Monday, 17 August 2009

Bedtime reading: National Diabetes Audit 2007/08

This Audit makes interesting reading. All complications of diabetes apart from eye disease are more common with increasing social deprivation with a two fold increase between the least and most deprived. Even more striking are the large differences in the rates of complications between regions with up to two fold difference for kidney failure. This variance suggests that significant improvements could be made and I think that also follows from a knowledge of the pathophysiology. It depends whether you are a glass half full or a glass half empty person on how you respond to the albuminuria testing data. This has improved from only 20% of registered patients having an ACR in 2003/04 to 62% in 2007/08. That's still nearly 40% of the people who are known to have diabetes who are not getting satisfactory kidney care, let along those who have not yet been identified with diabetes. There are clear opportunities to work locally, regionally and nationally with primary care and diabetes colleague to improve the kidney care of those with diabetes.

Thursday, 13 August 2009

Q & A: Wristbands improve patient safety

Q: Dear Donal, I was wondering if it would be possible for you to comment on the NPSA 'standardising wristbands' safer practice notice that will come into force on 18th July this year, in the context of outpatient haemodialysis?

We are experiencing some problems with various interpretations of the safer practice notice when applied to outpatient haemodialysis patients.

I have been asked to ensure that every patient has a new identification wristband attached, each time they attend for outpatient dialysis.

The nurses are being put into a panic by being told that it is 'illegal' to give any drug such as epo/iron during dialysis (and even saline washback at the end of dialysis) unless there is a wristband in place.

Looking at the actual NPSA document, it appears that it applies to "hospital inpatients in general acute and community settings". This infers that outpatient haemodialysis, as a chronic disese treatment., is not within the remit.

I am sure that this is not the only dialysis unit to be asking themselves this question, and so I wondered if you could clarify. David Gledhill, Unit Manager - Haemodialysis, North Cumbria University Hospital NHS Trust

A: Dear David, as you say, the wristband Safer Practice Notice specifies that the recommendations are to implemented by " all NHS organisations in England and Wales that use patient wristbands". It also says that the SPN "applies to hospital inpatients in general acute and community settings." As such, it is not necessary for outpatients attending for haemodialysis at renal units to wear wristbands. However, the purpose of the Notice was to make patient identification as safe as possible and that must be a concern in respect of patients attending for regular haemodialysis. The Safer Practice Notice relating to correct blood transfusion, recommends in 3b photo identification cards for patients who undergo regular blood transfusions. While few dialysis patients get regular blood transfusions, many of course get intravenous iron and quite frequently people on dialysis are receiving intravenous antibiotics. It may be appropriate to consider whether patients undergoing regular haemodialysis would be safer with a similar approach.

Doing more for less: so what should we stop doing then?

Well, bringing people back to hospital for intravenous iron for one!

The papers and news channels are full of the effects of the recession. “Recession starts to threaten home life” pronounced The Times leader on 12 August. Unemployment with its increasing alcoholism, domestic violence and drug addiction is set to surge the paper claims. The social and health consequences of economic downturns are well known. Not a day goes by that the NHS and other public services are not in the limelight for how we will cope with the global financial crisis. As the NHS faces its biggest financial challenge for decades what is absolutely essential is that we don’t lose sight of quality in healthcare. We need to focus on high value activities – early detection of kidney disease and good control of blood pressure, planning of renal replacement therapy including pre-emptive transplantation, home dialysis and helping those on the conservative kidney care pathway stay in their own homes. We know that the number of people with advanced kidney disease will continue to grow over the next decade. That’s inevitable given the aging population let alone the increasing obesity, diabetes and hypertension epidemics. So how can we afford high quality care in a “flat cash” environment? Flat cash is a term you will hear more of, it means what it says, little or no absolute increase in funding for the NHS after 2011 for some years. Most sources speculate that the NHS will barely keep pace with inflation. Add in the increased demand of an older population and you will realise the serious questions the public, our politicians and the health service faces.

