Strategic Health Care Network against CKD in Mexico (CKDSN)

Federal Health Secretariat Innovation and Quality Subsecretariat

Mexican Government 2010

Presented by: Librado de la Torre-Campos, MD Guillermo Garcia-Garcia, MD

Background

• Mexico has one of the highest prevalence of DM in the world.

• The prevalence of CNCDs, like DM, HTN, overweight has increased significantly in Mexico (Fig 1)

• It is estimated that 70% of CKD cases in persons >20 years is associated to one or two CNCDs.

Fig. 1. CNCDs Prevalence in Mexico

1993 (%) 2000 (%) 2006 (%)

Diabetes Mellitus

≥ 20 y 7.20 10.7 9.50

20-34 y 23.2 29.3

35-54 y 51.5 46.7

55-69 y 25.3 24.0

Hypertension

≥ 20 y 26.6 30.5 26.5

20-34 y 29.3 23.2

35-54 y 46.7 51.5

55-69 y 24.0 25.3

Overweight and Obesity

≥ 20 y 59.4 63.5 69.5

20-34 y 34.9

35-54 y 49.0

55-69 y 16.2

Background

• 12% of DM cases and 7% of HTN cases develop CKD. When the two co-exist, the risk increases to 40%.

• According to the National Health Survey and Nutrition 2006, 68% of hypertensive individuals and ##% of diabetics were not aware of their illness.

• 7% of the Mexican population is reported to have CKD, and many are not aware of it. 96% of these patients have CKD stage 1-3 and 300,000 individuals have CKD stage 4-5 (Fig. 2)

Fig.2. Burden of Disease

45%

19%

19%

16%

1%

CKD prevalence by age group

45-64

20-44

65-74

≥75

0-19

Background

• In conclusion, public health policy in Mexico has failed to promote health and prevention and detection of CNCDs.

Background

• Due to the lack of planning and coordination, CKD treatment has focused on costly RRT, neglecting early detection and treatment of early stages of CKD. (Fig 3)

• Additionally, access to RRT is universal to individuals with social security but severly restricted to those without insurance.

• Only 22% of the Mexican ESRD population has access to RRT at a cost of $ 580.00 US million dollars a year.

Background

• It has been estimated that universal access to RRT in Mexico will cost $ 3.0 US billion dollars, representing 40% of the national health budget.

• Fig. 3 describes the estimated cost of ESRD treatment in 5 different scenarios: a) partial (22%) vs universal (100%) coverage; b) current RRT vs alternative RRT distribution; c) 2009 vs 2025.

ANNUAL COST, CKD

PREVENTION

ANNUAL COST$

CKD STAGE 1-3 TREATMENT

ANNUAL COST $ ^ CKD STAGE 4-5 TREATMENT

RRT % Distribution PD---HD---KT

$ 0.0

22 %

100 %

$ 581

$ 2,538

100 %

$ 2,812

$ 3,833

100 % $ 3,336

2009

2025*

80 ---- 19.8 ---- 0.2

20 ---- 79.8 ---- 0.2

16- ---- 64 ---- 20

100 %

^millions of US dollars *50% estimated reduction of patients reaching ESRD

Fig. 3 CKD treatment. Current expenses.

22% $618

CKDSN: Target population

• General population

• High-risk population with CNCDs

• CKD population

CKDSN: Mission

• To promote renal health and prevention of CKD through early detection and treatment, under the supervision of a kidney specialist, and with strictly adherence to clinical guidelines.

• To provide informed patient care with a minimum of complications, improving patient’s quality of life and social rehabilitation, with optimization of the National Health System’s resources.

CKDSN: Vision

• To become an efficient and effective national health care network for the promotion of renal health, through early detection and treatment of CKD, and to achieve a 50% reduction of all CKD stages’ prevalence by the year 2025.

CKDSN: Objectives (Fig. 4)

• Promotion of Renal Health in the community

• CKD early detection and treatment to retard progression or reversion of kidney disease

• Decrease mortality

0 1 2 3 4 5 CKD Stage

Fig. 4 Network’s goals

Promotion of Renal Health: Objectives

• The community will become familar with normal kidney function

• The community will identify risk factors for CKD

• The community will identify the health clinics as the place to detect and treat CKD.

Promotion of Renal Health: Lines of action

• Permanent education community programs on CKD prevention and treatment.

