Victoria Briggs

Getting More out of Clinical Practice Guidelines

This short paper reviews the challenges of clinical guideline development, implementation, and efficacy measurement (“audit”). The objective of any clinical guideline is to advise health care teams on the optimal management of patients and also to provide standards by which to audit the quality of clinical care. The International Society for Peritoneal Dialysis (ISPD) has a strong tradition of clinical guideline development, covering themes that are intended to support the practice of effective peritoneal dialysis (PD). Most recently, those guidelines have addressed infection (1) and access management (2). The use of guidelines in clinical practice is ever increasing, and much discussion about the effectiveness of guidelines has occurred over the last few years.

Chapter 14 Comparative audit of peritoneal dialysis catheter placement in England, Northern Ireland and Wales in 2011: a summary of progress to July 2012.

Background: The central paradigm of effective peritoneal dialysis (PD) is an appropriate standard of PD catheter function. Aim: The ultimate aim of the project is to develop an effective national PD access audit which will identify what represents an ‘appropriate standard’ of PD catheter function. Methods: A 2009 Renal Association working party recommended that the UK Renal Registry should collect centre specific information on various PD access outcome measures including catheter functionality and post-insertion complications. Results: The first PD access audit covering England, Northern Ireland and Wales was conducted during April to June 2012 looking at incident dialysis patients in 2011. Forty three data collection spreadsheets were returned from a total of 63 centres describing 863 PD catheter placements of which 225 had a missing date of insertion. Results will be published on the UK Renal Registry website as soon as they are available. Discussion: There is clearly much to be learned as the project is progressed, including minimising data ambiguities and trying to maximise data completeness (for example it is possible that a patient with a catheter that never worked and never had PD may be overlooked in this audit). However, a comparative PD catheter audit has the potential to provide valuable information on an important patient related outcome measure and lead to an improvement in patient experience.

Appendix E Methodology for Estimating Catchment Populations of Renal Centres in England for Dialysis Patients

Providing accurate centre-level incidence and prevalence rates for patients receiving renal replacement therapy (RRT) in the UK has been limited in the past by the difficulty in estimating the catchment population from which the RRT population was derived. One reason for this is that the geographical boundaries separating renal centres are relatively arbitrary and dependent upon a number of factors including referral practice, patient choice and patient movement. Previously, incidence and prevalence rates have been calculated at Local Authority/Primary Care Trust/Health Board level where denominator data were available, but not at renal centre level. Previous UK Renal Registry (UKRR) Annual Reports have suggested an estimate of the size of the catchment populations. These were extrapolated figures originally derived from data in the 1992 National Renal Survey undertaken by Paul Roderick. The purpose of this appendix is to present an estimate of the dialysis catchment population for all renal centres in England. The document also contains a methodological description and discussion of the limitations of this estimate. These catchment population estimates have been used in this report (chapter 1: UK RRT Incidence in 2009: national and centre-specific analyses) to calculate RRT incidence rates by renal centre, rather than only by Primary Care Trust/HB.

United Kingdom Catheter Study- Protocol Synopsis

Background High-quality peritoneal dialysis (PD) catheter insertion pathways are essential for optimal access to the therapy. Dialysis outcomes are influenced by a range of patient and center-related factors, and there is a need to better understand these so that catheter insertion pathways can be better matched to individual circumstances. Objectives To examine how patient- and center-related factors influence the choice of catheter insertion pathways for a PD patient, and the impact of such factors and pathways on patient outcomes, and specifically, to compare the occurrence of and recovery from PD catheter-related adverse events and mortality in individuals who had surgical catheter insertion with those who had medical catheter insertion, and evaluate health economics. Study design A prospective multi-center cohort study of incident PD patients at catheter insertion. This is an ancillary study nested within the International Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). Methods Patients will be recruited during a 30-month recruitment period at 45 United Kingdom (UK) renal facilities, with a minimum 12-month follow-up. A graphical Markov model will be fitted to describe the associations between patient demographics, comorbidities, and catheter insertion pathways that are not explained by center practices and their impact on the occurrence of catheter-related adverse events, and patient-reported outcomes. The model will also explore the extent to which the catheter insertion pathway is determined by the center practice patterns, accounting for patient mix. Multi-state models will compare the rate of occurrence of a PD catheter-related adverse event, recovery from this, and mortality in individuals who had surgical catheter insertion compared with those who had medical catheter insertion, accounting for competing events, and adjusting for patient and center factors. A health economics evaluation will establish which, if any, catheter insertion pathway is superior in terms of cost effectiveness. Discussion The study will provide information on which catheter insertion pathways are better according to individual characteristics and whether it is acceptable for dialysis units to rely on a single catheter insertion technique or whether they should invest in developing flexible pathways that incorporate both medical and surgical PD catheter insertion techniques.

