Strategic Health Care Network against CKD in Mexico (CKDSN) Federal - - PowerPoint PPT Presentation

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,
• verweight 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
• f 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

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
• n 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
• utcomes 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
• utcomes 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
• utcomes 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
• peration

• Fig. 8 STRATEGIC NETWORK ORGANIZATION

INFORMATION PLATFORM

Consultant Nephrologist CESSA

UNEME SORID NODE

HEALTH CLINICS HEALTH CLINICS

Community Health Clinic UNEME, CESSA, SORID

General Practitioner trained on CNCDs and CKD guidelines

Health Promotion Schools Places of work Health Care Clinics Others Persons >20 years without DM, HTN or Obesity Patients with DM, Htn, Obesity Selection questionaire ACR 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.