• Equipment and upgrading of existing infrastructure of health clinics

• CKD on-line education programs for health professionals (general practitioners, nurses, nutritionists, medical students)

• Periodic evaluation of clinical competences

Promotion of Renal Health: Action Lines

• Accreditation of health clinics by the SI Calidad* program

• Organizing Renal Health Committees in each health clinic

• Certification of the health clinic by the General Health Council

• Fig. 5 describes the action lines and expected outcomes of health promotion and education

*Integral Health Quality System

STRATEGIC PLAN

EXPECTED OUTCOMES

CKD and CNCDs COMMUNITY EDUCATION

CONTINUOS QUALITY

IMPROVEMENT STRATEGIES

EQUIPMENT AND/OR

UPGRADING THE NETWORK’S

CLINICS INFRASTRUCTURE

CKD AND CNCDs HEALTH

PROFESSIONAL TRAINING

HEALTHY LIFE STYLE

TIMELY DETECTION AND

TREATMENT

RISK CONTAINMENT

EFFECTIVE COMMUNICATION BETWEEN HEALTH PERSONNEL AND THE COMMUNITY

LOWER CKD INCIDENCE

Fig. 5 RENAL HEALTH PROMOTION

CKD Prevention and Treatment: Objectives

• CNCDs treatment compliance

• Enforcement of treatment goals

• Early detection of kidney disease

• Timely CKD treatment to delay or prevent progression of kidney disease

• Periodic monitoring of kidney function

CKD Prevention and Treatment: Strategies

• Development of clinical guidelines

• Care coordination of CKD patients with existing CNCDs (DM, hypertension, and obesity) programs

• Inclusion of CKD stages 1-3 screening tests and treatment, in the catalog of the Popular Health Insurance (Seguro Popular).

• Development of an internet platform network

• Fig. 6 describes the strategies and expected outcomes of CKD prevention and treatment.

ACTION PLAN

EXPECTED OUTCOMES

DEVELOPMENT OF CKD CLINICAL GUIDELINES

REGISTRY OF CKD PATIENTS IN THE

ELECTRONIC DATA BASE

ACCESS TO THE ELECTRONIC

DATABASE IN EACH CLINIC

TIMELY AVAILABLITY OF DRUGS FOR TREATMENT OF CNCDs and CKD

STAGE 1-3

EFFECTIVE COMMUNICATIO

N BETWEEN NETWORK

PARTICIPANTS

UPTADATED AND RELIABLE DATA

BASE FOR REASEARCH AND

DECISION MAKING

CKD REGRESION OR DELAY IN CKD

PROGRESSION

TREATMENT PROVIDED BY

GPs WITH NEPHROLOGIST

AND NUTRITIONIST SUPERVISION

PATIENT SATISFACTION

WITH DELIVERY OF CARE

Fig. 6 CKD PREVENTION AND TREATMENT

Lowering ESRD mortality: Objectives

• CKD treatment to delay or prevent progression of renal function

• Timely nephrology referral

• Improving the quality of dialysis and kidney transplantation centers

• Implementation of third-party, dialysis and kidney transplantation programs

• Fig. 7 describes the strategies and expected outcomes to decrease ESRD mortality.

ACTION PLAN

EXPECTED OUTCOMES

INCREASE QALYs AND DECREASE DALYs OF CKD

PATIENTS

COMPETETIVE PRICE OFFERED BY PRIVATE HD AND

PD UNITS

DECREASE CKD COMPLICATIONS AND THE HIGH COST OF RRT

DECREASE PATIENT MORTALITY

ASSOCIATED TO ESRD

STRENGHTING THE

REGULATIONS FOR PD AND HD

CLINICS OPERATION

PROMOTE ORGAN DONATION AND

KIDNEY TRANSPLANTATION

INCREASE THE NUMBER OF

NEPHROLOGISTS

QUALITY IMPROVEMENT IN

PD AND HD PERSONNEL

ACREDITATION AND

CERTIFICATION OF RRT CENTERS

Fig. 7 LOWERING ESRD MORTALITY

Parties involved: Responsabilities

• National Center of Technological Excellence in Health: Development of clinical guidelines

• National Center of Disease Control and Epidemiology Surveillance: Coordination of existing Specific Programs for Diabetes Mellitus and Hypertension with the CKD Stratetegic Network

• Popular Health Insurance: Inclusion of screening tests and treatment of CKD in its disease catalog.

Parties involved: Responsabilities

• Health Risks Federal Commission (COFEPRIS): visual identification on labels of nephrotoxic drugs

• National Health Council: Certification of primary care clinics and dialysis and kidney transplantation centers.

• Quality and Health Education General Office: coordinate the education and training of health professionals in the prevention and treatment of CNCDs and CKD; promote the inclusion of CNCDs and CKD prevention and control in medical school curriculum

• Performance Evaluation Office: evaluation of the program outcomes

Parties involved: Responsabilities

• Health Informatics Office: development of the internet network platform and digital database

• Health Planning and Development Office: organization of the strategic network; establishing inclusion criteria for participating health clinics; strategies for delivery of drug and tests supplies to participating clinics.

• Health Promotion Office: health promotion and education in the community. Objectives:1) recognition of CKD risk factors ; 2) identification of the primary care clinic as the place for the treatment and detection of CNCDs and CKD; and 3) Impact of CKD in the individual and the community.