So how can we afford to increase quality for more patients at a time of effectively less cash? Well that was the subject of a Kidney Care Commissioning Workshop that Sir Muir Gray and I hosted last month. We do need efficient and effective pathways for those elements of care that add value – creating a fistula before the need for dialysis, using the 18 week pathway to accelerate live kidney donor transplantation, early recognition and prompt treatment of acute kidney injury to name a few. We also need to identify and eliminate low added value activities – hence the title of this blog.

Intravenous iron is an essential component of the management of anaemia of chronic kidney disease – of that there is no doubt. It improves the efficiency of EPO or, as we should call EPO now, Erythropoietic Stimulating Agents or ESAs. Now, I do have a bit of bee in my bonnet about this but why does so much intravenous iron entail long trips back and forth to the main kidney centre? Perhaps safety – well no; patient convenience – certainly not; what about clinical governance, by which I mean clinical responsibility since the hospital team have usually prescribed the iron treatment – well, no again.

The cynical might say it’s the budget. Who pays for the iron? And moving money from a hospital or secondary care budget to, for instance, a local health centre or community care team does feel a little like playing 3 dimensional chess. The budget is actually not an insurmountable problem – clearly giving IV iron locally without the inconvenience and cost of travelling to the hospital is better value for money than the IV iron service we provide for many patients at present.

Education, support and experience of colleagues in primary care has until recently been the stumbling block. That’s why I was so pleased to see “A guide to the administration of intravenous iron for people with anaemia of chronic kidney disease (CKD) in a non acute hospital setting” when it was published. It provides all that’s necessary to set up a local IV iron service.

What other low or no value activity would you like to confine to Room 101? Answers on a postcard (well email please); seriously, I would very much like to hear suggestions and views from patients, carers and all those working in kidney care. Anonymity will be preserved if you like.

Do let me have your ideas and do use the IV guide to improve local kidney anaemia management.

Tuesday, 4 August 2009

Incentives for home dialysis – End stage renal disease: CMS should monitor effect of bundled payment on home haemodialysis utilisation rates

This report from the United States Government accountability office makes interesting reading. In the USA approximately 92% of people receive their dialysis in a hospital or satellite unit, while about 7.4% perform peritoneal dialysis at home and only 0.7% receive home haemodialysis. The CMS, the agency that pays for dialysis wants to create incentives for providers to offer home dialysis and already requires providers to offer home dialysis or indicate why individual patients are unsuitable. Many of the medical experts and dialysis providers interviewed for this report estimate that from 15-35% of all dialysis patients would be good candidates for home dialysis.

Average costs per treatment for haemodialysis in a facility, is quoted at $243 versus $133 for haemodialysis at home, with peritoneal dialysis at home averaging $94. In the USA, training is billed separately, for instance $20 per training session to train a patient how to conduct haemodialysis, for 3 sessions per week for up to 3 months.

We have been looking at the findings in the Dialysis Best Practice Tariff Group to see what parallels there might be for our system. In the USA they have decided to bundle payments and will be monitoring the impact – I and I am sure others will be watching this with interest.

Bedtime reading: NHS clinical knowledge summaries

A new resource intended to support the management of chronic kidney disease is now available

The NHS Clinical Knowledge Summaries (formerly PRODIGY) are a reliable source of evidence-based information and practical 'know how' about the common conditions managed in primary care. They are aimed at healthcare professionals working in primary and first-contact care.

Monday, 3 August 2009

Quality, innovation, productivity and prevention

The health service is facing a major challenge and that challenge is not one of its own making nor is it an ideological threat. We are all aware that the public debt has doubled from 40% of the gross domestic product to 79% of GDP as a result of the banking bail out. However soon the recovery comes that debt will still have to be repaid and that will put unprecedented pressure on the NHS and other public services. David Nicholson, the Chief Executive of the NHS, has estimated that we will have to find between £15-£20 billion and the Kings Fund have predicted an even bigger shortfall after 2011 – between £20-£26 billion. Figures almost too big to comprehend. It may not be possible to predict the future but one thing is for certain, the next 7 years will be years of relative famine and it will be a period of massive change.

