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