impacto erc 2015 venezuela

IMPACTO ERC 2015

DIEGO L. GARCIA, MD

L.D. Byham-Gray et al. (eds.), Nutrition in Kidney Disease, Second Edition, Nutrition and Health, Springer Science New York 2014

Data presented only for countries from which relevant information was available. All rates are unadjusted. ^UK: England, Wales, & Northern Ireland (Scotland data reported separately). Japan and Taiwan are dialysis only. Data for Belgium do not include patients younger than 20. Data for Indonesia represent the West Java region. Data for France include 22 regions. Data for Spain include 18 of 19 regions.

Incidence rate of ESRD, per million population, by country, in 2012

USRDS 2014

Temporal trends in the incidence rate of ESRD, per million population, by country, years 2000-2012

(B) Countries in which the incidence rate of ESRD decreased at least 3% from 2006-2012

Data source: Special analyses, USRDS ESRD Database. All rates are unadjusted. Data are shown for countries with incidence increase or decrease from 2006 to 2012 or 2011. Data for U.S. are shown for comparison purposes. Abbreviations: ESRD, end-stage renal disease.

USRDS 2014

-3.50

0.00

3.50

7.00

10.50

14.00

0

6000

12000

18000

24000

2008 2009 2010 2011 2012 2013 2014

DIALISIS CAMBIO (%)

3.74

2.73

7.52

5.21

12.24

-2.26

2381622926

22300

2062419550

1715717544

-2.26

12.24

5.21

7.52

2.73

3.74

DIALISIS

%

Nm

ero

Prevalence of dialysis, per million population, by country, in 2012

Data source: Special analyses, USRDS ESRD Database. All rates are unadjusted and reflect prevalence at the end of 2012. Japan and Taiwan include dialysis patients only. ^UK: England, Wales, & Northern Ireland (Scotland data reported separately). Data for Spain include 18 of 19 regions. Data for France include 22 regions. Data for Belgium do not include patients younger than 20. Abbreviations: sp., speaking.

USRDS 2014

Distribution of the percentage of prevalent dialysis patients using in-center HD, home HD, and CAPD/CCPD, in 2012

Data source: Special analyses, USRDS ESRD Database. Denominator is calculated as the sum of patients receiving HD, PD, and Home HD; does not include patients with other/unknown modality. ^UK: England, Wales, & Northern Ireland (Scotland data reported separately). Data for Spain include 18 of 19 regions. Data for France include 22 regions. Data for Indonesia represent the West Java region. Data for Belgium do not include patients younger than 20. Abbreviations: CAPD, continuous ambulatory peritoneal dialysis; CCPD, continuous cycling peritoneal dialysis; ESRD, end-stage renal disease; HD, hemodialysis; PD, peritoneal dialysis; sp., speaking.

USRDS 2014

Kidney transplantation rate, per million population, by country, in 2012

Data source: Special analyses, USRDS ESRD Database. Data presented only for countries from which relevant information was available. All rates are unadjusted. ^UK: England, Wales, & Northern Ireland (Scotland data reported separately). Data for Belgium do not include patients younger than 20. Data for France include 22 regions. Data for Spain include all regions. There is underreporting of prevalent transplant patients in Turkey. Abbreviations: sp., speaking.

USRDS 2014

Data source: Special analyses, USRDS ESRD Database. Data presented only for countries from which relevant information was available. ^UK: England, Wales, & Northern Ireland (Scotland data reported separately). Data for Spain include 18 of 19 regions. Data for France include 22 regions. Data for Indonesia represent the West Java region. Data for Belgium do not include patients younger than 20. There were zero ESRD patients in Iceland with diabetes as the primary ESRD cause in 2012. Abbreviations: ESRD, end-stage renal disease; sp., speaking.

Percentage of incident ESRD patients with diabetes as the primary ESRD cause, by country, in 2012

USRDS 2014

Colombia 42.5%

Pas

Poblacin adulta

(20-79) en miles

Casos de diabetes en miles

Casos de diabetes no diagnosticada en miles

Prevalencia nacional de diabetes (%)

Prevalencia comparativ

a de diabetes

(%)

Muertes relacionada

s con la

diabetes

Costo por persona con diabetes (USD)

Muertes relacionadas con la

diabetes < 60 aos (%)

1 de cada X adultos tiene

diabetes

ERC 3-5 en miles (25%)

