Wednesday, 26 May 2010

Q & A: PD Tariff and BP targets on PD

Q: Dear Donal, I have just seen the PD tariffs, there appears to be no tariff for assisted PD. Secondly I am concerned about the quality marker of blood pressure targets. I am unaware of any data to support these targets, the Renal Registry did present an abstract that showed adverse outcomes for hypertensive peritoneal dialysis patients listed for renal transplantation, but the Registry does not have data to support such a blood pressure target for peritoneal dialysis population.

It is now becoming obvious that "normal" haematocrit is not the correct target for dialysis patients. and it may well be that "normal population" BP targets are not best for PD patients, there is increasing data that very low BP targets do NOT improve outcomes in type 2 diabetics,

My main concern is that a rush to introduce low BPs for PD patients may well result in an earlier loss of residual renal function. This reminds me of Tom Golper and his committee which drew up the standards for PD in the USA - the original DOQI clinical guidelines. They went for higher "adequacy" targets, on the basis to ensure patients were not under-dialysed, and thought that this would improve PD in the USA - but in time this resulted in a fall in US PD patients, as "larger" patients could not readily achieve the urea & creatinine targets.

Introducing spurious targets on the basis that "big brother" knows best, I suspect will lead to a further reduction in PD populations, by potentially wiping out residual renal function.

Presumably you had input into these targets? Best wishes Dr Andrew Davenport, Royal Free Hospital

A: Dear Andrew, thank you for your email of 7 May. I was pleased that we had the opportunity to discuss this at the Renal Association last week.

The non-mandatory peritoneal dialysis tariff is, as are other tariffs, derived from the reference costs returns each Trust has a statutory duty to provide. These are based on HRGs. At present we do not have HRG for assisted peritoneal dialysis and therefore as you say, no tariff for assisted PD. Assisted PD is relatively new in the UK and quite variable in uptake between units. It has been supported by local arrangements.

I am pleased that the draft scope for the NICE guideline on PD includes assisted PD and expect the guideline will produce some evidence based recommendations.

We are also in the process of reviewing the national renal dataset so that it reflects current and future practice and the expert working group for the renal HRGs is aware of the changes in practice and the need to review the dialysis HRG structure in due course.

The potential
quality indicators were consulted upon by the Information Centre some time ago. The consultation included a number of renal parameters derived from the quality and outcomes framework and from the Renal Association guidelines and audit measures. Several of these received strong support and have been adopted. A number of other indicators were highly endorsed but were not able to be adopted in the first wave of indicators as the ‘metadata’ required needed some additional work. You will be aware from the recent Renal NSF update that work continues on LT18 which covers phosphate control and LT20 which covers blood pressure control. It is the intention to split LT20 so that the renal association guidelines for haemodialysis and peritoneal dialysis can be considered separately. The quality indicators rely on professional advice and have been developed by the Information Centre in conjunction with the Royal Colleges and professional societies prior to the public consultation. There is no proposal to use the Indicators for Quality Improvement for payment for performance tariffs. The IQIs are intended to provide a menu of options from which providers and commissioners can choose items on which to focus on a locally negotiated basis.

It is important that the adoption of quality indicators does not lead to unintended consequences. I am hopeful that the NICE guideline on PD will provide an evidence based analysis which will be used to drive improvements in outcomes. The process may well also identify some of the important evidence gaps where research is needed. Best wishes, Donal