Transcript Slide 1

The future of haemodialysis in the UK
RCP advanced medicine 2013
Cormac Breen
Consultant Nephrologist
Guy's and St Thomas' Hospitals
London
Plan
Overview and demographics of haemodialysis
Description of technical challenges and opportunities of thrice weekly unit
dialysis
Vascular access
Self-care
Haemodialysis at home.
Extended hours high-frequency for improving clinical outcomes and quality of life
Viewing dialysis in terms of cost and quality in relation to NHS funding
Treatment modality in prevalent RRT patients on
31/12/2010
UK Renal Registry 14th Annual Report
The scope of Renal Replacement Treatment
Figure 2.2: Growth in prevalent patients, by treatment modality
at the end of each year 1982-2009
PD
Home HD
HD
Transplant
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
Year
UK Renal Registry 13th Annual Report
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
0
1982
Number of patients
50,000
The scope of Renal Replacement Treatment
Figure 2.10: Detailed dialysis modality changes in prevalent RRT patients
from 1997-2009
30
Percentage on modality
25
20
% Hospital HD
% CAPD
% Sattellite HD
% APD
% Home HD
15
10
5
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
UK Renal Registry 13th Annual Report
Demographics of RRT
Prevalence rate RRT All UK centres 51,835
(Total UK population 62.3 million)
Prevalence rate All RRT (pmp) 832 (428-1408)
Prevalence rate HD
360
Prevalence rate PD
64
Prevalence rate dialysis
424
Prevalence rate transplant
408
Figure 1.3. UK incident RRT rates between 1980 and 2010
UK Renal Registry 14th Annual Report
Figure 1.5. Number of incident patients in 2010,
by age group and initial dialysis modality
UK Renal Registry 14th Annual Report
Figure 1.8. RRT modality at day 90
(incident cohort 1/10/2009 to 30/09/2010)
UK Renal Registry 14th Annual Report
Growth in RRT numbers
• Change in RRT prevalence rates pmp 2005–
2010 by modality
Year to
HD
PD
Dialysis
Tx
RRT
2005
2006
2007
2008
2009
2010
6
3.9
5.8
3.5
1.5
4.1
-7.4
-2.1
-9.0
-7.8
-3.2
-5.9
3.1
2.7
2.9
1.6
0.8
2.2
6
3.2
4.9
3.7
5.4
4.6
4.4
2.9
3.8
2.6
3
3.3
Figure 2.3. Ethnicity and standardised prevalence ratios for all
PCT/HB areas by percentage non-White on 31/12/2010
(excluding areas with <5% ethnic minorities)
UK Renal Registry 14th Annual Report
Age range of RRT patients
Figure 2.4: Age profile of prevalent RRT patients on 31/12/2009
3.0
Transplant
Dialysis
Percentage of patients
2.5
2.0
1.5
1.0
0.5
0.0
15
25
35
45
55
65
75
Age (years)
UK Renal Registry 13th Annual Report
85
95
Treatment modality distribution by age in prevalent
RRT patients on 31/12/2010
UK Renal Registry 14th Annual Report
RRT Prevalence rates (pmp) by country in 2010
UK Renal Registry 14th Annual Report
Centre-based haemodialysis
The vast majority of Haemodialysis delivered in
dialysis centres (hospital and satellite)
Most have standard Haemodialysis (diffusive)
Smaller proportion have Haemodiafiltration
(convective with infusion)
All new dialysis centres generate ultrapure water,
much lower rates of contamination
Standardised treatment with improving outcomes
Trend in 1 year after 90 day survival by first established
modality 2003–2009 (adjusted to age 60)
(excluding patients whose first modality was transplantation)
UK Renal Registry 14th Annual Report
The quality challenges of Centre-based HD
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Travel times and Scheduling
Treatment times
The 3 day gap
Inflexible approach to the therapy
Cost
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A Snapshot of Patients Attending Haemodialysis on the 5th Floor Renal Satellite
Unit
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Key
Wait time
Travel time
Pre and post
dialysis
activities
Dialysis time
Arrival at RSU
5th Floor RSU
Patient Journeys
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Centre-based HD can be of low quality
Centre based HD can contribute to poorer
outcomes
How we organise dialysis is important
• peaks
• mean (TAC)
Serum Urea Concentration (mmol/l)
The ‘unphysiology’ of dialysis
TAC 3x/week
40
30
TAD
20
• fluctuations (TAD)
• ‘unphysiology’
10
7x/week
0
0
1
2
3
4
5
Day of the Week
same effect for volume!