TRR en la vida (2%) en

miles

Argentina 27236,1 1626,1 451,7 6,0 5,7 15221 1422,7 39,3 17 406,52 32,52

Bolivia 5890,1 371,1 103,1 6,3 7,3 4694 252,1 50,5 16 92,77 7,42

Brazil 133879,9 11623,3 3229,0 8,7 8,7 116383 1527,6 41,7 12 2905,83 232,47

Chile 12287,5 1513,4 325,5 12,3 11,2 8956 1427,0 35,6 8 378,35 30,27

Colombia 30581,7 2191,9 608,9 7,2 7,3 14168 805,0 55,5 14 547,98 43,84

Costa Rica 3298,2 305,7 84,9 9,3 9,5 1590 1364,4 45,2 11 76,43 6,11

Cuba 8395,4 702,4 195,1 8,4 6,7 5921 704,7 31,3 12 175,60 14,05

Dominicana 6239,6 669,9 186,1 10,7 11,4 7888 466,0 64,1 9 167,46 13,40

Ecuador 9539,2 544,4 151,2 5,7 5,9 4541 562,5 65,9 18 136,10 10,89

El Salvador 3667,8 386,8 107,5 10,6 11,8 3676 377,3 48,7 9 96,70 7,74

Guayana Fr 148,4 12,1 3,4 8,2 8,5 - - - 12 3,03 0,24

Guatemala 7618,0 680,0 188,9 8,9 10,8 7965 385,4 61,0 11 170,00 13,60

Honduras 4414,5 420,8 116,9 9,5 11,7 2774 319,7 59,9 10 105,20 8,42

Mexico 75686,3 9018,6 2254,7 11,9 12,6 68660 892,5 42,0 8 2254,65 180,37

Nicaragua 3451,3 356,1 98,9 10,3 12,5 3167 221,3 54,7 10 89,02 7,12

Panama 2417,1 202,2 56,2 8,4 8,5 1397 1096,2 42,1 12 50,54 4,04

Paraguay 3930,9 243,8 67,7 6,2 7,0 2242 658,2 45,2 16 60,94 4,88

Peru 18745,2 1143,6 317,7 6,1 6,5 7650 523,5 53,0 16 285,90 22,87

Puerto Rico 2562,2 397,1 110,0 15,5 13,0 - - - 6 99,28 7,94

Uruguay 2282,6 150,3 32,3 6,6 5,8 1040 1742,1 33,5 15 37,56 3,01

Venezuela 19035,6 1252,4 347,9 6,6 6,9 9778 935,5 53,1 15 313,11 25,05

TOTAL 381307,3 33811,9 9037,6 8,7 9,0 287710 825,5 48,5 12 8452,98 676,24

IDF 2014: AMRICA LATINA (estimados)

La Creciente Carga Global de ERC

Diabetic CKD: A Growing Global Disease Population

0

150

300

450

600

165.6

552

109.8

366 = current total population

of UK, France, and Spain5

55% Projected Prevalence Increase by 2035

1. International Diabetes Federation. IDF Diabetes Atlas. 6th ed. http://www.idf.org/diabetesatlas. Published 2013. Accessed January 2, 2014. 2. Schieppati A, Remuzzi G. Chronic renal diseases as a public health problem: epidemiology, social, and economic implications. Kidney Int. 2005;68(suppl 98):S7S10. 3. Parving H-H, Mauer M, Fioretto P, Rossing P, Ritz E. Diabetic nephropathy. In: Taal MW, Chertow GM, Marsden PA, Skorecki K, Yu ASL, Brenner BM, eds. Brenner & Rectors The Kidney. 9th ed. Philadelphia, PA: Elsevier/Saunders; 2012:1411-1454. 4. Reutens AT, Atkins RC. Epidemiology of diabetic nephropathy. Contrib Nephrol. 2011;170:1-7.5. Central Intelligence Agency. CIA World Factbook website. https://www.cia.gov/library/publications/the-world-factbook. Accessed January 2, 2014.

2013 2035 2013 2035Global Diabetes Population1-3 Projected Cases of Diabetic CKD1-4*

*Early diabetic CKD defined as albumin excretion rate of 20-200 g/min or 30-300 mg/24 h, or a spot urine albumin-to-creatinine ratio of 30-300 mg/g (3.5-35 mg/mmol) in males and 20-200 mg/g (2.5-25 mg/mmol) in females. Diabetic CKD is marked by proteinuria >500 mg/24 h or albuminuria >300 mg/24 h. Decreased estimated glomerular filtration rate

Reduced eGFR, Albuminuria, and Risk of Mortality in General Population

Matsushita K, Van der Velde M, Astor BC, et al; Chronic Kidney Disease Prognosis Consortium. Association of estimated glomerular filtration rate and albuminuria with all-cause cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet. 2010;375(9731):2073-2081.

eGFR=estimated glomerular filtration rate; HR=hazard ratio; CI=confidence interval; ACR=albumin-to-creatinine ratio.

All-cause mortality; eGFR

8

4

2

1

0.515 30 45 60 75 90 105 120

eGFR (mL/min/1.73 m2)

8

4

2

1

0.515 30 45 60 75 90 105 120

8

4

2

1

0.52.5(0.3)

5(0.6)

10(1.1)

30(3.4)

300(33.9)

1000(113.0)

ACR (mg/g [mg/mmol])

8

4

2

1

0.52.5(0.3)

5(0.6)

10(1.1)

30(3.4)

300(33.9)

1000(113.0)

All-cause mortality; ACR

Cardiovascular mortality; eGFR Cardiovascular mortality; ACR

eGFR (mL/min/1.73 m2)ACR (mg/g [mg/mmol])

HR (9

5% CI)

HR (9

5% CI)

HR (9

5% CI)

HR (9

5% CI)

Reprinted from The Lancet, with permission from Elsevier

Reduced eGFR, Albuminuria, and Risk of Mortality in General Population

Matsushita K, Van der Velde M, Astor BC, et al; Chronic Kidney Disease Prognosis Consortium. Association of estimated glomerular filtration rate and albuminuria with all-cause cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet. 2010;375(9731):2073-2081.

eGFR=estimated glomerular filtration rate; HR=hazard ratio; CI=confidence interval; ACR=albumin-to-creatinine ratio.