Parties involved: Responsabilities

• Informatics Technologies Office: validation of the electronic platform for the registry and follow-up of network patients.

• National Institute of Public Health: On-line training on CKD prevention and control for health professionals.

• Nephrology experts: designing of the CKD training course and tutoring students.

• Public Education Secretariat: Health education and promotion of CKD prevention at the basic education level

• State Health Secretariats: implementation of the program at the state level.

Network membership (Nodes)

Each node is integrated by:

• 4 to 12 primary care clinics geographically close to each other

• One Specialized Medical Unit (UNEME) or one Comprehensive Care Clinic (CESSA)

• One consultant nephrologist per 24 health clinics.

Network membership: inclusion criteria

• States interested in participating in the project • Internet availability at the health clinic • Previous experience in online-education programs • Accreditation by the Popular Health Insurance • Approval of the on-line CNCDs and CKD diploma by the

clinic’s primary health physician • Availability of tests supplies (microalbuminuria, serum

creatinine, glucose, cholesterol, triglycerides) and drugs for treatment of CNCDs

• Fig. 8 and 9 describe the network’s organization and operation

Fig. 8 STRATEGIC NETWORK ORGANIZATION

INFORMATION PLATFORM

Consultant Nephrologist

CESSA

UNEME SORID NODE

HEALTH CLINICS HEALTH CLINICS

Co

mm

un

ity

Hea

lth

Clin

ic

UN

EME,

CES

SA,

SOR

ID

Gen

eral

Pra

ctit

ion

er t

rain

ed o

n C

NC

Ds

and

CK

D g

uid

elin

es

Health Promotion Schools Places of

work Health Care

Clinics Others

Persons >20 years

without DM, HTN or

Obesity

Patients with DM,

Htn, Obesity

Sele

ctio

n

qu

esti

on

aire

AC

R

Negative Regular follow-up

Comprehensive treatment for CKD prevention and progression

Stage 1,2,3

Positive Stratification

Stage 4-5

Nephrologist Fig. 9 NETWORK OPERATION

Estimated Expenses (Fig. 10)

• Maximum investment per node = $ 21,923 to $ 59,000 USD

• Maximum investment per pilot study = $ 1.09 to 2.94 million USD

• Maximum national investment= $ 49.1 million USD

EXISTENT HEALTH CARE INFRASTRUCTURE

1 NODE= 1 US ó Cessa + 4 a 12 CS 50 Nodes = 200 – 600 CS 1000 Nodes= 10,000 CS

Equipment (per node)

- Laptop - Training of PHP in CKD management - Printer - Nephrologist's annual salary - Ophthalmoscope - Computer system maintenance - Software - Blood chemistry and microalbuminuria - Network platform

US= Specialized Medical Unit; CESSA= Comprehensive Health Center; CS= Health clinic. Total number of CS in the country= 10, 019

Fig. 10 ESTIMATED EXPENSES

Maximum investment per node = $ 21,923 to $ 59,000 USD Maximum investment per pilot study = $ 1.09 to 2.94 million USD Maximum national investment= $ 49.1 million USD

Estimated Expenses

• Fig. 11 describes the estimated cost of ESRD treatment under 5 different scenarios, when investing in CKD prevention and control : a) partial (22%) vs universal (100%) coverage; b) current RRT vs alternative RRT distributions: c) 2009 vs 2025.

• Estimated savings = $ USC 1,406 to $ USC 1, 668 million

ANNUAL COST, CKD

PREVENTION

ANNUAL COST$

CKD STAGE 1-3 TREATMENT

ANNUAL COST $ ^ CKD STAGE 4-5 TREATMENT

RRT % Distribution PD---HD---RT

MAXIMUN ESTIMATED COST

$ 49.1

22 %

100 %

$ 580.7

$ 2,538.4

100 %

$ 1,406

$ 2,301

100 % $ 1,668

2009

2025*

80 ---- 19.8 ---- 0.2

20 ---- 79.8 ---- 0.2

16 ---- 64 ---- 20

100 %

^millions USD *50% estimated reduction of patients reaching ESRD

Fig. 11 Estimated expenses when investing in CKD prevention

Final comments

• A pilot study began on June, 2011 in the state of Jalisco. • CKD screening training for primary health physicians was

provided by the Mexican Kidney Foundation. • A CKD and CNCDs on-line education program for primary

health physicians was jointly developed by the National Institute of Public Health and the Division of Nephrology, Hospital Civil de Guadalajara.

• 5,000 diabetic patients from 7 health districts (4 urban and 3 rural), have been screened for CKD.

• 80 primary health physicians have approved the on-line education program.

• 3 additional states (Nayarit, Michoacan, and Aguascalientes) will soon join the network.