5.7.5. Control tools and policies

Primary prevention

See Chapter 8

Secondary prevention

It is still uncertain whether screening the general population for CKD is cost-effective (Boulware et al, 2003; Atthobari et al, 2006). Targeting individuals with cardiovascular risk factors or with cardiovascular disease (i.e. those individuals in whom CKD acts as a risk amplifier) and diabetics appears to be a reasonable approach to the problem {14 National Kidney Foundation, 2002 79 /id}. Mass screening through the measurement of albumin excretion has been advocated by investigators in Groningen (The Netherlands) and a cost-effectiveness analysis in support of this contention has been provided (Gansevoort et al, 2005) . Patients with neoplasia and with chronic infectious diseases such as HIV and viral hepatitis (HBC and HBB) are at higher risk for CKD. When the risk of complications due to modifiable factors is high, for example when nephrotoxic drugs should be used for the treatment of neoplasia, screening for CKD appears advisable. Both in patients with neoplasia and in those with chronic infections, screening for CKD could be implemented using the existing infrastructures used for the detection of these diseases.

Policies

·          The Danish Health Ministry has had a quality improvement program for RRT, administered by the Danish Society of Nephrology since 2000. Up until now, the eight parameters collected have been mainly biochemical, but as of 2009, quality measures will be based on patient outcomes, referral patterns and hospital administration.

·          In Greece the Ministry of Health has not issued any objectives, nor have undertaken any initiative relating the incidence and the course of CKD. The only activities to inform the general population on the epidemiological problem of CKD have been related to the campaign of the Hellenic Society of Nephrology, particularly during the World Kidney Day, in the last two years.

·          In Poland in 2007 a programme to detect CKD in an early phase was presented to a Parliamentary Health Commission. Unfortunately, the plan has not yet been accepted at national level.

·          The public health policy in Finland is that all patients should receive RRT when deemed necessary. The patient association - which is supported by the Finnish Government - has issued a declaration on the quality of care for renal patients.

·          In Spain there is no single agenda for CKD and ESRD at national level, as the national health authorities have decided to incorporate these subjects into public health policies on cardiovascular disease and diabetes mellitus.

·          Since April 2007 German dialysis centres, by law, have regularly electronically reported four quality indicators. Since the beginning of 2008 a central organization has provided information to the centres about their quality based on these parameters in relation to the national average. It is planned that after 2008 dialysis centres will face disadvantages (most likely monetary), if more than 15% of their patients fail defined limits.

·          In The Netherlands, quality assurance is a vital element of the dialysis care system. The government has stepped back from a system of planning; now, licensing and market parties have to take responsibility for the provision and quality of health care. At present, there is a system of quality control, auditing and certification of dialysis providers. Nearly 90% of the dialysis centers have a quality certificate. The development of an efficient system for benchmarking clinical performance data is currently in progress.

·          In 2001 in France, the so-called "Graft plan" was set to improve organ donation and transplant activity. In 2002 new regulations on RRT, established that planning of the supply of care should be related to population needs, assessed at regional level. In 2004 the French Ministry of Health established a list of 100 public health objectives; two of which concerned chronic renal failure: (1) to stabilize (or decrease) the incidence of ESRD and (2) to reduce the impact of chronic renal failure on quality of life, especially in dialysis patients. Since 2005, it has been mandatory for laboratories to provide both serum creatinine and equation-based GFR estimates for any creatinine prescription in order to improve CKD diagnosis. Policies regarding evaluation of care including CKD are currently in progress.

·          In Italy, in March 2007, a report by the Istituto Nazionale di Statistica did not list CKD among chronic diseases. On September 26th 2007, after a special convention held in Rome, the Ministry of Health agreed that a public health policy should be developed to counter this disease. A proposal for a survey on the prevalence of CKD at community level has been submitted by the Italian Society of Nephrology to the Ministry of Health and it is possible that this survey will be included in the framework of an ongoing cardiovascular prevention project of the Istituto Superiore di Sanità. As for ESRD, reporting on quality of treatment is still not compulsory.

·          The UK Renal Registry monitors the quantity and quality of RRT care using electronic methods of data transfer from hospital based clinical renal IT systems. The NHS Healthcare Commission monitors quality improvement in England & Wales through the UK registry, while NHS Quality Improvement Scotland (QIS) does this in Scotland. The UK Renal Association has developed detailed guidelines and standards for audit measures in Renal Services. The NHS in England and also in Wales has published a national service framework for renal services. Although CKD has hitherto been an under-diagnosed condition, recent changes in the measurements of the kidney function and the introduction of CKD into the Quality and Outcomes Framework (QOF), which rewards GPs, have now made the UK a world leader in this field. Under QOF, GPs are now paid partly on the basis of how well they manage patients with CKD. This helps ensuring that once people are diagnosed with CKD, they get high quality advice and support in modifying the lifestyle factors which exacerbate the effects of their diseases. Early figures indicate that in the year up to to March 2007,the first in which this system was in operation, roughly 1.5 million people were diagnosed with CKD, creating an opportunity to provide potentially life-saving advice and treatment. CKD receives 27 points in QOF, with a further 9 for diabetes directly related to kidney disease. This significantly supports the implementation of the Renal National Service Framework (NSF) quality requirements which aim to minimise the imoact of kidney disease in its early stages.

·          The Ministry of Health in Norway has started a process to create a national action plan for CKD, including secondary prevention, dialysis and kidney transplant.

·          The Austrian Ministry of Health commissioned an institute (OEBIG) to issue an Austrian Health Plan (OESG).Regulations concerning the provision of ESRD treatment throughout Austria have been indicated in this Health Plan. The Plan also stated, that the Austrian Dialysis- and Transplantation Registry (OEDTR) shall take care of quality assurance in ESRD treatment. The Health Plan found its way to regional health legislation and planning in all nine Austrian counties via an agreement between the federal government and the counties, the so called "§15a-Vereinbarung".

·          In the Czech Republic, RRT is freely available for all citizens. The average waiting time for transplantation is about 2 years. Accessibility of dialysis therapy is possible in 92 dialysis centres; in 2006, there were 464 pmp under dialysis treatment. The registry of patients (i.e. The Statistical Yearbook of Dialysis Treatments) is organized by the Czech Society of Nephrology in cooperation with the Dialysis Centres.

·          There are no public health policies on CKD or RRT in Estonia and Sweden. We lack information on all other countries.

·          NephroQUEST (Jager and Zoccali, 2007) is an initiative promoted by the ERA-EDTA registry and co-funded by the European Commission whose aim is to give assistance in the collection of clinical performance indicators in RRT comparable at international level.