All-cause mortality; ACR studies Cardiovascular mortality; ACR studies

16

8

2

1

0.515 30 45 60 75 90 105 120

4


HR (9

5% CI)

16

8

2

1

0.515 30 45 60 75 90 105 120

4

HR (9

5% CI)


33.9 mg/mmol (300 mg/g)

Reprinted from The Lancet, with permission from Elsevier

3.4-33.8 mg/mmol (30-299 mg/g)

Risk of Albuminuria, Elevated Creatinine, and Death in Patients With Type 2 Diabetes

3.0%

4.6%

19.2%

The United Kingdom Prospective Diabetes Study: Newly diagnosed, predominantly white, medically treated (N=5,097)*

Adler AI, Stevens RJ, Manley SE, Bilous RW, Cull CA, Holman RR; UKPDS Group. Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney Int. 2003;63(1):225-232.

RRT=renal replacement therapy.

1.4%

D E A T H

2.0% per year

Microalbuminuria 50-299 mg/L

2.8% per year

Macroalbuminuria 300 mg/L

No albuminuria

Elevated plasma creatinine 175 mol/L (1.98 mg/dl)

or RRT

2.3% per year

per year

per year

per year

per year

Reprinted with permission from Macmillan Publishers

*Median patient follow-up was 10.4 years.

#

Prognosis for Dialysis Patients With Diabetes Is Worse Than That For Dialysis Patients Without Diabetes

1. Nordio M, Limido A, Maggiore U, et al; Italian Dialysis and Transplantation Registry. Survival in patients treated by long-term dialysis compared with the general population. Am J Kidney Dis. 2012;59(6):819-828. 2. European Renal Association-European Dialysis and Transplant Association. ERA-EDTA Registry: Annual Report 2011. http://www.era-edta-reg.org/files/annualreports/pdf/AnnRep2011.pdf. Accessed January 9, 2014.

5-year relative survival (%)10 20 40 60 80 100

Prostate cancer

Heart failure

Thyroid cancerBreast cancer

Hodgkin lymphomaBladder cancer

Non Hodgkin lymphomaKidney cancer

Colorectal cancerLeukemia

Long-term dialysis

Dialysis + diabetes*2

Pancreatic cancer

Stomach cancerEsophageal cancer

Lung cancer

*5-year adjusted survival in a different study based on data from the ERA-EDTA Registry.

Myeloma

Prognosis of dialysis patients with diabetes is comparable to that for patients with heart

failure or aggressive cancers

Reprinted with permission from Elsevier

Decline in Estimated Glomerular Filtration Rate and Subsequent Risk of End-Stage Renal Disease and Mortality. CKD Prognosis Consortium

JAMA. 2014;311(24):2518-2531.

ERCT

Risk of End-Stage Renal Disease by Change in Estimated Glomerular Filtration Rate (GFR) During a 2-Year Baseline Period, First Estimated GFR, and Subsequent Follow-up. Baseline risk is calculated for participants with 0% change in estimated GFR, estimated GFR of 50 mL/min/1.73 m2, age of 60 years, male sex, nonblack race, systolic blood pressure of 130 mm Hg, total cholesterol level of 5 mmol/L, and without diabetes or a history of cardiovascular disease.


JAMA. 2014;311(24):2518-2531.

ERCT

All-Cause Mortality Associated With Percentage Change in Estimated GFR During a 2-Year Baseline Period. Values trimmed at less than 70% change (0.30% and 0.050% of the study population for estimated GFR

Risk of All-Cause Mortality by Change in Estimated Glomerular Filtration Rate (GFR) During a 2-Year Baseline Period, First Estimated GFR, and Subsequent Follow-upBaseline risk is calculated for participants with 0% change in estimated GFR, estimated GFR of 50 mL/min/1.73 m2, age of 60 years, male sex, nonblack race, systolic blood pressure of 130 mm Hg, total cholesterol level of 5 mmol/L, and without diabetes or a history of cardiovascular disease.


JAMA. 2014;311(24):2518-2531.

Mortalidad Global

Renal survival by CKD stage and level of albuminuria.

Marks A et al. Nephrol. Dial. Transplant. 2012;27:iii65-iii72

TRANSLATING CKD EPIDEMIOLOGY INTO PATIENT CARE: THE INDIVIDUAL PUBLIC RISK PARADOX

Percentage initiating RRT by 5 years for age, gender, CKD stage and proteinuria level-specific subgroups. *There were only 18 patients with Stage 3a CKD (4569 mL/min/1.73m2) therefore results not presented. There were no individuals in this group.



TRR

Percentage of GLOMMS-I cohort alive and not on RRT by 5 years for age, gender, CKD stage and proteinuria level-specific subgroups. *There were only 18 patients with Stage 3a CKD (4569 mL/min/1.73m2) therefore results not presented. There were no individuals in this group.



Supervivencia

#

Costos Directos de la ERC

Small ESRD Population Accounts for Significant Health Expenditures

1. US Renal Data System. USRDS 2013 Annual Data Report. 2. CIA World Factbook website. https://www.cia.gov/library/publications/the-world-factbook. Accessed October 30, 2013. 3. Nephrol Dial Transplant. 2012;27(suppl 3):iii32iii38. 4. Peritoneal Dial Int. 2011;31(suppl 2):S58-S62. 5. Cuenta de Alto Costo. 2013

Total Medicare patient population

1.4% ESRD patients

Total Medicare spending*

7.2% spending on ESRD population

Total population

0.23% ESRD patients

Total health care budget

4.1% spending on ESRD population

Japan1-3

*Includes inpatient and outpatient costs related to dialysis and transplantation.Renal replacement therapy only.

