Localising Renal Care

Dr Sandip Mitra MD, FRCP

Consultant Nephrologist

Manchester Royal Infirmary

,Building Future Healthcare - Radical Approaches, HaCIRIC International Conference 2013, London

Kidney failure

The Challenge

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1998 - 2008

Pa

tie

nts

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mp

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Dialysis

ESRD

UK Renal Registry 13th Annual Report

The scope of Renal Replacement Treatment

Hospital dialysis Implications

For NHS For patients

Poor outcomes

High expense

Huge capital outlay

High complication rates

High bed occupancy

Skilled workforce shortage

Life changing treatment

Highly restrictive

Poor quality of life

Travel to units

Deferred “Death sentence”

Hospital HD survival at 5 yr < 50% !

Kidney care (NHS)

Cost of Centre-based HD

Satellite unit 80 patients

• Total annual income £1,738,464

• Variable costs non-pay £591,840 (Transport 20%)

• Fixed costs non-pay £222,005

• Fixed costs pay £681,082 (91% nursing)

Opportunity to reduce costs mostly from reducing requirement on nursing staff and on transport

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30000

MHD SatHD APD CAPD Home HD

Dialysis Costs Comparison UK

PbR for Kidney Dialysis Project Group Report June 2009

Time to death in patients treated with nocturnal haemodialysis, deceased and living donor kidney transplantation (log-rank test, P = 0.03). Pauly R P et al.

Nephrol. Dial. Transplant.

2009;24:2915-2919

© The Author [2009]. Published by Oxford University Press on behalf of ERA-EDTA.

Survival Equivalence of Home HD to Transplantation

Different Types of Economic Analysis Home Haemodialysis :

A Neglected Opportunity

• All suitable patients should be offered the choice

between home HD or HD in a hospital/satellite unit.

• 10% to 15% of dialysis patients, given the choice,

would opt for home HD and therefore, expansion of

the services to support home HD is recommended

NICE guidelines

Home Haemodialysis

2002

Media Attention NKF & Kidney Alliance Campaigns

Kidney care improvement hampered by insufficient home dialysis, warn charities 15th Dec, 2009 | By Moya Sarne

Drivers for Self care in UK healthcare system

“The time has come for the NHS to make a decisive shift in providing more care

out of hospitals and in the patient’s community and home. NHS needs to do more

to plan services around patients – even taking services into their home. Dialysis

at home is a perfect example, which can mean patients no longer have to worry

about long trips to their nearest hospital three times a week while also enjoying

better clinical outcomes”….

Health Secretary Feb 2010

Department of Health

Around 7000 patients across England could benefit from home dialysis, Burnham said, cutting out the need for regular long visits to hospital and allowing patients to lead "more normal lives". Burnham said: "The time has come for the NHS to make a decisive shift in providing more care out of hospitals and in the patient's community and home ....For too long, services have been organised to fit the convenience of the system. But care in the home can also achieve better results and save money. So this is the right move at the right time.“

Health Secretary, Feb 2010

Translating knowledge on best practice A systematic review of implementation strategies

• 93 QI initiatives examined that aimed to implement knowledge on best practice into daily dialysis care

• Key finding :

Combining multiple strategies is more effective than using a single strategy

Sabine N. et al Kidney International (2011) 80, 1021–1034

Multiple Chaotic pathways

Manchester Model of Home Hemodialysis Therapy

An Environment for Dialysis Learning Dedicated Hemodialysis patient training centre in Manchester

1 : 1 Q & A

Group work & lectures

Modular Training Schedule Competency Levels

Manchester HHD trends

15 % prevalent HHD

Phase 1:

The Honeymoon

Phase 2:

Reality Sets In

Phase 3:

The Uncomfortable Gap Phase 4:

Consistency Phase 5:

Mature prgram

Home HD Program – 5 LIFE STAGES

Results : HHD Manchester 2004- present

Total patients trained 201 (72 prevalent)

All backgrounds (22 – 72 yr, 33% F, 11% ethnic)

Low technique failure rate (4% training, 8% technique)

Low catheter use (AVF 85%)

Superior survival (83% at 5y) (Hosp HD 50%)

Improved biochemical control

Flexibility (at least 6 schedules at home)

2178 days equivalent travel time avoided

Home Haemodialysis survival Survival of Data 4:Survival proportions

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Time

Perc

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All patients starting Home HD at MRI (2003 – 2008) n = 50

Age <50> ; Sex M:F

Log-rank (Mantel-Cox) Test

Gehan-Breslow-Wilcoxon Test

P value = ns

Helsinki 1998 – 2007 Honkanen et al

85% at 5

yr

83% at 5

yr

Manchester Helsinki

10 yr retrospective Canadian study show survival of

nocturnal home dialysis similar to cadaverc transplantation

Dialysis capacity with substantial cost avoidance Up to 40% savings on Home HD

Cost Type I 18,904 32,233 37,716

Cost Type II 26,289 40,145 45,629

Home DialysisIn Centre - MRI

dialysis

In Centre -

Satellite dialysis

Projected costs ££s per patient per year by modality in 2011 Financial report 2010 (Manchester Business School project)

What did patients say ?

