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Scottish national audit

All renal units in Scotland submit full demographic and survival data, and limited other information reflecting quality standards, to the Scottish Renal Registry. More extensive data is collected by the UK Renal Registry, but it covers only a minority of renal units within the UK. Pooled Scottish data can be seen with the UK Renal Registry data on the UKRR website. Edinburgh data is not separated in this analysis, but it is separated in the data released (on paper only, and not yet publicly) to Scottish renal units. Data for Edinburgh have been comparable to Scottish data in most respects. Where it is not, local audits are undertaken to understand possible explanations for any divergence.

Example: in 1999 anaemia levels were shown to be significantly worse in Edinburgh than in the rest of Scotland. An audit confirmed that restriction in the availability of Erythropoietin therapy seemed likely to be largely responsible for this. Protocols for the optimal use of erythropoietin were introduced and representations to the Health Board led to an increase in Erythropoietin prescribing. The 'haemoglobin gap' had largely disappeared by early 2001. Haemoglobin level is one of the parameters continuously monitored by the Scottish Renal Registry.


2001 Lothian audit of outcomes and associated factors

A detailed analysis of outcomes undertaken in 2001 is described in detail here.

 

Recent and current audit projects

(To follow)
 

Go to Continuing performance monitoring
(including
November 2001 Peer Review
process summary)
Go to National and International standards

 

2001 analysis of outcomes for Lothian patients 

During 2000/2001, the Edinburgh Unit took a particularly close look at outcomes for a group of patients who commenced renal replacement therapy (dialysis or transplantation) between July 1997 and June 2000. The results of this are described below.

Background

The Edinburgh Renal Unit provides a comprehensive service for renal replacement therapy (RRT) for patients with end-stage renal disease (ESRD) in the Lothian and Borders Health regions, covering a population of 730,000.  This study aimed to define the results being achieved, and to investigate possible influences on these outcomes.  Patients with ESRD who were treated conservatively were not included in the study. 

This study included all adult patients from Lothian and Borders Health Boards who started renal replacement therapy (RRT; dialysis or renal transplantation) between July 1997 and June 2000.

This section comprises the executive summary of a larger report that is predominantly a collection of statistics and figures without detailed explanation. Contact us at renal@ed.ac.uk if you would like further information.

Summary points

Provision of dialysis for ESRD in Lothian is consistent and appropriate

The acceptance rate is slightly below the average Scottish figure but rising at approximately the same rate

Outcomes in Edinburgh are similar to national and international comparators

For most patients, survival on dialysis is good

For some patients the risks of dying remain high, despite dialysis

Reliable identification of 'high risk' patients cannot be achieved by simple criteria suchas age or number of diseases

 

Data collection and analysis

Data collection and analysis was undertaken by members of staff of the Edinburgh Unit supported by ISD Scotland, between November 2000 and May 2001.  It involved extraction of data recorded on the Unit database, interrogation of clinical notes to extract information on comorbid conditions, and obtaining comparative data from the Scottish Renal Registry, the UK Renal Registry, and published literature.  Data included demographic factors, the presence of other diseases at the time of starting RRT, and other factors thought likely to have an impact on outcomes.  Measures of functional ability and quality of life were also made, but in a cross-sectional manner on survivors from the cohort at the beginning of 2001.  These are presented in the full report.  Hospitalisation data was obtained for patients commencing RRT before January 2000.  

You can download this report as a printable pdf file
Contents
Background
Data collection and analysis
Results
Acceptance for treatment
Prevalence
Treatment modality
Patient survival
Hospitalisation
Comments and conclusions
References

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Results

Acceptance for treatment

249 patients, 143 male and 106 (43%) female, commenced RRT during the 3 year period July 1997 - June 2000, a take-on rate of 94 pmp per year.  At the same time, the take-on rate for Scotland was 107 pmp per year. The equivalent rate from the UK Renal Registry was 97 pmp.  All these figures are low by European standards, but there may be epidemiological as well as resource reasons for some of the differences noted internationally. The rates in Germany and Canada were approximately 150 pmp; in the USA, 320 pmp. A male excess is observed in all surveys of ESRF.  In all countries, including Scotland and the UK, the take-on rate is rising steadily. 

The proportions of patients with ESRF caused by inherited disease (12%), glomerulonephritis (16%), and the proportion with diabetes (20%; labelled as causing ESRF in 14%) were similar to those in Scotland and in the UK Renal Registry. 