United States1

Total population

0.05% ESRD patients

Total National Health Service budget

1%-2% spending on ESRD population

United Kingdom4

Colombia5

0.05% ESRD patients 4.7% spending on ESRD population

Estimated annual cost of direct CKD care, RRT and non-RRT patients.

Kerr M et al. Nephrol. Dial. Transplant. 2012;27:iii73-iii80

ESTIMATING FINANCIAL COST OF CHRONIC KIDNEY DISEASE TO THE NHS IN ENGLAND

Preventing Progression of Diabetic CKD Reduces National Healthcare Spending

Trivedi HS, Pang MM, Campbell A, Saab P. Slowing the progression of chronic renal failure: economic benefits and patients perspectives. Am J Kidney Dis. 2002;39(4):721-729.

-80

-60

-40

-20

0

-COP60

-COP39

-COP19

Billion

s

*Mathematical model developed estimate for 10-year period from 2000-2010.

10% decrease in rate of GFR decline



Estimated reduction in 10-year spending if rate of GFR decline decreased in all US patients with GFR of 60 mL/min*

#

Estrategias de Prevencin y Tratamiento

Necesidades Insatisfechas en ERC Diabtica

No hay esfuerzos eficaces de salud pblica para reducir la tasa de diabetes1

Las prcticas de tamizaje necesitan ser adoptadas ms ampliamente para la identificacin y manejo de los pacientes con ERC diabtica2

Las estrategias renoprotectoras actuales son solo parcialemente efectivas1

Lentifican pero no previenen la progresin a TRR para muchos pacientes T 20% a40% de los pacientes con ERC progresan a resultados desfavorables a

pesar de las mejores prcticas clnicas Es necesario tener estrategias y tratamientos adicionales para mejorar

los resultados y para atrasar o parar la progresin a TRR3

1. Braun L, Sood V, Hogue S, Lieberman B, Copley-Merriman C. High burden and unmet patient needs in chronic kidney disease. Int J Nephrol Renovasc Dis. 2012;5:151-163. 2. KDIGO CKD Work Group. 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kid Int Suppl. 2013;3(1):1-150. 3. Matthews DR, Matthews PC. Banting Memorial Lecture 2010^. Type 2 diabetes as an 'infectious' disease: is this the Black Death of the 21st century? Diabet Med. 2011;28(1):2-9.

Necesidades Insatisfechas de la Creciente Carga de ERC Diabtica

La obesidad, la diabetes y las enfermedades renales relacionadas son un problema mdico creciente en el mundo

La progresin de la ERC est relacionada directamente con aumentos de la morbilidad, mortalidad, carga econmica y reduccin de la calidad de vida

Hay una necesidad crtica de esfuerzos efectivos de salud pblica para prevenir la diabetes en el mundo

El tratamiento estndar actual atrasa o previene la progresin de la nefropata diabtica de forma inadecuada

Hay una necesidad urgente de la adopcin general de estrategias de prevencin e intervencin eficaces en la poblacin diabtica y con ERC

Una importante estrategia de intervencin es el modelo de cuidado estructurado de monitoreo cercano de los pacientes, educacin y manejo farmacolgico intensivo treat-to-target de los pacientes con ERC por diabetes1

1. Leung WYS, So W-Y, Tong PCY, et al. The renoprotective effects of structured care in a clinical trial setting in type 2 diabetic patients with nephropathy. Nephrol Dial Transplant. 2004;19:2519-2525.

Estrategias Potenciales para Prevenir o Reducir las Tasas de Diabetes

Estrategias poblacionales para alentar el comportamiento saludable y prevenir la aparicin de diabetes, independiente del riesgo

Estrategias enfocadas a reducir la progresin en poblaciones de alto riesgo con intervencin intensiva en el estilo de vida

Ciruga baritrica para los pacientes con obesidad severa con diabetes de inicio reciente

Backholer K, Peeters A, Herman WH, et al. Diabetes prevention and treatment strategies: are we doing enough? Diabetes Care. 2013;36(9):2714-2719.

The Lancet Diabetes & Endocrinology 2014 2, 963-968

Incidence of type 2 diabetes after bariatric surgery: population-based matched cohort study

#

Lifestyle Changes Effectively Prevent Diabetes Onset

Program goals1,2:

#

Diet and Exercise Has a Lasting Effect on Diabetes Risk Reduction

In a 6-year Chinese study in patients with impaired glucose tolerance, Dietary change led to a 31% reduced risk of developing diabetes (P

#

Tamizaje e Intervencin Temprana para la ERC: Una Solucin Crtica

identification of people at earlier time points in the trajectory of CKD, with appropriate management and earlier referral of those who would benefit from specialist kidney services, should lead to both economic and clinical benefits.

KDIGO 2012 Clinical Practice Guideline

KDIGO CKD Work Group. 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kid Int Suppl. 2013;3(1):1-150.

KDIGO=Kidney Disease: Improving Global Outcomes.

#

Addressing Treatment Gaps in Diabetic CKD

* Patients with type 1 diabetes with disease duration 5 years; All patients with type 2 diabetes starting at diagnosis. RAAS=renin angiotensin aldosterone system; ARB=angiotensin II receptor blocker; ACE=angiotensin-converting-enzyme.