6
7
days
Cost of Centre-based HD
Satellite unit Kent 80 patients (2011)
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
Simple interventions can be effective
Percentage of patients achieving simple, intermediate and complex tasks
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
simple
intermediate
Progress of Haemodialysis Self-Care Education Programme
700
600
declined / unable to self
care
partial independence
Number of patients
500
400
full indpendence
patients approached for
teaching
Goal of 10%
300
200
Goal of 50%
100
Pilot Phase
0
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M
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M
J
J
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Month
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M
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complex
Provision of Haemodialysis facilities in flat cash
NHS
Originally all dialysis units in main hospital centres
Growth of satellite Haemodialysis a mix of units
built from NHS capital and units run by private
providers with patient cohorts contracted
Wide variation in costs, per sqm, per dialysis chair
Little if any opportunity for NHS capital investment
from now on
2 options: contract capacity from private provider;
make more use of home dialysis
Treatment modality in prevalent RRT patients on
31/12/2010
UK Renal Registry 14th Annual Report
Vascular access
All patients on haemodialysis dependent on stable
circulatory access for good treatment
Options are for native arteriovenous fistula, PTFE
graft, or percutaneous venous catheter
“Quality measure” AVF = AVG > catheter
Best practice tariff £159 > £128
Figure 12.1. Number of MRSA bacteraemia episodes by access type and renal centre: 1/04/2009 to 31/03/2010
UK Renal Registry 14th Annual Report
Figure 12.4. Number of MRSA bacteraemia episodes by access and renal centre: 1/04/2010 to 31/3/2011
UK Renal Registry 14th Annual Report
Box and whisker plot of MRSA rates by renal centre per
100 prevalent HD/PD patients by reporting year
UK Renal Registry 14th Annual Report
Figure 12.8. Number of MSSA bacteraemia episodes by access and renal centre: 1/01/2011 to 30/06/2011
UK Renal Registry 14th Annual Report
Why is our patient still complaining?
diet
itchy
tired
hypertension
pain
can’t work
can’t sleep
thirsty
25 pills
feel lousy
will die young
infarction
restless
CVA
Improved ‘modern’ approach to home HD
Address the quality gap
Improve cost efficiency
Reduce the dependence of dialysis facilities
Reduce the dependence on nurses
Move care out into the community
Improve clinical outcomes, quality of life
Standardized Kt/V
F Gotch. Seminars in Dialysis 14: 15-17, 2001
Avoid long gaps between sessions
Bleyer et al. KI, 1999
Bleyer et al, KI, 2006
Getting the dialysis schedule right
When we talk about survival with
patients we need to be making
meaningful comparisons
BP control and cardiovascular
health
Fagugli et al. AJKD, 2001
Chan et al. KI, 2002
Pill burden high
Chiu Y et al. CJASN 2009;4:1089-1096
Getting the dialysis schedule right
• More dialysis vs more restrictions
• Shorter gaps vs fluid gain & BP
• Higher HD dose vs more pills
• Recovery time quicker (min vs
hrs)
• More free time vs better free time
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Getting the dialysis schedule right
7
•Which clinical parameters matter most
to patients?
•Do our usual markers help us?
•Should other blood values indicate more
factors to the patient?
•Keeping the patient well and free of
complications matters most
6
5.12
sKt/V
5
3.82
4
2.46
3
2
1
Equivalent B2 microglobulin clearance
(ml/min)
Phosphate removal (mg/day)
1600
1218
1200
1000
800
600
400
415
299
+39%
200
+328%
0
Control
Daily HD
+108%
Daily HD
Nocturnal HD
0
Control
1400
+55%
Nocturnal HD
12
10
9.03
8
6
4.88
4.73
4
2
+91%
Daily HD
Nocturnal HD
0
Control
45
+ 3%
+39%
Getting the dialysis schedule right
• More dialysis vs more restrictions
• Shorter gaps vs fluid gain & BP
• Higher HD dose vs more pills
• Recovery time quicker (min vs
hrs)
• More free time vs better free time
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Transplantation or not
• Daily nocturnal HD compares
favourably to first deceased
donor Tx
• No data for older, comorbid
pts
• No data for higher
immunological risk pts
• Should this be part of
discussion of RRT choices?
Pauly et al
47
Distribution of dialysis time & frequency
3 x weekly
Alternate
days
4 x weekly
5 x weekly
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< 3.5 hours
3.5 – 4.25 hours
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4.25 – 5 hours
5 – 6 hours
6 – 8 hours
6–7x
weekly
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Distribution of dialysis time & frequency
3 x weekly
Alternate
days
4 x weekly
5 x weekly
< 3.5 hours
3.5 – 4.25 hours
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4.25 – 5 hours
5 – 6 hours
6 – 8 hours
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6–7x
weekly
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Figure 2.8. Percentage of prevalent haemodialysis patients treated with satellite or
home haemodialysis by centre on 31/12/2010
UK Renal Registry 14th Annual Report
The future of Haemodialysis in the UK
Centre based HD - improved efficiency,
continuous improvement in quality. Changing
models of care to improve affordability
Self care HD - increasingly 'normal', better cost
model, link to patient benefit
Home HD - best use of resources. Become the
norm, measure quality differently by reducing
impact on health and lifestyle.