UK Renal Registry 15th Annual Report: Appendix D Methodology used for Analyses of PCT/HB Incidence and Prevalence Rates and of Standardised Ratios

The areas used were the 146 English primary care trusts (PCTs), the five English care trusts, the seven Welsh Local Health Boards, the fourteen Scottish Health Boards and the five Health and Social Care Trusts in Northern Ireland – these different types of area are collectively called PCT/HBs here. These areas in England are likely to undergo significant reorganisation in the next few years with the introduction of clinical commissioning groups. There will be more of these areas each containing smaller population groups, although the boundaries have yet to be finalised.

UK Renal Registry 15th Annual Report: Appendix H Coding: Ethnicity, EDTA Primary Renal Diagnoses, EDTA Causes of Death

Ethnicity data is recorded in the clinical information systems in the individual renal centres in the format of 9S. . . read codes. If extracted from local PAS systems in a different format, it is recoded to the 9S. . . format by the centre, before being sent to the UKRR. For report analyses, ethnic categories are condensed into five groups (White, Asian, Black, Chinese and other). For some analyses Chinese are grouped into other.

UK Renal Registry 15th Annual Report: Appendix I Acronyms and Abbreviations used in the Report

ACE (inhibitor) Angiotensin converting enzyme (inhibitor) ANZDATA Australia and New Zealand Dialysis and Transplant Registry APD Automated peritoneal dialysis ADPKD Autosomal dominant polycystic kidney disease APKD Adult polycystic kidney disease AV Arteriovenous AVF Arteriovenous fistula AVG Arteriovenous graft BAPN British Association of Paediatric Nephrology BCG Bromocresol green BCP Bromocresol purple BMI Body mass index BP Blood pressure BTS British Transplant Society CAB Clinical Affairs Board (Renal Association) CABG Coronary artery bypass grafting CAPD Continuous ambulatory peritoneal dialysis CCL Clinical Computing Limited CCPD Cycling peritoneal dialysis CHr Target reticulocyte Hb content CI Confidence interval CK Creatine kinase CKD Chronic kidney disease CK-MB Creatine kinase isoenzyme MB COPD Chronic obstructive pulmonary disease CRF Chronic renal failure CRP C-reactive protein CVVH Continuous veno-venous haemofiltration CXR Chest x-ray DBP Diastolic blood pressure DCCT Diabetes Control and Complications Trial DH Department of Health DM Diabetes mellitus DOPPS Dialysis Outcomes and Practice Patterns Study E&W England and Wales E, W & NI England, Wales and Northern Ireland EBPG European Best Practice Guidelines ECG Electrocardiogram EDTA European Dialysis and Transplant Association EF Error factor eGFR Estimated glomerular filtration rate

Appendix F Additional Data Tables for 2010 Incident and Prevalent Patients

Abrdn 76 24 L Rfree 74 11 15 Airdrie 88 13 L St.G 75 13 12 Antrim 95 5 LWest 89 2 8 B Heart 81 16 3 Leeds 72 19 9 B QEH 75 19 6 Leic 67 20 13 Bangor 81 19 Liv Ain 94 6 Basldn 94 6 Liv RI 57 30 13 Belfast 87 8 4 M Hope 55 31 14 Bradfd 83 14 3 M RI 65 21 14 Brightn 72 28 Middlbr 83 12 5 Bristol 79 11 11 Newc 65 17 18 Camb 63 11 26 Newry 90 10 Cardff 73 19 8 Norwch 74 26 Carlis 76 24 Nottm 66 27 6 Carsh 85 8 7 Oxford 65 21 14 Chelms 62 38 Plymth 69 27 4 Clwyd 92 8 Ports 65 26 9 Colchr 100 Prestn 83 14 3 Covnt 71 23 6 Redng 52 38 10 Table F.1.2. Number of patients per treatment modality at 90 days (incident cohort 1/10/2009 to 30/09/2010)

Appendix D: Methodology Used for Analyses of PCT/HB Incidence and Prevalence Rates and of Standardised Ratios

The areas used were the 147 English primary care trusts (PCTs), the 5 English care trusts, the 7 Welsh Local Health Boards, the 14 Scottish Health Boards and the 5 Health and Social Care Trusts in Northern Ireland – these different types of area are collectively called PCT/ HBs here. For Wales, Scotland and Northern Ireland this is the first report in which we have used these areas – previously local authorities/council areas/district council areas were used.