1. American Diabetes Association. Standards of medical care in diabetes2013. Diabetes Care. 2013;36(suppl 1):S11-S66. 2. KDIGO CKD Work Group. 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kid Int Suppl. 2013;3(1):1-150.

Optimize blood pressure and glucose control1

Perform annual albuminuria test1*

Measure serum creatinine at least annually1

Blood pressure control2 RAAS interruption via ARB

or ACE inhibitor in patients with albuminuria2

What can be done about residual risk in treated patients?

Undiagnosed diabetic CKD

Diagnosed with diabetic CKD but untreated or inadequately treated

Diabetic CKD is progressing despite

standard of care

#

0

10

20

30

0 12 36 4824Months of study

Risk reduction, 28% P=0.002

Current Antihypertensive/Antiproteinuric Therapies Are Inadequate in Preventing Progression of Diabetic CKD Benefits of delayed ESRD progression became apparent after

approximately 18 months of RAAS blockade therapy

Mean follow-up time in RENAAL was 3.4 years (42 months)1

1. Brenner BM, Cooper ME, de Zeeuw D, et al; for RENAAL Study Investigators. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345:861-869. 2. Lewis EJ, Hunsicker LG, Clarke WR, et al; for Collaborative Study Group. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345(12):851-860.

ESR

D (%

)

Placebo Losartan

ESR

D (%

)

Placebo Irbesartan

RENAAL1 IDNT2

No. at riskPlacebo 762 715 610 347 42Losartan 751 714 625 375 69

No. at riskIrbesartan 579 549 523 501 418 327 234 162 78 7Amlodipine 565 538 510 482 408 310 221 152 58 7

Placebo 568 542 517 487 418 302 205 141 63 2

0

20

30

0 12 42 5430Months of study

483624186

10

Amlodipine

Relative risk reduction, 23% P=0.07

RAAS=renin-angiotensin-aldosterone system. IDNT=Irbesartan Diabetic Nephropathy Trial.

Residual Risk Residual Risk

Reprinted with permission from Massachusets Medical Society

#

Multifactorial Intervention for Diabetes and CKD (Steno-2 Trial)

Summary of Steno trial multifactorial intervention for diabetes and CKD

Treatment Goals

SBP < 130 mm Hg

DBP < 80 mm Hg

Glycosylated hemoglobin < 6.5%

Total cholesterol < 175 mg/dL (4.53 mmol/l)

Triglycerides < 150 mg/dL (1.7 mmol/l)

ACE inhibitor or ARB irrespective of blood pressure

Aspirin irrespective of prevalent vascular disease

Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med. 2008;358(6):580-591.

#

Residual Mortality Risk With Intensified Multifactorial Intervention in Patients With Type 2 Diabetes With Persistent Microalbuminuria

*Time to death from any cause. **Post-Trial refers to the number of patients in whom the condition progressed during the period from the end of the original intervention trial to the endpoint examination after an average of 13.3 years of follow-up.

The following targets were used for the Intensive therapy group: HbA1c

Systemic Implementation Strategies to Improve Hypertension: The Kaiser Permanente Southern California

Experience

Canadian Journal of Cardiology 30 (2014) 544-552

Canadian Journal of Cardiology 30 (2014) 544e552

Systemic Implementation Strategies to Improve Hypertension: The Kaiser Permanente Southern California

Experience

El papel de especialistas en el manejo de la salud de poblaciones con enfermedades crnicas: el ejemplo de la ERC.

BMJ 2009;339:b2395

Kaiser Permanente Hawaii: 240000 afiliados con 10000 pacientes con ERC (TFG < 60 o Proteinuria 0.3 g/d) 110 mds generales remiten a 6 nefrlogos

Estratificacin del riesgo

Alto: TFG< 20 O TFG20-39 con 2 gram proteinuria O 4 gram proteinuria Bajo: TFG 30 Y

Menor eficaca Y eficiencia

Mayor eficaca Y eficiencia

Cualquiera con ERC

Pacientes con dao orgnico

Pacientes con mayor riesgo de progresin y de morbimortalidad

Pacientes con riesgo alto que se benefician ms con la ayuda de un especialista que de un generalista

Pacientes con riesgo alto que se benefician ms y son ms costo efectivo con la ayuda de un especialista que de un generalista

BMJ 2009;339:b2395

El papel de especialistas en el manejo de la salus de poblaciones con enfermedades crnicas: el ejemplo de la ERC.

0%

15%

30%

45%

60%

Remisin tarda HD inicio ambulatoio

56%

36%

12%

35%

18%

32%

2004 2008

RESULTADOS

The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease

BMJ 2009;339:b2395

Cumplimiento de metas del Programa PREVEN-SER - COMFAMA Julio 2012 - Junio de 2013

Medida/Meta % inicial que cumplen la meta% ltima consulta

que cumplen la meta

P < 5 mg/dL (> 80%) 82.0% 87.5%

Que reciban Nefroprotectores (> 80%) 37.9% 82.5%

Hb > 11 g/dL (> 80%) 68.7% 82.4%

Albmina 3.8 g/dL (>80%) 68.2% 80.0%

HbA1c < 7.5% (> 80%) 71.4% 79.6%

PA 140/80 mmHg (> 80%) 55.3% 68.2%

Albuminuria < 300 mg (>75%) 54% 64.2%

PTH < 110 pg/dL (> 70%) 55.4% 62.1%

C-LDL 100 mg/dL (> 80%) 52.2% 68.3%

Deterioro de TFG > 5 mL/min/ao (< 20%) 16.9%

N = 1263

Alvaro Mercado MD

46

0

25

50

75

100

HbA1c

Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug

prescribing and increased renal function

Kidney International (2013) 84, 174178;

