Renal Association, CD Forum, Guy’s, March 2010Renal Association, CD Forum, Guy’s, March 2010

Roger Greenwood Roger Greenwood

Lister Renal UnitLister Renal Unit

Stevenage, UKStevenage, UK

Home Dialysis – Operational and Home Dialysis – Operational and Financial AspectsFinancial Aspects

15% HD Patients at Home 15% HD Patients at Home is Realisticis Realistic

Greenwood vs Raftery Greenwood vs Raftery

Renal Association, CD Forum, March 08

Growth of the UK dialysis population 1982-2002

UK Renal Registry 9th Annual Report 2006

Fig 17.5 Prevalent patients, percentage by each dialysis modality

0

10

20

30

40

50

60

70

80

90

100

Country

% p

ats

on D

ialy

sis

mod

ality

% PD% Home HD% In Centre HD

Months on Dialysis

1201201081089696848472726060484836362424121200

Cu

mu

lati

ve S

urv

ival

1.01.0

.9.9

.8.8

.7.7

.6.6

.5.5

.4.4

.3.3

.2.2

.1.1

0.00.0

HDHD

PDPD

Transplants

Survival on RRT – Lister Renal Unit 1999

Utilometer

Cost Utility Analysis, USA

Bell et al. Med Decision Making ,2001, 21, 288

“GFR”

I

II

III

IV

V

Dialysis Initiation

Dialysis Patients Remain in Stage 4/5 CKD

Residual Renal Function

Time Frequency

Delivering More Dialysis by Increasing:

Power

Impact of Power: HEMO Trial (USA 2002)

TM0065 Rev BNxStage has prepared this tool to assist providers in the development of their staff training

materials. This document is not intended to replace the NxStage

User’s Guide or cartridge Instructions for Use. NxStage® is a

registered trademark of NxStage Medical, Inc. TM0065

Rev B

Gotch, 1999

Impact of Frequency: Standard Kt/V (stdKt/V)

Day-of-Week, Association with Mortality

• DOPPS study, 1996-2004DOPPS study, 1996-2004• 18,000 patients in USA and Europe18,000 patients in USA and Europe• All had 2 consecutive days without dialysisAll had 2 consecutive days without dialysis• Death significantly higher after ‘long break’Death significantly higher after ‘long break’• Death from cardiovascular eventDeath from cardiovascular event

Zhang H et al, American Society of Nephrology, Philadelphia, Nov 2008

I

II

III

IV

V

In Centre ?Home

HD x 3

HD x 4

HD x 6

Transplant

‘GFR’ Replacement Therapy

Home HD - Distribution of time & frequency

3 x weekly Alternate days

4 x weekly 5 x weekly 6 Š 7 x weekly

< 3.5 hours

3.5 Š 4.25 hours

4.25 Š 5 hours

5 Š 6 hours

6 Š 8 hours

Guys &St Thomas, London, 09

TM0065 Rev BNxStage has prepared this tool to assist providers in the development of their staff training

materials. This document is not intended to replace the NxStage

User’s Guide or cartridge Instructions for Use. NxStage® is a

registered trademark of NxStage Medical, Inc. TM0065

Rev B

Mobile HD Machines – At Last!

Home Travel

TM0065 Rev BNxStage has prepared this tool to assist providers in the development of their staff training

materials. This document is not intended to replace the NxStage

User’s Guide or cartridge Instructions for Use. NxStage® is a

registered trademark of NxStage Medical, Inc. TM0065

Rev B

NxStage: Simple-to-use supplies

Drop-in, disposable cartridge Disposable Purification Pack

Disposable Dialysate

Sack

Portable Fluids

Can we afford daily dialysis?

Purification Pack (good for 6-12 weeks)

Water

Sediment Filter

UV Light Carbon Resin

KDF

Media

Dual-bed Resin X3

Mixed-bed DI Resin

Ultra-filter

X2

Ultra-pure

Water

0.2 micron filter

Dialysate Sack

Purification Pack

Sensor 1 Sensor 2

TM0065 Rev BNxStage has prepared this tool to assist providers in the development of their staff training

materials. This document is not intended to replace the NxStage

User’s Guide or cartridge Instructions for Use. NxStage® is a

registered trademark of NxStage Medical, Inc. TM0065

Rev B

Similarities APD and NxStageSimilarities APD and NxStage

APD NxStage

Mobile cycler Mobile cycler

‘Fully saturated’ dialysate ‘Fully saturated’ dialysate

Healthy membraneDwell time

High blood flowLow dialysate flow*

115-140 L lactate/wk 100-180 L lactate/wk

7 divided doses 5/6 divided doses

Daily disposables Daily disposables

* Different from traditional HD

Dialysis Reference Costs, 16 NHS Trusts, 2008

£

• Centre HD 23,868

• Home HD (3 X weekly) 12,948• PD 20,805

Home HD brings less income to the Trust

NHS Kidney Care, PbR Working Group, 2008

Home Dialysis – Operational Aspects

• Promote frequent dialysis to optimise health prospectsPromote frequent dialysis to optimise health prospects• Self-care first policySelf-care first policy• Dialysis initiation with APD, including late presentersDialysis initiation with APD, including late presenters• 4.5 sessions weekly using traditional machines4.5 sessions weekly using traditional machines• 5.5 sessions weekly NxStage5.5 sessions weekly NxStage• Expect significant demand for mobile machinesExpect significant demand for mobile machines

