the future of haemodialysis in the uk rcp advanced medicine 2013 cormac breen
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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 - PowerPoint PPT PresentationTRANSCRIPT
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The future of haemodialysis in the UKRCP advanced medicine 2013
Cormac BreenConsultant Nephrologist
Guy's and St Thomas' HospitalsLondon
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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
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UK Renal Registry 14th Annual Report
Treatment modality in prevalent RRT patients on31/12/2010
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UK Renal Registry 13th Annual Report
Figure 2.2: Growth in prevalent patients, by treatment modality at the end of each year 1982-2009
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The scope of Renal Replacement Treatment
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UK Renal Registry 13th Annual Report
Figure 2.10: Detailed dialysis modality changes in prevalent RRT patients from 1997-2009
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The scope of Renal Replacement Treatment
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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 360Prevalence rate PD 64Prevalence rate dialysis 424Prevalence rate transplant 408
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UK Renal Registry 14th Annual Report
Figure 1.3. UK incident RRT rates between 1980 and 2010
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UK Renal Registry 14th Annual Report
Figure 1.5. Number of incident patients in 2010,by age group and initial dialysis modality
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UK Renal Registry 14th Annual Report
Figure 1.8. RRT modality at day 90(incident cohort 1/10/2009 to 30/09/2010)
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Growth in RRT numbers
• Change in RRT prevalence rates pmp 2005–2010 by modalityYear to HD PD Dialysis Tx RRT
2005 6 -7.4 3.1 6 4.42006 3.9 -2.1 2.7 3.2 2.92007 5.8 -9.0 2.9 4.9 3.82008 3.5 -7.8 1.6 3.7 2.62009 1.5 -3.2 0.8 5.4 32010 4.1 -5.9 2.2 4.6 3.3
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UK Renal Registry 14th Annual Report
Figure 2.3. Ethnicity and standardised prevalence ratios for allPCT/HB areas by percentage non-White on 31/12/2010
(excluding areas with <5% ethnic minorities)
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UK Renal Registry 13th Annual Report
Figure 2.4: Age profile of prevalent RRT patients on 31/12/2009
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Age range of RRT patients
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UK Renal Registry 14th Annual Report
Treatment modality distribution by age in prevalentRRT patients on 31/12/2010
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UK Renal Registry 14th Annual Report
RRT Prevalence rates (pmp) by country in 2010
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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 contaminationStandardised treatment with improving outcomes
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UK Renal Registry 14th Annual Report
Trend in 1 year after 90 day survival by first establishedmodality 2003–2009 (adjusted to age 60)
(excluding patients whose first modality was transplantation)
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The quality challenges of Centre-based HD
• Travel times and Scheduling• Treatment times• The 3 day gap• Inflexible approach to the therapy • Cost
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Key
Wait time
Travel time
Dialysis time
Pre and post dialysis activities
Arrival at RSU
5th Floor RSU Patient Journeys
A Snapshot of Patients Attending Haemodialysis on the 5th Floor Renal Satellite Unit
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Centre-based HD can be of low quality
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Centre based HD can contribute to poorer outcomes
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How we organise dialysis is important
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The ‘unphysiology’ of dialysis
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‘unphysiology’
3x/week
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TADTAC
same effect for volume!
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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
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Simple interventions can be effective
Progress of Haemodialysis Self-Care Education Programme
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patients approached forteachingGoal of 10%
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Percentage of patients achieving simple, intermediate and complex tasks
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Provision of Haemodialysis facilities in flat cash NHS
Originally all dialysis units in main hospital centresGrowth 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 chairLittle if any opportunity for NHS capital investment
from now on2 options: contract capacity from private provider;
make more use of home dialysis
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UK Renal Registry 14th Annual Report
Treatment modality in prevalent RRT patients on31/12/2010
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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 > catheterBest practice tariff £159 > £128
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UK Renal Registry 14th Annual Report
Figure 12.1. Number of MRSA bacteraemia episodes by access type and renal centre: 1/04/2009 to 31/03/2010
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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
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UK Renal Registry 14th Annual Report
Box and whisker plot of MRSA rates by renal centre per100 prevalent HD/PD patients by reporting year
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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
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Why is our patient still complaining?
tired
pain
can’t sleep
feel lousy
itchy
hypertension
can’t workthirsty25 pills
will die young restless CVAinfarction
diet
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Improved ‘modern’ approach to home HD
Address the quality gapImprove cost efficiencyReduce the dependence of dialysis facilitiesReduce the dependence on nursesMove care out into the communityImprove clinical outcomes, quality of life
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Standardized Kt/V
F Gotch. Seminars in Dialysis 14: 15-17, 2001
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Avoid long gaps between sessions
Bleyer et al, KI, 2006Bleyer et al. KI, 1999
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Getting the dialysis schedule right
When we talk about survival with patients we need to be making meaningful comparisons
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BP control and cardiovascular health
Fagugli et al. AJKD, 2001 Chan et al. KI, 2002
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Pill burden high
Chiu Y et al. CJASN 2009;4:1089-1096
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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
5.12
3.82
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Control Daily HD Nocturnal HD
sKt/V
+55% +108%
299415
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+91%
•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
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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?
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Pauly et al
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Distribution of dialysis time & frequency
3 x weekly Alternate days
4 x weekly 5 x weekly 6 – 7 x weekly
< 3.5 hours
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3.5 – 4.25 hours
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4.25 – 5 hours
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5 – 6 hours
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6 – 8 hours
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Distribution of dialysis time & frequency
3 x weekly Alternate days
4 x weekly 5 x weekly 6 – 7 x weekly
< 3.5 hours
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3.5 – 4.25 hours
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4.25 – 5 hours
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5 – 6 hours
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6 – 8 hours
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UK Renal Registry 14th Annual Report
Figure 2.8. Percentage of prevalent haemodialysis patients treated with satellite orhome haemodialysis by centre on 31/12/2010
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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.