medisch team Maatschappij



Zin:   

Patient Arts/medisch team Maatschappij



Zin: 

Patient  Betere overleving  Betere gezondheid  Betere zorg (Cure? Of Care?)

 Financiele winst



Zin: 

Patient  Betere overleving  Betere gezondheid  Betere zorg (Cure? Of Care?)

 Financiele winst 

Arts/medisch team  Betere geneeskunde (cure of care?)  Meer patienten



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



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



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

Overgang eerste lijnsniveau naar specialistisch niveau

Andere spelers, vb huisarts, andere specialisten, thuisverpleging, dietiste

orgaanspecialist

huisarts

specialisten

Should everybody be treated by a nephrologist?

Lee, B. J et al. BMJ 2009;339:b2395

Copyright ©2009 BMJ Publishing Group Ltd.

Should everybody be treated by a nephrologist?

Lee, B. J et al. BMJ 2009;339:b2395

Copyright ©2009 BMJ Publishing Group Ltd.

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.

Prevalentie lage kostdialyse (increasing acceptance of elderly) 10000 9000 8000 7000

0-24jaar 25-34 jaar

6000

35-44 jaar 45-54 jaar

5000

55-64 jaar 65-74 jaar

4000

75-84 jaar

85 en ouder

3000

Totaal

2000 1000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

SBP (mm Hg) 130

134

138

142

146

150

154

170

180

GFR (mL/min/y)

0

-2 -4 -6

Untreated hypertension

-8 -10

-12

-14

r=0.69; P<0.05.

Parving HH et al. Br Med J. 1989. Viberti GC et al. JAMA. 1993. Klahr S et al. N Eng J Med. 1994. Hebert L et al. Kidney Int. 1994. Lebovitz H et al. Kidney Int. 1994.

Bakris et al. Am J Kidney Dis. 2000;36:646.

Moschio G et al. N Engl J Med. 1996. Bakris GL et al. Kidney Int. 1996. Bakris GL. Hypertension. 1997. GISEN Group. Lancet. 1997.

Laattijdige verwijzing minder dan zes maanden

Laattijdige verwijzing minder dan één maand

60%

50%

55% 45% 50% 40%

45%

35%

40%

30%

35%

25%

30% 25%

20%

20% 15% 15% 10%

10%

5%

5%

0%

0% 2000

2001

2002

2003

2004

2005

2006

2007

2000

2001

2002

2003

2004

2005

2006

2007

Mortaliteit na één jaarMinder dan 6

35%

Mortaliteit na één jaar

40%

maanden

Meer dan 6 maanden 30%

Minder dan 1 maand

35%

30% 25% 25% 20% 20% 15% 15%

10%

10%

5%

5%

0%

0% 2000

2001

2002

2003

2004

2005

2006

2007

2000

2001

2002

2003

2004

2005

2006

2007

Mortaliteit na één jaarMinder dan 6

35%

Mortaliteit na één jaar

40%

maanden

Meer dan 6 maanden 30%

Minder dan 1 maand

35%

Niet veel verschil in overleving tussen 1 en 6 maand opvolging... 30% 25% 25% 20% 20% 15% 15%

10%

10%

5%

5%

0%

0% 2000

2001

2002

2003

2004

2005

2006

2007

2000

2001

2002

2003

2004

2005

2006

2007

60 50

% Patients

PD HD

52 39

40 25

30 20

16

21 11

22

14

10 0 <1 * Modality on about day 60 of ESRD ** Excludes PD-2%, HD-6% “not sure”

1 to 3

4 to 12

>12

# Months Pre-ESRD

The USRDS Dialysis Morbidity and Mortality Study (Wave 2), USRDS 1997 Annual Data Report

70,0%

60,0%

50,0%

60

PD HD

52

50

% Patients

40,0%

30,0%

39

40

Minder dan 1 maand

25

30 20

Tussen 1 en 6 maanden

21

16

11

20,0%

22

Meer dan 6 maanden onbekend

14

10 10,0%

0 <1

1 to 3

>12

# Months Pre-ESRD

0,0%

* Modality on about day 60 of ESRD 2000 2001 2002 ** Excludes PD-2%, HD-6% “not sure”

4 to 12

2003

2004

2005

2006

2007

Totaal

The USRDS Dialysis Morbidity and Mortality Study (Wave 2), USRDS 1997 Annual Data Report

All late referrals are equal?