Within the region there was no significant difference in the take-on rate or time of referral by Carstairs index (a measure of socioeconomic deprivation) or area of residence, although small differences could not be confidently excluded because of the size of the study. 

26% of patients commencing RRT had been known to the Unit for less than 90 days. 

The median age of patients commencing RRT was 63y but rose slowly during the study.  The equivalent figure for Scotland was 65y, with a similar rate of rise. Comparing the take-on rate to the age profile of the general population, and what is known of the incidence of renal impairment with age (it rises sharply in older age groups), the expected bulge of very elderly patients is not seen in the RRT programme in Lothian, or elsewhere in the UK.

 

Prevalence

On 27th April 2001, 449 patients in the region were alive and receiving RRT. This gives a prevalence for treated ESRD of 616 pmp.  The figure for Scotland is 563 pmp.  Within the local region, 52% (232) had a functioning renal transplant, 35% (160) were receiving haemodialysis and 13% (57) were receiving peritoneal dialysis. 

 

Treatment modality

The modality of first RRT was haemodialysis (HD) for 76%, peritoneal dialysis (PD) for 22.5%, and transplantation for 4 patients.  Commencement on HD was more likely for patients referred late (<90 days), and for higher risk-group or older patients. Of total (stock) dialysis patients, 74% were receiving HD, 26% PD.

The proportion of patients receiving HD as a first treatment was similar to the Scottish proportion (76.5%) but higher than the England and Wales figure of 59%. By international standards England and Wales treats an unusually high proportion of patients by CAPD, although this is falling. Lothian PD patients had higher patient survival, technique survival, and transplantation rates than those reported for PD patients by the UKRR. 

 

Patient survival

Overall patient survival was 91% at 90 days, 87% at 6 months, and 79% at one year.  This was strongly influenced by age and by the presence of other diseases.  There were no significant influences from other factors, including late referral or modality of first RRT, when these were adjusted for age and comorbidity. Risk group analysis appeared to offer the most useful information.

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Survival by risk category

Patients were stratified into risk groups using age and comorbidity.  These groups were determined by testing previously used and published criteria against the local population, leading to the definition of three groups of similar size, which were analysed in detail.  Comorbid conditions were defined as:

  • Ischaemic Heart Disease (eg, myocardial infarction or heart attack)
  • Cerebrovascular Disease (eg stroke)
  • Peripheral Vascular Disease (eg amputation or claudication)
  • Diabetes
  • Cancer (not including skin tumours)

Category

Description
Patient survival (%)
90d
6 mo
1y
2y

LOW RISK

Age <70y with no comorbid diseases

[median age 49y]


99

96

96

93

MEDIUM RISK

Age 70-79y, or <70y with 1 comorbid disease

[median age 71y]


92

88

76

63

HIGH RISK

Age 80y, or any age with 2 or more comorbid diseases, or any age with cancer

[median age 67y]


81

76

63

33

Survival in the low risk group over the period of the study was excellent. However in the high risk group median survival was only 14 months.  Nevertheless 1 in 3 of this group remained alive at two years, and mortality in the group had almost plateaued by this time. The unexpectedly low median age of the high risk group is probably caused by low referral rates of elderly patients with comorbid conditions. 

Study of individual diagnoses or age showed weaker effects than provided by the risk group categorisation.  Age had the most powerful effect as a single factor:  the risk of death for patients over 75y was 12 times that of patients aged <59y.  However it was equally high for patients aged 65-74y, at 13-fold increased risk.  For patients over 75, median survival was 18 months.  Few comparable data are available but an equivalent figure for patients in Leicester (Munshi 2000) was 16 months. 

Studies using similar risk group categorisation show similar effects but of variable degree. The survival curve for patients treated in Aberdeen and Dundee is closely similar to that in Edinburgh, with 35% 2 year survival for the High Risk group. In a survey using a similar classification across European centres, the overall figure was about 40%, but the range of 2-year survival was from 27% (Netherlands) to 72% (Nantes). The nature of comorbid illnesses differed in the different centres - for example the centres with lower survival experienced a much higher incidence of peripheral vascular disease.

The use of risk groups was imperfect as a guide to prognosis, but gave a better guide than using single risk factors or age alone.  The inadequacies of this simple classification of risk were illustrated by the fact that 3 patients (4%) from the group classified as High Risk by this algorithm were deemed to be fit for renal transplantation. However patients thought to be at high risk after an extended clinical assessment are not accepted for transplantation.  No simple way of identifying the 'high risk' patients who became long-term survivors could be found, either during the study, or in a follow-up analysis that looked closely at survivors. 

