Expert Systems Expert Systems in Renal Diseasein Renal Disease

Kent Renal ServiceKent Renal Service University of KentUniversity of Kent Salford Salford HospitalHospitalChris FarmerChris FarmerBernhard Klebe Bernhard Klebe Jean IrvingJean Irving Donal O’DonoghueDonal O’DonoghuePaul StevensPaul Stevens Roger CooleyRoger Cooley Rachel MiddletonRachel MiddletonHelen HobbsHelen Hobbs

Referral Variance

SD

+2.0

0.0

-2.0

Referral variance Corrected for age, gender, ethnicity and populationExtremal Quotient 52.72Farmer C, Hobbs H, Klebe B, Stevens P

Referral Rates 2003-Referral Rates 2003-20062006

0

20

40

60

80

100

120

140

160

AUG OCT DEC FEB APR JUN AUG OCT DEC FEB APR JUN AUG OCT DEC FEB APR

2003

2004

2005

2006

Proportion of Referrals Proportion of Referrals SeenSeen

0

10

20

30

40

50

60

70

80

90

100

JUN JULY AUG SEP OCT NOV DEC JAN FEB MAR APR MAY

2005

2006

Perc

en

tag

e

Outpatient ActivityOutpatient Activity

623 forms assessed623 forms assessed

53.2% Male53.2% Male

Median Age 59 (16-93)Median Age 59 (16-93)

Median SCr 124 Median SCr 124 mol/L (35-832)mol/L (35-832)

Median calculated GFR 50.4 Median calculated GFR 50.4

(4.7>90) ml/min(4.7>90) ml/min

John RI, Farmer CK, Abbs I, Stevens PE

Intervention in the Last Intervention in the Last YearYear

0

10

20

30

40

50

60

Biopsy BP Angioplasty Immunosupn Statin Aspirin Renal Comp

*

* Denotes number of biopsies performed ever

Possible to identify patients who could Possible to identify patients who could be discharged based on:be discharged based on:

Stable Chronic Kidney DiseaseStable Chronic Kidney DiseaseBlood Pressure under 140/85Blood Pressure under 140/85No alteration in treatment in the past yearNo alteration in treatment in the past year

29.8% of patients followed 29.8% of patients followed

upup

Possible to identify patients who could Possible to identify patients who could be discharged based on:be discharged based on:

Stable Chronic Kidney DiseaseStable Chronic Kidney DiseaseBlood Pressure under 140/85Blood Pressure under 140/85No alteration in treatment in the past yearNo alteration in treatment in the past year

29.8% of patients followed 29.8% of patients followed

upup

Provided there is a robust

follow up arrangement

UK Referral GuidelinesUK Referral GuidelinesNEOERICNEOERICAA

Per Per MillionMillion

ActionAction

Stage 3Stage 3 20472047 1262612626 Other Tests Other Tests Stable Stable

1818 111111 Refer Hb<11Refer Hb<11

2727 167167 Refer BP Refer BP >130/90 >130/90 On 3 agentsOn 3 agents

240240 14801480 Refer GFR Refer GFR fallingfalling

Stage 4Stage 4 4545 278278 Another test Another test then referthen refer

99 6060 ReferRefer

Stage 5Stage 5 55 3636 ReferRefer

UK Referral GuidelinesUK Referral GuidelinesNEOERICNEOERICAA

Per Per MillionMillion

ActionAction

Stage 3Stage 3 20472047 1262612626 Other Tests Other Tests Stable Stable

1818 111111 Refer Hb<11Refer Hb<11

2727 167167 Refer BP Refer BP >130/90 >130/90 On 3 agentsOn 3 agents

240240 14801480 Refer GFR Refer GFR fallingfalling

Stage 4Stage 4 4545 278278 Another test Another test then referthen refer

99 6060 ReferRefer

Stage 5Stage 5 55 3636 ReferRefer2

55

8

Referral Rates 2003-Referral Rates 2003-20062006

0

50

100

150

200

250

AUG OCT DEC FEB APR JUN AUG OCT DEC FEB APR JUN AUG OCT DEC FEB APR

2003

2004

2005

2006

Referral Rates 2003-Referral Rates 2003-20062006

0

50

100

150

200

250

AUG OCT DEC FEB APR JUN AUG OCT DEC FEB APR JUN AUG OCT DEC FEB APR

2003

2004

2005

2006

ARF

Stage 5

Stage 4Unstable 3

Immunosuppressed

Stage 4 (stable)

