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.

Wednesday, 16 March 2011

Q & A: Operating Framework - 30 day readmissions

Q: Dear Donal, we, along with all other Trusts, have been trying to make sense and work out the implications of the new Operating Framework. With regard to the matter of penalties for 30 day re-admissions I am told that patients on regular outpatient haemodialysis, who are admitted 3x per week for their routine treatment, will NOT be excluded from this measure … meaning that, as I understand it, commissioners will be able to refuse to pay for any emergency admissions that these patients require, because when they return a few days later for routine dialysis, they will be ‘re-admitted’. This is (technical term) bonkers. I’m sure that you will already be aware of the issue, but can I ask if you think it’s going to be possible to resolve it sensibly? And is there anything that we can do to help? Regards, Dr John Firth, Deputy Medical Director; Debbie Morgan Commissioning Lead, Addenbrookes Hospital , Cambridge

A: Dear John & Debbie, thanks for raising this issue. My apologies that it is consuming your valuable time. It would be a complete nonsense if people who were regular attenders for haemodialysis were to be included in the emergency re-admissions non payment policy. I have raised the question directly with the Payment by Results team here at the Department and I can confirm that the Department of Health position is that renal dialysis is excluded from the 30 day emergency re-admissions non-payment policy in 2011/12. Therefore, there is no reason for detailed local discussions and negotiations to ensure that “sense prevails”. The exclusion is based on the technicality that dialysis does not have a mandated national tariff in 2011/12 although it does, as you know, have a mandatory currency with a mandatory 50% transition towards a national tariff price in 2011/12. So here the technicalities are working with us and support common sense.

The national tariff for dialysis itself will of course be mandatory in 2012/13 but it is likely that re-admission policy for 2012/13 will be subject to review and, having now flagged the issue of regular dialysis attenders, I expect that to be taken on board when the financial guidance and instructions are written for 2012-13. I will also be making the current position clear to all our Clinical Directors and Specialist Commissioning colleagues so that valuable time addressing quality and productivity is not squandered on unnecessary discussions. Kind regards, Donal

Thursday, 10 March 2011

Nice standards if we can achieve them

To mark World Kidney Day the National Institute for Health and Clinical Excellence (NICE) have published the chronic kidney disease (CKD) standards to which the NHS will be held to account. The Information Centre has also uploaded the results showing how different services are performing against the indicators of quality improvement. The quality standards cover the whole of the CKD pathway from risk through early detection and management to reduce vascular risk and progressive kidney injury, preparation, shared decision making, replacement therapy, conservative and end of life care.

Nice quality standards are central to the delivery of quality and improvement in outcomes. The CKD pathway is one of the first NICE quality standards to cover the whole spectrum of disease, some of the other recently published standards only focus on one part of the pathway but as we know healthcare is only as reliable as its weakest link.

CKD is common, harmful and treatable. The recently published Health Survey England data showed that more than 1 in 10 adults have either proteinuria or reduced kidney function as measured by an estimated GFR. Most people remain undetected. Yet we have easy ways to identify kidney disease – simple blood and urine tests that are being performed hundreds of thousands of times a day up and down the country and sometimes ignored. We know for instance that probably only 40% or 50% of those with a reduced GFR are on primary care CKD registers and that overall probably only a third of people with CKD have their blood pressure controlled to the target set by NICE.

The NICE quality standards have been developed by healthcare professionals and patients working together and set the standards of excellence for kidney care. They are aimed at patients, commissioners and service providers as much as healthcare professionals. The standards are based on the best available evidence, much of it drawn from the NICE clinical guideline on chronic kidney disease published in 2008 but augmented by new research findings over the last 3 years. They form the cornerstone of the new NHS Outcomes Framework which sets out the aims and objectives for the NHS.

Most but not all of the standards are relatively easy to measure. We don’t collect national data on all the standards and their power will only be maximised if individual local communities – the kidney community working with primary and secondary care - and commissioners in their local networks use the standards to drive up quality and productivity to achieve value-based kidney care that improves both experience and outcome for patients by engaging the healthcare professionals providing support and management across the CKD pathway and activating patients so they have a better understanding of what kidney disease means for them and how they might reduce their own future risks by lifestyle changes, tailoring the clinical management to the individual and encouraging self care.

Tuesday, 8 March 2011

Print a kidney

.... in 7 hours. A long time to print a picture of a kidney but what Anthony Atala is describing on TED is "printing" a solid 3 dimensional kidney made up of human cells!

It's a fascinating concept and a fitting presentation for World Kidney Day.

Tuesday, 1 March 2011

Q & A: A Coding conundrum for CKD

Q: Dear Donal, connecting for health are telling our coders that the term CKD is not acceptable. To quote:
“I am afraid we have a problem with our Local Policy with you and your team around the stages of CKD, when it is stated on the discharge summary/case notes CKD 1 – 5.
Connecting for Health have informed us that we are unable to assign Chronic Kidney Failure codes to this abbreviation as it is not a mandated instruction in our ICD 10 Clinical Coding Manual (please see attachment above). This means that without the term ‘kidney failure’ written on the discharge summary (which is our source documentation for coding) we can not code CKD as kidney failure.”

Clearly we cannot go back and uneducate all our docs to stop using terms like CKD or AKI. Can you sort out Connecting for Health? Kerry Tomlinson

A: Dear Kerry, thank you for your email highlighting the difficulties you are having in Stoke capturing the coding on Chronic Kidney Disease because of the lack of codes within the current version of ICD-10. I too have taken some advice from the comorbidity coding group within Connecting for Health and on the basis of their advice suggest the following;

First we are assured that version 4 of ICD-10 will contain specific codes and guidance for chronic kidney disease and it's stages. Version 4 will be implemented in the NHS from April 2012 and should provide a robust means of capturing CKD in clinical coding.

Until April 2012 we need to work with the existing ICD-10 codes, which as you appreciate do not contain CKD codes or indeed terribly satisfactory means of capturing CKD using existing chronic renal failure coding. CfH have suggested the following "work around";

"The term Chronic Kidney Disease (CKD), when referring to CKD with stages 1-5 does not exist in the current mandated version of ICD-10.
However at present, for consistency, we must follow the existing index trail for a documents diagnosis of chronic kidney disease, which is:

- kidney (functional) (pelvis) (see also Disease, renal)
- renal
- - chronic – see nephritis, chronic
Nephritis, nephritic
- chronic N03.-
N03 Chronic nephritic syndrome
(Fourth character assignment will depend on the additional information
provided in the casenotes.)
As stated by the note on page 680 of ICD-10 Volume 1; an additional
code must be used to identify the external cause (chapter XX) or the
presence of renal failure (N17-N19).

Please note that the presence of renal failure is not always recorded in the patient care record when the clinician has stated that the patient has CKD, and it is not the responsibility of the coder to determine whether a patient has renal failure based on the stage of the chronic kidney disease. Therefore, coders must liaise with their Trust renal physicians on this matter, to ensure that the relevant information is recorded in the patient care record."

In practice I think what it comes down to most is you agreeing a local system where clinicians, aware of the coding restrictions, and coders familiar with their clinicians practice come to a consensus on making the coding work for you for the next 12 months.

I hope that this information is helpful; CfH are well aware of the deficiency in the current coding structure and hence the planned change to a system enabling coding it correctly. Donal