 

Hospitalisation

Percentage of time spent in hospital was increased markedly by risk group (12% of time for high risk group, 4% for low), and age (10% over 75y, 3% under 50y). 

 

Comments and Conclusions

The outcomes observed in this study compare favourably with those achieved in comparable centres.  Outcomes were excellent for low and medium risk patients.  The mortality of the high risk group is of concern, but is similar to that encountered elsewhere, and in large part is likely to be related to comorbidity, rather than directly to renal failure and its treatment. 

Continued careful assessment of appropriate therapy for patients believed to be at high risk will be important, as this is the major growth area for the expansion of dialysis provision at present.  It will be important to continue to seek to identify avoidable reasons for excess mortality. 

 

References

Ansell D & Feest T.  The 3rd annual report, The UK Renal Registry 2000. http://www.renalreg.com/
Beddhu S, Bruns FJ, Saul M, Seddon P, Zeidel ML.  A simple comorbidity scale predicts clinical outcomes and costs in dialysis patients. Am J Med 2000; 108: 609-13
Barrett BJ, Parfrey PS, Morgan J, Barre P, Fine A, Goldstein MB, Handa SP, Jindal KK, Kjellstrand CM, Levin AL, Mandin H, Muirhead N & Richardson R.  Prediction of early death in end-stage renal disease patients starting dialysis.  American Journal of Kidney Diseases 1997; 29: 214-222.
Chandna SM, Schulz J, Lawrence C, Greenwood RN & Farrington K.  Is there a rationale for rationing chronic dialysis?  A cohort based study of factors affecting survival and morbidity.  British Medical Journal 1999; 318: 217-223.
Hirsch DJ, West ML, Cohen AD & Jindal KK.  Experience with not offering dialysis to patients with a poor prognosis.  American Journal of Kidney Diseases 1994; 23: 463-466.
Khan IH, Catto GRD, Edward N, Fleming LW, Henderson IS & MacLeod AM.  Influence of coexisting disease on renal-replacement therapy. Lancet 1993; 341: 415-418.
Munshi SK, Vijayakumar N, Taub NA, Bhullar H, Lo TC, Warwick G. Outcome of renal replacement therapy in the very elderly.  Nephrol Dial Transplant 2001; 16: 128-33
Rodger RSC & Briggs JD.  Renal replacement therapy in the elderly.  Scottish Medical Journal 1997; 42: 143-144.
Walters G, Warwick G & Walls J.  Analysis of patients dying within one year of starting renal replacement therapy.  American Journal of Nephrology 2000; 20: 358-363.
U.S. Renal Data System, USRDS 2001 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2001. 
http://www.usrds.org/

You can download the above report as a printable pdf file
 

Continuing performance monitoring

Edinburgh has participated with the Scottish Renal Registry's continuous data collection and comparisons since its commencement in 1990. In the last few years comparisons have gone further than just comparing numbers - Units have been visited by outside review groups, each visit including doctors, nurses, paramedical staff, and patients. Edinburgh was visited at the end of 2001 and the 2002 report can be read here.

 

National and International standards

Scotland - The Clinical Standards Board for Scotland is generating a set of standards that all units in Scotland should seek to fulfill, and on which they will be assessed. Each standard is graded as 'essential' or 'desirable'. The standards are deliberately worded so that you do not need to be an expert to understand them, and they extend to non-medical areas such as the availability of supporting services, and whether transport arrangements are adequate. However in some aspects they are quite limited during the current first cycle of the process. The February 2002 document can be reached from their website - go to 'publications'. It draws on the UK standards:

UK - The Renal Association of the UK is working on the Third edition of the Renal Association Standards Document. It is more comprehensive, but also more complex and difficult to read than the Scottish one.

USA - The USA has gone furthest with its definition of desirable standards. The National Kidney Foundation (USA) has sponsored the development of a series of guidelines originally known as the DOQI guidelines. (DOQI = Dialysis Outcome Quality Initiative). This has now become a huge and complex series of documents renamed K/DOQI (Kidney Disease Outcomes Quality Initiative) that is available online at K/DOQI. Most of the guidelines related to dialysis are still under the DOQI heading.

You may find more useful information from our Links page


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This page last modified 02.12.2009 14:02 by Emma Farrell. edren and edrep are produced by the Renal Unit at the Royal Infirmary of Edinburgh and the University of Edinburgh. CAUTIONS and Contact us.