Put another way, the challenge is to continue to drive up quality whilst improving productivity – a challenge which means harnessing and spreading innovation. It means going further faster rather than slowing down. No one in the health service wants to see a reduction in quality of care. Neither do the patients nor the public, who fund the system, wish to see that. So quality remains the organising principle of the NHS but now innovation, productivity and prevention are sitting alongside quality as core objectives for the whole health system and everyone who works in or with our health system.

What will this mean for kidney services? Well we know that the number of people with kidney disease will continue to grow because the population is aging and because of vascular disease and diabetes. The number of people needing a kidney transplant or dialysis will continue to grow. Conservative kidney care, the no dialysis option, has been highlighted by NHS Kidney Care as an area for quality improvement. The recent NCEPOD report into acute kidney injury is a chilling read – acute kidney injury is often unrecognised and when identified poorly managed. None of these aspects of kidney care can be put on a back burner. Lord Darzi’s Next Stage Review put in place a compelling, ambitious and patient-focussed vision. We must plan to deliver significant efficiency savings whilst remaining true to our vision of high quality care for all. I believe that is possible because doing the right thing, at the right time, every time almost always costs less and the staff in the health sector really believe in providing quality of care.

Over the past 5 years, since the publication of the National Service Framework for kidney services I have seen quality move from a rather ill defined concept to clear objectives in the plans of every kidney service covering all the dimensions of quality-safe, timely, effective, efficient, equitable and patient centred. Since 2006 chronic kidney disease has been part of the primary care quality and outcomes framework. Quality metrics have recently been published covering much of the kidney care pathway including end of life care. The development of a comprehensive mandated data set means we will get even better information in the future. The dataset has also led to inclusion of aspects of kidney care in the Commissioning for Quality and Innovation (CQuIns) payment system for acute trusts and raises the possibility of kidney care being considered as part of the quality accounts.

In my visits across the country I have the privilege of meeting many patients and frontline staff. Nearly everywhere I go I learn about innovations that have been tried and tested locally. At the British Renal Society meeting in June there was a wealth of good practice on show, but we have to sustain, spread and systemise our quality improvement projects.

Productivity in chronic kidney disease management is sometimes difficult to demonstrate. Let me ask you a question – what is cheaper – a high rate of line use for vascular access with a high rate of MRSA and other infections leading to unnecessary bacterial endocarditis and spinal abscesses or good pre end stage renal failure care offering choice with shared decision making and establishing vascular access before the need for haemodialysis. Or for that matter performing a live donor kidney transplant before the start of dialysis. No need to answer. The 62% reduction in MRSA we have achieved by improving our systems for advanced kidney disease care and establishing vascular access at the right time has resulted in massive productivity gain as well as improved the experience and outcome of kidney care. So in chronic diseases, as opposed to for instance some surgical specialties, we need to consider the whole pathway of care not just the cost of a single procedure or admission. We need to focus commissioning on pathways of care and on population needs rather than episodes of care. At NHS Kidney Care we are taking just that approach for peritoneal dialysis and will extend the work to other modalities.

Kidney disease is part of NHS checks the ambitious programme to offer vascular risk assessment to every person between 40 and 74. This programme will result in people understanding their individual risk much earlier than they do at present. The preventative dividend of including chronic kidney disease in the Quality and Outcomes Framework is already being seen in a reduction in “crash landers” or unplanned starts on dialysis.

So the quality, innovation, productivity and prevention agenda is already part of our culture and is embedded in the workstreams of NHS Kidney Care whose mission is to ensure a complete, equitable and consistent implementation of our NSF. When the NHS was formed in 1948 the national debt to GDP was 213%. Together we can deliver better services at a better price.