“A better quality of life, knowing the chemicals are more balanced and that I would be healthier when I got a transplant...”

Switching hospital to home alternate day dialysis

Daily dialysis

“Home dialysis has suddenly made me feel more interested, happier & relaxed...”

Home HD modalities – a choice of menus………

4 hrs x 3 = 10 pts =12

3 hrs x 4 = 2 pts =12

4.5 hrs x 3 = 5 pts = 13.5

5 hrs x 3 = 6 pts = 15

5.5hrs x 3 = 2 pts = 16.5

6 hrs x 3 = 8 pts = 18

7 hrs x 3 = 2 pts = 21

8 hrs x 3 = 2 pts = 24

2 hrs x 6 = 2 pts = 12

3 hrs x 5 = 1 pt = 15

2 hrs x 5 = 1 pt = 10

Conventional

12rs/wk

23%

13-17 hrs/wk

29%

18-24 hrs/wk

27%

Frequent

Therapy

21%

4-6 per

week

53 yr old social worker after 6 yrs incentre, embraces daily dialysis at home, with improved well being and saves her job.

76 y old man enjoys privacy at home on HHD.

42y diabetic overcomes needle phobia to go home to spend more time with kids.

H O M E DIALYSIS

Paradigm shift: 3 critical elements to make home therapy a reality for any interested patient!

Nephrology professionals

Balanced guidance of patients towards all dialysis

modality options for a functioning independent life

Patients

Empowered patients through pre-dialysis and

ongoing education, living a full life with the continuum

of chronic kidney disease options

Providers

Accessible infrastructure for all dialysis modalities

enables nephrology professionals and patients to

make an individualized modality choice a reality

for all patients.

5 steps Reforming Health Care

5 phases of reform to achieve transformation:

Phase 1 – Defining a Vision and Strategy to Deliver Value

Vision: perfect care = efficient + safe + best practice

Strategy: focus on the front line, aim for ambitious targets, leadership support of continuous improvement

Phase 2 – Targeting a Solution

Developed Perfecting Patient Care -a quality improvement method based on Lean , enlisted Champions of Reform

Phase 3 – Demonstrating the Value . tested in various settings

Phase 4 – Aligning Incentives

Create climate and infrastructure for change

Change policy; reward quality by reforming payment systems

Use good data for credible results

Phase 5 – Spread and Stabilization

Knowledge networks spread quality and contain cost , Quality management tools create quality Champions

National Recognition for the Manchester team Ministerial visit to a patient in training

Early Successes Recognised

NHS Innovations Challenge First Prize

Home Haemodialysis UK

Manchester HHD trends

Variation in Home Haemodialysis:

Adapted from Renal Registry 12th Annual Report 2009

%HHD prevalence in

dialysis popn

2008

Innovation

Relationship of practice to sustained change

No Change in Practice

Transformation in Practice

No Change in Culture

Stasis

Reluctant participants

Failed

implementation

Transformation in Culture

Turnover, loss of best people

Sustainable model of transformation

Vest and Gamm Implementation Science 2009 4:35 doi:10.1186/1748-5908-4-35

A INTEGRATED DIALYSIS SYSTEMS SOLUTION : CLOSER TO HOME as the NORM

The next step.......

Paradigm shift in dialysis care for all

Thank you

Reforming Health Care

• Phase 3 – Demonstrating the Value of PPC

PPC tested in various settings

• Phase 4 – Aligning Incentives

• Create climate and infrastructure for change

• Change policy; reward quality by reforming payment systems

• Use good data for credible results

• Phase 5 – Spread and Stabilization

• Knowledge networks spread quality and contain cost

• Quality management tools create quality Champions

1) Towards enabling home HD for all those who might

benefit

2) Aim to achieve the QIPP for home dialysis (March

2012)

3) Efficient use of resources and collaboration

Goal : Regional initiative

The next steps...

1. Scoping exercise (October 2011)

2. Define metrics for performance (October 2011)

3. Evaluate strengths and weaknesses (SWOT)

4. Baseline provision and unmet need

5. Define action plans for each centre

6. Explore new ways of working : Buddy schemes

7. Monthly meeting (ideal)

Is Dialysis coming of age ?

Implantable cardioverter defibrillators — Is there a

lesson to learn ?

Cardiac monitoring bed

Bedside treatment

Manual treatment modes

Automated rhythm recognition and sensing

Setting up at home and community

Implantation in high risk patients

Solid state electronics

Understanding signal processing

A Sound Alternative:

Home Haemodialysis

• Cost Effectiveness

• Improved Patient

Outcomes