J Am Soc Nephrol 25: 390398, 2014

El Cuidado de Enfermera Mejora los Resultados Renales en Pacientes con ERC

Multifactorial Approach and Superior Treatment Efficacy in Renal Patients with the Aid of Nurse Practitioners (MASTERPLAN)

Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes

J Gen Intern Med 2011. 27(5):5206

#Level 1 of patient activation (scores 047.0) indicates that an individual may not yet believe the patient role is important, level 2 (scores 47.1

55.1) indicates a patient lacks confidence and knowledge to take action, level 3 (scores 55.267.0) indicates a patient is beginning to engage in

recommended health behaviors, and level 4 (scores 67.1100) indicates a patient is proactive about health and engages in many recommended

health behaviors

Kidney International (2013) 84, 436438.

Educacin basada en auditora: un programa potencialmente efectivo en mejorar los logros

de las guas en ERC

with patients treated according tousual practice (4.9 versus 3.7mmHg;Figure 1). In addition, in the audit-based education arm, 2.7% more pa-tients reached the target of 140/90mmHg compared with the usual practicearm (12.0% versus 9.3%; Figure 1).Unfortunately, it remains unclear whythe authors chose this target and notthe target of 130/80mm Hg for patientswith albuminuria (it is unclear whatproportion of patients has albuminuria,but the US Renal Data System estimates70%8).

The question arises of whether sucha reduction in systolic blood pressure isrelevant to CKD patients in terms ofclinical outcomes. A reduction of 5mmHg indeed has beneficial effects onseveral clinical outcomes in the generalpopulation.9 However, these studypopulations consisted of relativelyyoung and healthy people, in contrastto the elderly CKD patients (mean age75 years) in the trial by de Lusignanaet al.,5 in whom blood pressure lower-ing may have a different effect. In linewith this, the effect on other clinicallyimportant outcomes in the trial ofde Lusignana et al.,5 such as stabiliza-tion of renal function and prevention ofcardiovascular events and death, wasless pronounced (Figure 1). Patientsfollowing the audit-based educationprogram experienced a similar changein estimated glomerular filtration ratecompared with patients following usualpractice (increase of 2.0ml/min per1.73m2 during a follow-up period ofapproximately 22.5 years). Further-more, the incidence of cardiovascular

events and mortality was 2.4 and 5.0%,respectively, in the audit-based educa-tion program and 3.0 and 6.6%,respectively, during usual practice. Thelatter implies that approximately 167and 63 patients need to be treated for22.5 years according to the audit-basededucation program in order to preventone cardiovascular event and onedeath, respectively (number needed totreat 1/ risk difference). These num-bers indicate that the positive effect ofthe audit-based education program oncardiovascular events is quite small butthat its positive effect on mortality issubstantial.

The effect on mortality could not beentirely explained by a greater switch toACEi and ARB medication, as sug-gested by de Lusignana et al.5 Indeed,the percentage of patients starting withan ACEi or ARB was comparable bet-ween the audit-based education armand the guidelines and prompts arm(6.5 versus 6.9%), in contrast to theincidence of mortality, which wasdifferent (5.0 versus 7.8%; Figure 1).Therefore, it needs to be exploredwhich element of the audit-based edu-cation program is actually causing thelower mortality. With respect to renalfunction stabilization and cardiovascu-lar events, we have to keep in mind thatthe follow-up time in the trial ofde Lusignana et al.5 may be too shortto detect large effects on these out-comes. The above-mentioned resultsraise the question of whether theclinical effects of the audit-based edu-cation program were worth the asso-ciated time, efforts, and costs.

The audit-based education programconsists of several steps that can beexperienced as burdensome, time-consuming, and costly. The step of dataextraction and processing is time-con-suming for the executive authorities.Following this audit, an individualizedaction plan needs to be developed andexplained to all treating physicians.To achieve this feedback and education,physicians need to attend workshopsor meetings that can be experiencedas burdensome. In this respect,de Lusignana et al.5 encountered a sub-optimal attendance of physicians at thefeedback workshops in the study. As theadherence to treatment guidelines out-side a clinical trial is expected to beeven lower, the application of the audit-based education program to all primarypractices may lead to a lower atten-dance and thereby a smaller effect onblood pressure and cardiovascularburden. Furthermore, in the trial ofde Lusignana et al.5 the local querieswere excluded from the trial forpractical reasons (concerns aboutethics and recruitment of practices).Theoretically, local queries could havesignificantly increased the effect onblood pressure, because they provide alist of patients who need to be targeted.However, if concerns about thefeasibility of local queries are presentin a highly standardized trial, they willdefinitely not be feasible in real clinicalpractice. Altogether, the audit-basededucation program may be seen as atime-consuming and costly program,which is justified only when the accom-panying clinical effect is substantial.