• NxStageNxStage• QuantaQuanta• Deka (Baxter)Deka (Baxter)

EAST OF ENGLAND SCG – Strategy and Capacity Plan - 2008EAST OF ENGLAND SCG – Strategy and Capacity Plan - 2008

Sites for New Renal Units Identified

Expansion of HD Stations by PCT

Assumptions in EoE Strategy and Capacity PlanAssumptions in EoE Strategy and Capacity Plan

• 5% annual growth in dialysis (NSF 2004/5)5% annual growth in dialysis (NSF 2004/5)• 2.4% annual growth in transplant procedures2.4% annual growth in transplant procedures• 3.8% annual growth in functioning transplants3.8% annual growth in functioning transplants• PD up to national average (10.7% RRT) by 2015PD up to national average (10.7% RRT) by 2015• 10% HD patients self-caring on Home HD by 201510% HD patients self-caring on Home HD by 2015

Business case to Board of E&N Herts NHS TrustBusiness case to Board of E&N Herts NHS Trust

Scenario 1 Scenario 2

• Total Dialysis Annual Growth 5%• 10% HD Patients Self Caring by 2015• PD increase to 15% all dialysis by 2015

• Total Dialysis Annual Growth 5%• Limit Home HD to 5 Patients• PD continues to decline (current 9.7%)

Assume 50% HHD patients will choose NxStage

4/09 4/10 4/11 4/12 4/13 4/14 4/15

HD (all) 365 378 392 406 422 439 458

HD (Centre) - CHD 364 369 375 381 389 399 412

Pts/CHD station 6 5.9 5.8 5.6 5.4 5.2 5

Total CHD stations required 61 63 65 68 72 77 82

CHD stations required in new units in Beds and Herts   2 5 9 14 19

Patients treated in new units   10 28 49 71 97

Total staff req. for CHD     7 12.5 17.7 20.8 29.3

Home HD 1 9 17 25 33 40 46

% HD patients at home 0.3 2.4 4.3 6.2 7.8 9.1 10

Total staff req for HHD 1 2.3 2.5 2.5 3 4 4

PD 38 45 52 60 67 74 81

% Total dialysis on PD 9.4 10 11 12 13 14 15

Total staff req. for PD 2 3 3.5 4.5 5.25 5.5 5.5

TOTAL DIALYSIS PATIENTS 403 423 444 466 489 513 539

Projected Patients and Extra Staff Required from 2009 - 2015

Scenario 1: Aspire to EoE strategy to promote home therapies

4/09 4/10 4/11 4/12 4/13 4/14 4/15

HD (all) 365 387 410 435 461 487 516

HD (Centre) - CHD 364 382 405 430 456 482 511

Pts/CHD station 6 5.9 5.8 5.6 5.4 5.2 5

Total CHD stations required 61 65 70 77 84 93 102

CHD stations reqd in new units in Beds and Herts   2 7 14 21 30 38

Patients treated in new units   6 40 77 116 154 196

Total staff req. for CHD     3 16.3 22.6 35 45.3 60

Home HD 1 5 5 5 5 5 5

% HD patients at home 0.3 1.3 1.2 1.1 1.1 1 1

Total staff req. for HHD 0.25 0.25 0.25 0.25 0.3 0.3 0.25

PD 38 35 32 30 27 25 23

% Total dialysis on PD 9.4 8.3 7.2 6.4 5.5 4.9 4.3

Total staff req. for PD 2 2 2 1.75 1.5 1.4 1.25TOTAL DIALYSIS PATIENTS 403 423 444 466 489 513 539