Hypertension

Stable Stage 3

Stage 1 or 2

At Risk Populations

Intensive Management

Hospital Based Care

Community based care

Incr

easing

Lev

el

Of Car

e Nee

ded

Structured delivery of care

Expert System in Kidney Expert System in Kidney DiseaseDisease

Identify patients requiring intensive Identify patients requiring intensive managementmanagement

Facilitate robust follow up of patients Facilitate robust follow up of patients discharged from hospital based caredischarged from hospital based care

Provide patient specific guidance for further Provide patient specific guidance for further investigations of patients with CKDinvestigations of patients with CKD

Manage stable chronic kidney disease in the Manage stable chronic kidney disease in the communitycommunity

General Practice

Database Systems

Data Extraction

MIQUEST

Database

Reporting Tool

Complete Database

Study Data

Patient Reports

Decision Support

Expert System

General Practice

Database Systems

Data Extraction

MIQUEST

Database

Reporting Tool

Complete Database

Study Data

Patient Reports

Decision Support

Expert System

General Practice

Database Systems

Data Extraction

MIQUEST

Database

Reporting Tool

Complete Database

Study Data

Patient Reports

Decision Support

Expert System

General Practice

Database Systems

Data Extraction

MIQUEST

Database

Reporting Tool

Complete Database

Study Data

Patient Reports

Decision Support

Expert System

Patientid varchar (20)pracid intsex varchar(6)dob dategp varchar(8)regDate date

Creatinineid varchar (20)date datevalue intpracid int

ReportedGfrid varchar (20)date datevalue floatpracid int

Bpid varchar (20)date datesystolic intdiastolic intpracid int

Calciumid varchar (20)date datevalue floatpracid int

Hbid varchar (20)date datevalue floatpracid int

Phosphateid varchar (20)date datevalue floatpracid int

Potassiumid varchar (20)date datevalue floatpracid int

Pthid varchar (20)date datevalue intpracid int

Knownid varchar (20)code varchar(30)date datepracid int

Tables are linked by id and pracid to patient table.

Tables created by SetupDatabase and filled by MiqReader.

Resultid varchar (20)date datestage intexitno intpracid int FurtherAction

id varchar (20)date dateactionid int pracid intdone boolean

RecommendationsexitNo intrecommendation varchar(500)

Actionsactionid intaction varchar(30)

Practicepracid intname varchar(30)

KnownRubriccode varchar(30)rubric varchar(30)

Treatmentid varchar (20)code varchar(30)date datepracid inttype int

Drugcode varchar(30)rubric varchar(200)

Categorytype intcategory varchar(30)

Populationpracid intpopulation intdate date Gfr

id varchar (20)date datevalue floatpracid int

(may decide not to keep this – recalculable)

Diabeticid varchar (20)code varchar(30)date datepracid int

DiabeticRubriccode varchar(30)rubric varchar(30)

Glucoseid varchar (20)date datevalue intpracid int

HbA1cid varchar (20)date datevalue intpracid int

Cholesterolid varchar (20)Codedate datevalue intpracid int

Proteinuriaid varchar (20)Codedate datevalue intpracid int

Triglycerideid varchar (20)date datevalue intpracid int

PCR

id varchar (20)date datevalue intpracid int

Proteinuriaid varchar (20)Codedate datevalue intpracid int

GPDecisionid varchar (20)date datepracid intdecisionCode int

DecisionsdecisionCode intrubric varchar(30)

B12id varchar (20)Codedate datevalue intpracid int

Referralid varchar (20)code varchar(30)date datereferralType intpracid int

Initially to indicate clinic attendance

General Practice

Database Systems

Data Extraction

MIQUEST

Database

Reporting Tool

Complete Database

Study Data

Patient Reports

Decision Support

Expert System

DevelopmentDevelopment

Recruitment of GP SurgeriesRecruitment of GP Surgeries 8 Practices8 Practices 100,000 people registered with their GP100,000 people registered with their GP

Development of decision support tool and Development of decision support tool and secondary checking of outputssecondary checking of outputs

Development of “expert” areas such as rate Development of “expert” areas such as rate of decline of renal functionof decline of renal function

Implementation and checking in a second Implementation and checking in a second UK regionUK region

Cluster randomised controlled trial Cluster randomised controlled trial