It is indisputable that the strictimplementation of treatment guidelinesis necessary to improve quality ofcare, thereby leading to better clinicaloutcomes. The trial of de Lusignanaet al.5 showed that an education-basedprogram slightly improves the imple-mentation of one treatment targetguideline, blood pressure control.Unfortunately, it was not assessedwhether the intervention was cost-effective, and further research shouldfocus on this aspect. Despite thesmall clinical effect, the audit-basededucation program can still be a

Systolic blood pressure (mm Hg)Target achievement (%)

Renal function (ml/min per 1.73 m2)Cardiovascular event (%)

Mortality (%)ACEi/ARB medication (%)

Usual practiceGuidelines andpromptsAudit-basededucation

05 1010 15Change

Effect on clinical outcomes

5

Figure 1 |Overview of the effect of audit-based education on clinical outcomes.ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker.

Kidney International (2013) 84 437

commentary

AVANCE EN EL SISTEMA DE SALUD EN PAGO POR RESULTADOS

COLOMBIA

MINSALUD COLOMBIA. RESOLUCION 248 DE 2014

El monto total recaudado ser distribuido en el primer ao de aplicacin de la presente resolucin, con base en el periodo julio 2013 a junio 2014 con la informacin que publique la cuenta de alto costo en enero de 2015, atendiendo los siguientes porcentajes: el 40% para ajustar la siniestralidad que enfrenta cada EPS-C, EPS-S y E0C; y el 60% restante, entre las EPS-C, EPS-S y EOC que cumplan los indicadores o metas propuestas por el Ministerio de Salud y Proteccin Social, con el fin de incentivar la gestin del riesgo en salud. Los indicadores o metas sern de proceso o resultado y tendrn que centrarse en las enfermedades precursoras de la enfermedad renal crnica. Con el fin de incentivar la gestin de riesgo en salud, los resultados en salud y evitar la seleccin adversa por parte de las aseguradoras, los indicadores o metas se estructuran por etapas.

En una primera etapa, los indicadores o metas se centrarn en procesos y en resultados y conforme se mejore la gestin y la informacin, se migrar exclusivamente hacia indicadores de resultados. En esta primera etapa se establecern dos indicadores de proceso y dos de resultado y se distribuirn los recursos entre las EPS-C, EPS-S y EOC que superen el promedio, meta o variacin establecida en cada indicador segn anexo que hace parte integrante de esta Resolucin. Los indicadores de proceso pesarn el 70% y los indicadores de resultado el 30%. Esta primera etapa no podr durar ms de dos aos, contados a partir del 2015, y se podrn incorporar indicadores de resultados o modificacin a las metas de medicin en el 2016. En el Anexo de la presente resolucin se presentan los indicadores iniciales.

En la segunda etapa se deber migrar hacia indicadores de resultados de salud y el Ministerio de Salud y Proteccin Social establecer metas concretas para cada indicador. Los indicadores se debern concertar con el Ministerio de Hacienda y Crdito Pblico, las EPS y las sociedades cientficas, segn corresponda. Los recursos se distribuirn entre las EPS- C, EPS-S y EOC que superen la meta.


COLOMBIA


ANEXO Primera etapa Indicadores iniciales A. Indicadores de Proceso: Al. Porcentaje de pacientes captados con enfermedades precursoras. Mide: La bsqueda activa de accesibilidad de afiliados en riesgo de desarrollar Enfermedad Renal como consecuencia de padecer la Hipertensin Arterial y la Diabetes Mellitus las cuales son consideradas como enfermedades precursoras de la Enfermedad Renal Crnica. Numerador: Se toma de la base entregada por la CAC los pacientes diagnosticados con las enfermedades precursoras (HTA DM) Denominador: Se toma la poblacin registrada en BDUA activos entre los 18 y 69 aos y las prevalencias de cada enfermedad, la fuente de informacin fue la ENS 2007.

A.2. Porcentaje de pacientes con enfermedades precursoras, estudiados (pacientes con los exmenes necesarios para confirmar el diagnstico) para ER. Mide: El diagnstico temprano de la enfermedad renal crnica. Este indicador mide el porcentaje de pacientes que una vez diagnosticados con HTA o DM, se les realiza el estudio pertinente para confirmar o descartar compromiso renal. Numerador: Se toma de la base entregada por la CAC los pacientes con alguna de las enfermedades precursoras (HTA DM) a los cuales se les prctico el examen que confirma o descarta la ERC. Denominador: Se toma de la base entregada por la CAC los pacientes diagnosticados con las enfermedades precursoras (HTA DM).

B. Indicador de resultado

B.1. Incidencia de ENFERMEDAD RENAL CRNICA estadio 5 Mide: La tasa de incidencia de ENFERMEDAD RENAL CRNICA estadio 5 proporciona una estimacin de la evolucin de la enfermedad renal, permitiendo a su vez estimar el grado de progresin. Se espera una disminucin en la aparicin de nuevos casos estadio 5 en respuesta al diagnstico y manejo oportuno y adecuado. Numerador: Se toma de la base entregada por la CAC los pacientes a los que durante el periodo inician alguna TRR desagregados por grupos etarios y distribuidos entre las diferentes EPS-C, EPS-S o EOC. Incidencia ajustada de ERC5 Denominador: Poblacin registrada y activa en BDUA desagregada por grupos etarios y distribuida entre las diferentes EPS-C, EPS-S o FOC. Numerador: Casos esperados por grupos etarios por EPS Denominador: Poblacin total registrada y Activa en BDUA.

