Wednesday, 25 July 2007

Q & A - Anaemia in Renal Patients

Q: My name is Cathy Johnson, Anaemia pre dialysis coordinator at Derby Hospital & President of ANSA. All stakeholders at the recent dialysis summit would, I am sure, recognise the positive impact optimising care of the patient with anaemia has on outcomes. However, Registry data shows variation between units achieving accepted standards in dialysis patients. A key message from the summit was the inequity of service provision and our members describe inequalities in thresholds for intervention in both dialysis and pre dialysis patients, targets and provision of ESAs.The current market place was described as being both positive and one responsive to negotiation (from which I am sure many units have benefitted), allowing the opportunity to treat more patients without increased costs. Certainly, we have an ever changing market place with potential new products coming on line. Early idintification of these patients (with early intervention impacting positively on outcomes) was mentioned, however, it has been suggested that if we identified those patients with renal anaemia, the service in its current configuration could not manage.Our members describe many patients with stable renal function (who could be managed in primary care), being referred to the renal service purely for management of their anaemia and, whilst it is appropriate to manage complex cases in-house, isn't there an opportunity here to engage with primary care to deliver anaemia management to the more stable patient? It should of course be acknowledged that this approach may present a risk to secondary care.Anaemia is managed by a variety of healthcare professionals, however it is predominantly nurse-led and some of these posts are still soft funded. In this day of restructure and reorganisation some of our members have expressed vulnerability within their role and we have seen examples of highly experienced renal nurses being lost to the service.

A: Dear Cathy, many thanks for your comments. The ability to be able to treat renal anaemia is one of the outstanding achievements that has occurred during my professional career. I recall John Saville (now the Professor of Medicine in Edinburgh) telling me about the treatment of the first patients at Hammersmith Hospital and describing the "miraculous change" as being akin to what Banting and Best must have felt when they first administered insulin. Those who have entered renal practice after 1990 may not fully appreciate the dramatic change that Erythropoeitic stimulating agents have made to kidney care - we should not minimise the remarkable improvement in quality of life that ESAs can bring although I think most of us are disappointed that the recent trials haven't shown cardiac or renal benefits. The variance that you point out is disturbing. As you say, we know from the Registry data that many units do not achieve the targets and standards set by the NICE Guidance. The Registry reports on dialysis patients and I am pleased that Charlie Tomson (Chaiman of the Registry) with the British Renal Society, is piloting a virtual quality collaborative to share best practice in anaemia management in that setting. The NICE Guidance is quite clear that any person with CKD who might benefit from ESA treatment should be considered and there is no rationale to set different treatment thresholds and goals for patients with advanced kidney disease who are not on replacement therapy. You are also probably aware that many transplant recipients have low haemoglobins that go untreated. The systems that we have in place for the dialysis programme are often not utilised for our transplant patients.

Cathy, you are right that we have to do things differently if we are to achieve our goals of a world class service and improved patient experience. The way we are currently configured, we are set up to fail - we respond to problems rather than manage risk and take avoiding action. CKD is now well recognised in primary care but the imlementation of the UK CKD Guidelines which provide an algorithym for monitoring haemoglobin, renal function and other relevant parameters is not part of the quality and outcomes framework. There remains a big eduction gap. I am hopeful that the forthcoming NICE Guidance on CKD will help address some of the issues of what could and should be done in primary care as well as provide guidance on models of care.

Currently we have people on hospital waiting lists for intravenous iron or travelling long distances by hospital transport to have the iron - this does not make sense. We need to implement a chronic disease management model of care for people with kidney disease - central to that is coordination and care planning.Many aspects of kidney care, such as aspects of anaemia management, could be more effectively delivered in primary care or the community than in hospitals. The model of care needs to be worked out to provide the best patient experience - providing high quality is the best way of providing value for money. Currently we don't have a tariff for pre dialysis care but such a mechanism could be used to drive integrated care for patient benefit and need not be a mechanism for competition which in this situation might put coordination and seamless care at risk. I would be very interested in discussing further with yourself and other ANSA colleagues how we might promote more effective integrated models of anaemia management in this patient group. Like you, I have been dismayed at the behaviour of some Trusts where highly experienced renal nurses have been made redundant to balance the books in the short term. Such staff often have had leadership roles within the multidisciplinary team - the impact on team morale and patient experience can be very negative. In the end, that will not be cost saving - poorly managed patients will access more expensive aspects of our service such as inpatient care disproportionately. The multidisciplinary team is the key to good outcomes for patients before dialysis, for transplant recipients, on dialysis and for those who choose supportive and palliative care.