Projected Patients and Extra Staff Required from 2009 - 2015

Scenario 2: Current trends in dialysis case mix continue

Cumulative (extra) costs by year 2015/16

Scenario 1 – 10% HHD Scenario 2 – Mainly CHD

Pay 1,254,486 2,037,096

Consumables 1,093,293 502,730

Machine Lease Costs 175,478 112,893

Home Conversion 118,688 2,000

Pathology Savings -34,200 -3,040

Pharmacy Savings -79,639 18,011

Travel Savings -44,000 5,500

Holiday Dialysis Saving -56,700 -5,040

Total Non-Pay 1,172,919 633,054

Total Revenue Costs 2,427,404 2,670,150

GBP GBP

*before depreciation and capital charges

Cumulative (extra) costs by year 2015/16

Scenario 1 – 10% HHD Scenario 2 – Mainly CHD

Pay 1,254,486 2,037,096

Total Non-Pay 1,172,919 633,054

Revenue Costs (excl) 2,427,404 2,670,150

New Dialysis Centres

Depreciation over 40 yr 200,000 450,000

Capital Charges (3.5%) 280,000 630,000

Total Revenue (incl) 2,907,404 3,750,150

Capital Build (new centres)

2,000,000 6,000,000

GBP GBP

Reimbursement (PbR), NHS Kidney Care, June 2009

• Hospital HD £28,860• Satellite HD £22,152• Home HD (4X weekly) £17,264• CAPD £18,980• APD £21,900

• All HD LC02A £23,868• All PD LC04A £20,805

But: Self –Care at home brings less income to the Trust

Need to test whether Trust can afford a home dialysis programme by feeding these reimbursement rates into the model

Cumulative (extra) costs by year 2015/16

Scenario 1 – 10% HHD

Scenario 2 – Mainly CHD

Compare Scenarios 1 and 2

Extra Revenue (expenditure)

2,907,404 3,750,150 842,746

Income (PbR) 12,907,400 13,369,500 462,100

Effective Savings to Trust

380,646

Capital Build (new centres)

2,000,000 6,000,000 4,000,000

Business Case – bottom line

• Self-Care will result in costs savings of £842,746 p.a. by 2015• Self-Care will create a revenue deficit of £462,100• Current PbR tariffs likely to dampen the enthusiasm

Denoument:

• Challenge traditional funding model • Patient advocacy - Kidney Alliance, NKF• Work with SCGs, NHS Kidney Care, PbR team at NHS• Pull levers - Payment for Performance, Patient Choice

Kidney Alliance, 09/10

• Mission Statement re Home Therapies • World Kidney Day, March 2009

– Home HD featured in Commons Terrace reception • Questions in Commons, Lords, through 09/10• Patient presence in SCG Strategy meetings

DH, Payment by Results, Draft Guidance, December 2010DH, Payment by Results, Draft Guidance, December 2010

Paras 283-292: Renal Non-Mandatory Prices for 2010/11 £ £

Centre HD 144 session 22,464 annumHome HD 144 session 33,696 annumCAPD/APD 48 day 17,520 annum

....this recommendation is intended to incentivise an increase in provision of home dialysis options...

....sessional payment since patients may dialyse 4 or 5 session a week...

....we encourage commissioners, where there are low levels of provision, to work with their providers to create effective choices…

DH PbR Team 17DH PbR Team 17thth Dec 2009 Dec 2009

Kidney Alliance Response to PbR Consultation, Jan 10

• Plea for a soft landing for some Trusts• Don’t over-incentivise HHD, suggest parity with CHD• Clarify tariff includes home conversion costs• Address Assisted PD (aAPD)• Clarify drug in(ex)clusions – anaemia, bone-mineral-metab• ‘Unbundling’ exposes Conservative Mgnt, Pre-Dial, Transp w/u, f/u• ‘Unbundling’ exposes dietetics, SW and counselling

Commissioning for Quality and Innovation (CQUIN)Commissioning for Quality and Innovation (CQUIN)

...CQUIN monies linked to this indicator will be at risk of being withdrawn if non-submission of data or failure to achieve interim targets...

EoE SCG 15EoE SCG 15thth Feb 2010 Feb 2010

• CQUIN part of ‘Payment for Performance’ scheme • Proportion of provider income conditional on agreed goals• Worth 0.5% contract value in 09/10 rising to 1.5% in 10/11

EoE Renal CQUIN for 2010/11EoE Renal CQUIN for 2010/11

‘‘Providers in EoE to achieve a 10% Home HD rate by April 2015’Providers in EoE to achieve a 10% Home HD rate by April 2015’

Summary

• Rejuvenation of interest in Home HD (HHD)Rejuvenation of interest in Home HD (HHD)• HHD chief aim is to deliver more (frequent) dialysisHHD chief aim is to deliver more (frequent) dialysis• Mobile machines will be in demandMobile machines will be in demand• HHD insufficiently incentivised with traditional reimbursement HHD insufficiently incentivised with traditional reimbursement • PbR rates recently proposed will incentivise HHDPbR rates recently proposed will incentivise HHD• HHD can also be incentivised through Payment by Performance HHD can also be incentivised through Payment by Performance • At least 2 English regions have adopted HHD for their renal CQUINAt least 2 English regions have adopted HHD for their renal CQUIN