Thursday, 17 March 2011

Future Dialysis and Transplant needs

Demand for renal replacement therapy represents a significant healthcare burden consuming between 1.5-2% of the National Health Service budget in England. Programme budgeting data available from the Department of Health continues to show large year-on-year increases in spending on kidney disease (category 17b). Our strategies to address the growing number of people with chronic kidney disease and ERSD are multi-pronged including early detection and management of CKD; timely preparation and choice now supported by a augmented tariff for multiprofessional care and pre-emptive transplantation. Planning for renal replacement capacity is essential due to the high cost and resource intensive nature of dialysis and the lead times involved in bringing new capacity into operation.

MORRIS (Model for Optimising Renal Replacement Investment and Services) has been developed to help this planning both locally and nationally – it can be used to predict the future demand depending on how acceptance rates, transplantation and survival may change and also estimates the cost of providing treatment. The projections are based on observed numbers of dialysis and transplant patients at the end of 2008 with assumptions on annual take-on rates, mortality rates and transplant supply updated to reflect the latest available data on each. However there is considerable uncertainty over how certain important parameters will change in the future. The most significant of these is the take-on rate and in planning it’s therefore sensible to model several alternative trajectories and also to consider a number of scenarios looking at the impact of increasing transplant supply and the prevalence of home therapies on the in-centre dialysis population and overall costs.

Incidence of RRT in England increased rapidly between 2001 and 2006 (annual growth of 2.8%) and although the rate declined in 2007, new patients in 2008 reflected a continuation of the previous trend. While these recent fluctuations may represent a tailing off in the increase in incidence (a hypothesis supported by experience in other European countries), the data is not conclusive. Demographics (ageing and an increasing proportion of ethnic minorities) account for around 0.8% of the historical increase, meaning that the remaining 2% annual increase must have been driven by other factors. These are likely to include the increasing prevalence of diabetes and other risk factors and increased access to the treatment, some of which may be supply led. Data from NHS Blood and Transplant shows that the annual number of kidney transplants undertaken in England grew by 25% between 2007 and 2010, with similar increases in live and deceased donor transplants. Since there is no national collection of information about the number and quality of conservative kidney care this cannot yet be modelled but might be an important variable affecting future dialysis needs. It should also be noted that the projections do not include demand for renal replacement therapy in children. MORRIS models only adults (18+).

The survival of patients receiving RRT has improved consistently since 2001. On average mortality rates have decreased by 1% pa in transplant patients and by 2% pa in dialysis patients.
If take-on rates continue to grow at their high historic rate and no further improvements are made to transplant supply, the number of dialysis patients would grow by an average of 4.4% pa up to 2018 giving 30,900 patients by 2018. This becomes 28,600 (3.5% pa growth) if there is a more moderate take-on rate. If, in addition, the target growth in transplant supply were to be achieved, the number of dialysis patients in 2018 is predicted to be 24,000. The numbers future demand would fall further to 22,300 by 2018 if growth in take-on is based solely on demographic change - the aging of the population. In this scenario, the dialysis population would be 22,400 in 2013 and remains at around this peak level until 2015 before gradually decreasing.

Best-practice tariffs for 2011/12 have been used to estimate annual dialysis costs on centre based HD and PD, based on a patient receiving three sessions per week. The cost for home HD is taken from 06/07 reference costs, based on four sessions per week, and uplifted to 10/11 prices but its important to be aware that transport costs, which we do not have national data on are therefore not included. Cost of providing treatment for a year (10/11 prices) would therefore be: HD in a centre £24,351, Home HD £19,131,PD £18,339.

Costs for transplant patients are taken from the NHS Kidney Care Report “Developing robust reference costs for kidney transplantation in adults”, March 2010. Unfortunately, no figures are given for the treatment of the donor patient in the case of live donors and therefore this cost has been assumed to be the same as for the assessment and operation element of the recipient patient’s treatment (£26,991). The costs used are as follows (in 10/11 prices): Transplant cost – deceased donor £34,736, Transplant cost – live donor £61,727. Ongoing annual post-transplant care is assumed to cost £7,274. The cost of providing RRT in 2009 is thus estimated to have been £733m. Future costs vary between £829 M and £868 M in 2013 rising to between £927M and £1,040M in 2018.

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