al. BMJ 2009;339:b2395 Copyright 2009 BMJ Publishing Group Ltd.

10 Should everybody be treated by a nephrologist? Lee, B. J et al. BMJ 2009;339:b2395 Copyright 2009 BMJ Publishing Group Ltd.

11 Should everybody be treated by a nephrologist? Accordingly, Clear guidance on whom and when to refer on which criteria all patients with potential renal related disaese should at least Lee, B. J et al. BMJ 2009;339:b2395 once be seen by a nephrologist to plan follow up and goals of treatment Copyright 2009 BMJ Publishing Group Ltd.

12

13 Prevalentie lage kostdialyse (increasing acceptance of elderly) jaar jaar jaar jaar jaar jaar jaar 85 en ouder Totaal

14 GFR (ml/min/y) SBP (mm Hg) Untreated hypertension r=0.69; P<0.05. Parving HH et al. Br Med J Viberti GC et al. JAMA Klahr S et al. N Eng J Med Hebert L et al. Kidney Int Lebovitz H et al. Kidney Int Moschio G et al. N Engl J Med Bakris GL et al. Kidney Int Bakris GL. Hypertension GISEN Group. Lancet Bakris et al. Am J Kidney Dis. 2000;36:646.

15 50% Laattijdige verwijzing minder dan één maand 60% Laattijdige verwijzing minder dan zes maanden 45% 55% 50% 40% 45% 35% 40% 30% 35% 25% 30% 20% 25% 15% 20% 15% 10% 10% 5% 5% 0% 0%

16 35% 30% Mortaliteit na één jaarminder dan 6 maanden Meer dan 6 maanden 40% 35% Mortaliteit na één jaar Minder dan 1 maand 30% 25% 25% 20% 20% 15% 15% 10% 10% 5% 5% 0% 0%

17 35% 30% 25% Mortaliteit na één jaarminder dan 6 maanden Meer dan 6 maanden 40% 35% 30% Mortaliteit na één jaar Minder dan 1 maand Niet veel verschil in overleving tussen 1 en 6 maand opvolging... 20% 25% 20% 15% 15% 10% 10% 5% 5% 0% %

18 % Patients PD HD * Modality on about day 60 of ESRD ** Excludes PD-2%, HD-6% not sure <1 1 to 3 4 to 12 >12 # Months Pre-ESRD The USRDS Dialysis Morbidity and Mortality Study (Wave 2), USRDS 1997 Annual Data Report

19 % Patients 70,0% 60,0% 50,0% 40,0% 30,0% 20,0% Minder dan 1 maand Tussen 1 en 6 maanden Meer dan 6 maanden onbekend PD HD 10,0% 0,0% 0 <1 1 to 3 4 to 12 >12 * Modality on about day 60 of ESRD ** Excludes PD-2%, HD-6% not sure # Months Pre-ESRD Totaal The USRDS Dialysis Morbidity and Mortality Study (Wave 2), USRDS 1997 Annual Data Report

20 All late referrals are equal?

21

22 % Patients PD HD * Modality on about day 60 of ESRD ** Excludes PD-2%, HD-6% not sure <1 1 to 3 4 to 12 >12 # Months Pre-ESRD The USRDS Dialysis Morbidity and Mortality Study (Wave 2), USRDS 1997 Annual Data Report

23 % Patients PD HD * Modality on about day 60 of ESRD ** Excludes PD-2%, HD-6% not sure <1 1 to 3 4 to 12 >12 # Months Pre-ESRD The USRDS Dialysis Morbidity and Mortality Study (Wave 2), USRDS 1997 Annual Data Report

24 Causes of late referral? True late referral late diagnosis of chronic CKD well taken care of late referral intrinsic causes (unavoidable): AKI, vasculitis... acute on chronic: avoidable late referral nephrotoxic medication and interventions

25 What is the practice in the UK in 1999? Referral of diabetics to a renal clinic - 63% high BP 33% of hypertensives not receiving therapy 50% not on ACE inhibitors 80% with high cholesterol 14% receiving inappropriate drugs Dunn, Burton and Feast QJM 1999

26 Percent Both Tight Glucose and Blood Pressure Control Reduce Cardiovascular Outcomes: UKPDS 0 Stroke Any diabetes end point Microvascular outcomes Death * * * * Tight BP control Tight glucose control *P<0.05. Tight BP control = 144/82 mm Hg. Tight glucose control = HbA 1c = 7.0%. UKPDS Group. BMJ. 1998;317:703; UKPDS Group. BMJ. 1998;317:713.

