the burden, impact and costs of dialysis - the data … burden, impact and costs of dialysis ......
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The Burden, Impact and Costs of Dialysis
- The Data Viewpoint
Dr Shona Methven
Senior Clinical Research Fellow
UK Renal Registry
Aim
To implement and evaluate a quality improvement programme toidentify patients at high risk of progressive renal decline, usingeGFR graph reports sent to primary care in sites across the UK
P - Patient population
I - Intervention
C - Comparator
O - Outcome
S - Study Design
Patients with CKD not yet referred to nephrology
Graph of eGFR over time with individualised advice
Routine care
Late referral rate to nephrology
Step Wedge RCT
• Improve outcomes
– Reduce avoidable late presentation
– Reduce ESKD
• Improve equity of access
• Reduce costs
– For individuals
– For society
• Improve outcomes
– Reduce avoidable late presentation
– Reduce ESKD
• Improve equity of access
• Reduce costs
– For individuals
– For society
• Improve outcomes
– Reduce avoidable late presentation
– Reduce ESKD
• Improve equity of access
• Reduce costs
– For individuals
– For society
Comparative audit of all UK Renal Units
- Quality assurance
- Dashboard indicators
- Commissioning data
- Efficient clinical trials
UK Renal Registry 18th Annual Report
Percentage of people presenting late (2013/2014)
Inequity of Access
to Specialist Services
Late presentation of ESKD
• Unavoidable
vs
• Avoidable
Acute Diagnoses Group
Crescentic GN/ anti GBM disease
Cisplatin Nephrotoxicity
Malignant Hypertension
Polyarteritis/ GPA/ cryoglobulinaemia
Myeloma/ LCDD
Systemic sclerosis
Cortical necrosis/ irreversible ATN
Surgery/trauma
Late presentation of ESKD
• Unavoidable
vs
• Avoidable
UK Renal Registry 18th Annual Report
BurdenImpact
Costs
Consequences of late presentation
Low prevalence of permanent access
Delayed referral for transplant
Greater initial hospitalisation rate
Higher mortality
Reduced patient choice of RRT modality
Anaemia and bone disease
Severe hypertension & fluid overload
Worse psychosocial adjustment
Consequences of late presentation
Low prevalence of permanent access
Delayed referral for transplant
Greater initial hospitalisation rate
Higher mortality
Reduced patient choice of RRT modality
Anaemia and bone disease
Severe hypertension & fluid overload
Worse psychosocial adjustment
Consequences of late presentation
Low prevalence of permanent access
Delayed referral for transplant
Greater initial hospitalisation rate
Higher mortality
Reduced patient choice of RRT modality
Anaemia and bone disease
Severe hypertension & fluid overload
Worse psychosocial adjustment
Consequences of late presentation Benefits of early presentation
Low prevalence of permanent access Greater proportion with permanent access
Delayed referral for transplant Reduced need for urgent dialysis
Greater initial hospitalisation rate Reduced hospital LOS and costs
Higher mortality Improved survival
Reduced patient choice of RRT modality Greater choice of treatment options
Anaemia and bone disease Improved nutrition
Severe hypertension & fluid overload Better CVD and comorbidity management
Worse psychosocial adjustment Delay need to initiate RRT
Overall 2-fold increased risk of
death in group referred late (Chan Am J Med 2007)
UK Renal Registry 18th Annual Report
Survival of incident patients (unadjusted), 1997–2013
Burden
ImpactCosts
Quality of Life with CKD
0% 20% 40% 60% 80% 100%
Mobility
Self-care
Usual Activities
Pain or Discomfort
Anxiety or Depression
Absent Mild Moderate Severe Overwhelming
Data from Transforming Participation in CKD
Burden
Impact
Costs
Costs attributable to CKD (to the nearest £million), 2009–10.
Marion Kerr et al. Nephrol. Dial. Transplant. 2012;27:73-80
Estimated annual cost of direct CKD
care, RRT and non-RRT patients.
Marion Kerr et al. Nephrol. Dial. Transplant. 2012;27:73-80
Do NothingDo Nothing
DANGER
Maintain Invest
Do Nothing MaintainMaintain Invest
Do Nothing Invest
To Save
Maintain
Estimated annual cost of direct CKD
care, RRT and non-RRT patients.
Marion Kerr et al.
Nephrol. Dial. Transplant.
2012;27:73-80
Evaluation using Mixed Methods Approach
Quantitative• 1y outcome uses routinely collected data
• Efficacy of the intervention
• Balancing measure of OP appt activity
Qualitative• Acceptability
• Barriers and facilitators to spread
• Advanced Kidney Disease
– Burden
– Impact
– Costs
• By working together we can show the worth of the ASSIST-CKD intervention
Thank you to you and your colleagues for taking part in this
project