60 50

% Patients

PD HD

52 39

40 25

30 20

16

21 11

22

14

10 0 <1 * Modality on about day 60 of ESRD ** Excludes PD-2%, HD-6% “not sure”

1 to 3

4 to 12

>12

# Months Pre-ESRD

The USRDS Dialysis Morbidity and Mortality Study (Wave 2), USRDS 1997 Annual Data Report

60 50

% Patients

PD HD

52 39

40 25

30 20

16

21 11

22

14

10 0

* Modality on about day 60 of ESRD <1 sure” ** Excludes PD-2%, HD-6% “not

1 to 3

4 to 12

# Months Pre-ESRD

>12

The USRDS Dialysis Morbidity and Mortality Study (Wave 2), USRDS 1997 Annual Data Report

•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

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

Both Tight Glucose and Blood Pressure Control Reduce Cardiovascular Outcomes: UKPDS

0

Stroke

Any diabetes end point

Microvascular outcomes

Death

Percent

-10

-20

*

-30 -40

-50

*

*

* Tight BP control Tight glucose control

*P<0.05. Tight BP control = 144/82 mm Hg. Tight glucose control = HbA1c = 7.0%. UKPDS Group. BMJ. 1998;317:703; UKPDS Group. BMJ. 1998;317:713.

% of hypertensive patients prescribed NSAID’s at discharge

15% 12,5%

10%

8,8% 6,0%

5%

0%

<1.5-1.99 >2 Total Serum Creatinine (mg/dl)

McClellan WM, et al, Am J Kidney Dis, 1999; 29:368-375

Table 1 Impact of risk driven consultations on patterns of care. Values are numbers (percentages) unless otherwise stated

2004

2005

2006

2007

2008

All dialysis

113

89

94

86

84

Outpatient

39 (35)

44 (49)

50 (53)

54 (63)

47 (56)

108

75

87

75

76

Using mature arteriovenous fistulas

19 (18)

19 (25)

25 (29)

26 (35)

27 (36)

Using central venous catheter

83 (77)

54 (72)

55 (63)

46 (61)

45 (59)

Total* Referrals <120 days before onset

116 37 (32)

90 17 (19)

94 16 (17)

87 10 (12)

84 10 (12)

Referrals <365 days before onset

54 (47)

33 (37)

27 (29)

24 (28)

16 (19)

Difference in percentage points, 2004-8 (P value)

Starting dialysis

All haemodialysis

21 (P=0.003)

18 (P=0.006)

End stage renal disease

–20 (P=0.001)

–28 (P<0.0001)

John et al AJKD 43:825-835.

Impact of screening and referral of CKD patients

Jones et al, AJKD 2006

Survival in ESRD patients after 1 year

Cass et al, Med J Aust, 2002

Late referral in the elderly

Schwenger et al, NDT, 2006

The late referred early known patient

Buck et al, NDT 2007

Empowerment and Outcome Curtis et al, NDT, 2005, 147-154

Wu et al, NDT 2009

Wu et al, NDT 2009

Sodium intake and cardiovascular mortality

He et al, JAMA 1999

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

Bibbins-Domingo, NEJM, 201

Bibbins-Domingo, NEJM, 201

Bibbins-Domingo, NEJM, 201

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

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)

Underlying renal diagnosis

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

Underlying renal diagnosis in diabetics

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

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

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

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

Education Level

Waist circumference

Waist circumference Diabetics vs non diabetics

Bloodpressure

Nutritional status

Nutritional status

DPI g/kg/day

1,20 1,00 0,80 0,60 0,40 0,20 0,00

>50

50-25

25-10

<10 Ccrea ml/min

Ikizler et al, JASN,6, 1386-1391, 1995

Karp et al, Calcif Tissue Int, 200

Shinaberger et al, Am J Clin Nu

Shinaberger et al, Am J Clin Nu

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!

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