27 % of hypertensive patients prescribed NSAID s at discharge 15% 12,5% 10% 8,8% 5% 6,0% 0% < >2 Total Serum Creatinine (mg/dl) McClellan WM, et al, Am J Kidney Dis, 1999; 29:

28 Table 1 Impact of risk driven consultations on patterns of care. Values are numbers (percentages) unless otherwise stated Difference in percentage points, (P value) Starting dialysis All dialysis Outpatient 39 (35) 44 (49) 50 (53) 54 (63) 47 (56) 21 (P=0.003) All haemodialysis Using mature arteriovenous fistulas Using central venous catheter 19 (18) 19 (25) 25 (29) 26 (35) 27 (36) 18 (P=0.006) 83 (77) 54 (72) 55 (63) 46 (61) 45 (59) End stage renal disease Total* Referrals < (32) 17 (19) 16 (17) 10 (12) 10 (12) 20 (P=0.001) days before onset Referrals <365 days before onset 54 (47) 33 (37) 27 (29) 24 (28) 16 (19) 28 (P<0.0001)

29 John et al AJKD 43:

30 Impact of screening and referral of CKD patients Jones et al, AJKD 2006

31 Survival in ESRD patients after 1 year Cass et al, Med J Aust, 2002

32 Late referral in the elderly Schwenger et al, NDT, 2006

33 The late referred early known patient Buck et al, NDT 2007

34 Empowerment and Outcome Curtis et al, NDT, 2005,

35 Wu et al, NDT 2009

36 Wu et al, NDT 2009

37 Sodium intake and cardiovascular mortality He et al, JAMA 1999

38 Lowering sodium intake by 44 (33)mmol/24hour resulted in a 25% reduction in mortality Decrease in ml/min/month Low salt High salt 0,6 0,5 0,4 0,3 0,2 0,1 0 Cook et al, BJM, 2007 Cianciaruso et al, Mineral elektrolyte metabolism, 1998

39 Bibbins-Domingo, NEJM, 201

40 Bibbins-Domingo, NEJM, 201

41 Bibbins-Domingo, NEJM, 201

42 CKD care UZ Ghent N= 845 (720 official) 466 males, 35 non-white 294 diabetics 98 diagnosis by biopsy 125 post transplantation follow up 118 have proteinuria >1G/day; only 29 have proteinuria>1g and MDRD>45

43 CKD care other centres 5 (=vijf) centra (buiten UZG) hebben geantwoord geen hebben weet van huisartsen die actief de zaak blokkeren verwijzing door huisarts lijkt eerder mondjesmaat administratieve aanpak verschillend centrum a: 468 (352 in 2009) centrum b: 50 centrum c: geen echte lijst, vermoedelijk >80%vd gevolgde patienten centrum d: 229 centrum e: 134 (46 in 2009)

44 Underlying renal diagnosis 1= DM1 2=DM2 3=Vascular 4= Glomerular 5= interstitial 6= ADPKD 7 = Other 8= Unknown

45 Underlying renal diagnosis in diabetics 1= DM1 2=DM2 3=Vascular 4= Glomerular 5= interstitial 6= ADPKD 7 = Other 8= Unknown

46 Referring physicians 1= General Practitioner 2=Hospitalization ward 3=Patient 4= occupational physician 5= cardio 6= Endocrinologist 7 = geriatric 8= general internist 9= other internist 10= urologist 11= Vascular surgeon 12= surgeon 13= other

47 Referring physicians (diabetics) 1= GP 2=Hospitalization 3=Patient 4= occupational 5= cardio 6= Endocrino 7 = geriatric 8= general internist 9= other internist 10= urologist 11= Vascular surgeon 12= surgeon 13= other

48

49

50 Centrum e: mannen gemiddel 68 jaar en vrouwen gemiddeld 72 jaar

51

52

53

54 Education Level

55 Waist circumference

56 Waist circumference Diabetics vs non diabetics

57 Bloodpressure

58

59

60 Nutritional status

61 Nutritional status

62 Ikizler et al, JASN,6, , 1995 DPI g/kg/day 1,20 1,00 0,80 0,60 0,40 0,20 0,00 > <10 Ccrea ml/min

63

64 Karp et al, Calcif Tissue Int, 200

65 Shinaberger et al, Am J Clin Nu

66 Shinaberger et al, Am J Clin Nu

67

68

69

70

71 So: In this cohort of pre-esrd patients: low education level High age Multiple comorbidities some degree of malnutrition mixed evolution of renal function Mostly prevalent cohort!

72 Hoewel geen harde eindpunten, enkel indicaties veel politiek/filosofische scepsis en voetangels Lijkt het concept van een zorgtraject met een gestructureerde aanpak van chronische aandoeningen zinvol Voor alle partijen