B.2. Variacin de la incidencia por EPS-C, EPS-S y EOC. Este indicador incentiva la reduccin de casos incidentes de un ao a otro entre las EPS-C, EPS-S o EOC que muestren dicha condicin. Este indicador aplicar siempre y cuando la incidencia del pas disminuya entre un ao y otro. En el evento que la incidencia Pas aumente estos recursos se distribuirn mediante el indicador B.1. Mide: la variacin de la tasa de incidencia de ENFERMEDAD RENAL CRNICA estadio 5 entre el ao t-1 y el ao t. Se espera una disminucin en la aparicin de nuevos casos estadio 5 en respuesta al diagnstico y manejo oportuno y adecuado. Numerador: Se toma de la base entregada por la CAC los pacientes a los que durante los periodos t y t-1 inician alguna TRR desagregados por grupos etarios y distribuidos entre las diferentes EPS-C, EPS-S o EOC. Denominador: Poblacin registrada y Activa en BDUA desagregadapor grupos etarios y distribuida entre las diferentes EPS-C, EPS-S o EOC medida en el ao t.


# TIPO INDICADOR NUMERADOR DENOMINADOR

1 ResultadoControl de la hipertensin arterial para poblacion no diabetica

Nmero de pacientes con ERC e hipertensin y sin diabetes mellitus con cifras tensionales inferiores a 140/90 mmHg

Nmero de pacientes con diagnstico de ERC e hipertensin arterial sin diabetes mellitus.

2 ResultadoControl de la hipertensin arterial para poblacion diabetica

Nmero de pacientes con diagnstico de ERC y diabetes mellitus e hipertensin arterial con cifras tensionales iguales o inferiores a 130/80 mmHg

Nmero de pacientes con diagnstico de ERC e hipertensin arterial y diabetes mellitus.

3 Resultado Control de la diabetes mellitusNmero de pacientes con diagnstico de ERC y diabetes mellitus con HbA1c


EPS Millones ($)

1. SALUD TOTAL 79192. COOMEVA 7341

3. SURA 6135

4. SANITAS 2062

5. FERROCARRILES 1294

6. SOS 1272

7. CAFESALUD 1231

8. CRUZ BLANCA 1055

9. COMFENALCO VALLE 992

10. COMFAMILIAR CARTAGENA

284

11. CAPRESOCA 273

12. EPM 184

www.cuentadealtocosto.org


COLOMBIA

www.cuentadealtocosto.org

Colombia tiene el mejor registro de Enfermedad Renal Crnica , Hipertensin y Diabetes de Amrica Latina , segn

investigadores europeos quienes revisaron los registros de esta patologa en el mundo.

Colombia es pionero en Amrica Latina en promover la gestin de riesgo e introducir el pago por resultados en

salud.

Es uno de los pases con mayor disminucin de la incidencia de ERC terminal. (USRDS).

Disminucin del costo del tratamiento en la terapia dialtica por paciente con un ahorro de 900 mil millones de

pesos en 5 aos (US$450 millones) al sistema de salud.

Segn el comportamiento de la enfermedad renal crnica en estadio terminal presenta un crecimiento anual en

su incidencia cerca del 6%; sin embargo, en 4 aos se han evitado el ingreso a TRR aproximadamente de 5.169

casos lo cual significa un ahorro para el sistema de salud aproximadamente de 600 mil millones de pesos.

Este mecanismo de pago por resultados en ERC, HTA y DM impacta positivamente en los pacientes porque se

identificar que prestador y asegurador realiza adecuadamente los programas de control de hipertensin, diabetes

y nefroproteccin, y de esta forma se garantiza una mejor calidad de la atencin a travs del cumplimiento de guas

de manejo clnico de las patologas, lo cual se evidencia en la evaluacin por resultados.

[SP027] A GLOBAL OVERVIEW OF RENAL REGISTRIES - NEED FOR CONSISTENCY, ADDITIONAL OUTCOMES DATA AND WIDER GEOGRAPHICAL COVERAGE. ERA-EDTA 51st Congress, Amsterdam 2014

Patients starting RRT per year at HEFT displayed as the incident count

and the adjusted rate per million population aged >14 years.

Does community-wide chronic kidney disease management improve patient outcomes?

Nephrol Dial Transplant (2014) 29: 644649

Changes in distribution of modality at start of RRT between 2000 and

2012. Percentage starting with a catheter in 2012 is significantly lower

than in 2005, P = 0.001.

To assess the care of patients known to the nephrologyservice dying with ESRD without dialysis irrespective of theirplanned treatment, we identied patients dying withoutRRT with an eGFR 14years. (GP, general practice, i.e. primary care; HT, hypertension;QOF, Quality and Outcomes Framework.)

F IGURE 2 : Number of patients starting RRT per year at HEFT:(a) by diabetes status, (b) by ethnic origin. Diabetes may not havebeen the cause of ESRD.

ORIG

INALARTIC

LE

646 H.C. Rayner et al.

at BIBLIOTECHE BIOMEDICHE UNIVERSITA' DEGLI STUDI DI TORINO on M

arch 14, 2014http://ndt.oxfordjournals.org/

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SISTEMAS DE SALUD

CAMBIO DEMOGRAFICO

ENFERMEDADES CRONICAS

EXPECTATIVA PACIENTE

CONTENCION DE COSTOS

DESCENTRALIZACION DE RESPONSABILIDAD

NUEVO SISTEMA DE INCENTIVOS

TRANSPARENCIA

ENFASIS EN PREVENCION

ENFOQUE CENTRADO EN EL PACIENTE

RETOS Y TENDENCIAS EN LOS SISTEMAS DE SALUD

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