Shared Decision Making to Improve Care and Reduce Costs

I have just been reading this editorial by Lee and Emanuel, which makes the point that randomised trials have consistently demonstrated the effectiveness of patient decision aids. In 2011, a Cochrane collaborative review of 86 studies showed that, compared with patients who used usual care, those that used decision aids had increased knowledge, more accurate risk perceptions, reduced internal conflict about decisions and a greater likelihood of receiving care aligned to their values. Moreover, fewer patients were undecided or passive in the decision making process- changes that are essential for patients’ adherence to therapies.

The authors note that progress in embedding shared decision making into routine care has been slow, despite the recommendation of the Institute of Medicine about SDM in the seminal publication "Crossing the Quality Chasm"  back in 2001.

The New England Journal of Medicine editorial, and you don’t get more influential than that, points out that studies in the USA also illustrate the potential for wider adoption of shared decision-making to reduce costs. Consistently, as many as 20% of patients who participate in shared decision making choose less invasive surgically options and more conservative treatment, than patients that do not use decision aids.

The authors suggest that providers who do not document shared decision making processes for preference sensitive health care choices about procedures, should face a 10% reduction in payments for those procedures with reductions in payment gradually increase to 20% over 10 years. It will be interesting to read the letters page of the NEJM next week!!

Consistent recording of pre-renal replacement clinic activity

Preparation and choice are essential to achieving good outcomes in end stage renal failure- whether that is a pre-emptive transplant, one of the modalities of dialysis or conservative kidney care. Good preparation for renal replacement therapy requires a whole team. Money well spent, when one considers the positive impact preparation can have on the experience of care and the clinical outcomes.

From April 2013, the NHS Commissioning Board will directly commission the care of patients approaching renal replacement therapy and today I have written to kidney care clinical directors, finance leads and commissioner colleagues, setting out the coding that will be required to identify this important activity. Details of the expected arrangements can be found below.

Developing a currency for Transplantation

A new landscape for commissioning comes into place from April 2013, where all parts of the kidney transplant pathway will be commissioned directly by the NHS Commissioning Board. This will include transplant work-up, maintenance on the list, live donor work-up, the transplant operation and life long follow-up. This is a change from the current arrangements, where transplant surgery is commissioned at a regional level but clarity about assessment, arrangements for maintenance on the transplant list and long-term surveillance is often lacking, leading to unwarranted variation in practice and sometimes delays or worse for patients.

The NHS Atlas of Variation inhealth care for people with kidney disease shows some of these variations. There is nearly a two-fold variation in the rate of kidney transplantation from live-in donors between regions and a staggering thirty-fold variation in pre-emptive transplantation depending on where you live! NHS data is normally based on the financial year, but units do not have to wait until April to look at their 2012 performance. Some people are a bit apprehensive about the word performance but we should not be- it describes quality of care provided. Locally, for instance, our specialist transplant nursing colleagues Angela Bailey, Helen Flood and Jane Redshaw set themselves the task of improving on the very good figures in 2011/12, when 30 live donor transplants were performed and have increased that to 34 this last year, nearly half of which were pre-emptive transplants. If that were scaled to the country, it would result in 1,360 live donor kidney transplants being performed. That would be over 350 more live donor kidney transplants in the UK than in 2011/12.

To provide a more coordinated and holistic approach to kidney transplantation, our Clinical Reference Group under the masterful stewardship of Mr Keith Rigg – Consultant transplant surgeon in Nottingham, has developed a pathway approach for adult kidney transplantation with the aim of providing the best possible experience, quality outcomes for those who might be suitable for kidney transplantation.

The pathway has been designed from a clinical perspective, has widespread support and makes sense from whatever angle you view transplantation. The next step on the pathway, if I am permitted that play on words, is to record practice and activity in a consistent way – so we can measure quality and provide the service in an efficient manner, in terms of timeliness and costs. This builds on the NHSKidney Care Developing Robust Reference Costs for Kidney Transplantationreports in 2010 and 2011 and moves us onto a national currency to deliver a complete pathway of care for adult transplant patients.

The technical building blocks of a commissioning currency are the Health care resource groups (HRGs) or outpatient attendance and treatments (treatment function codes (TFCs) that group clinical activity requiring similar resources together and they in turn, are based on clinical coding to clearly identify the conditions patients have and what procedures they have undergone. That means the coding is based on the individual patients clinical record. Good record keeping is therefore the key, not only to good personalised patient care, but also, for clinical audit and improvement for the whole of the transplant population.

Introducing a national currency for the pathway of transplantation will not change this fundamental need for good quality record keeping. Some of the codes, particularly procedures and the parts of the pathway they mapped to will require a more precise definition and accuracy of coding will need to be quality controlled. This consistency will enable a clearer understanding of quality across the whole pathway; it should not interfere with practice but will allow benchmarking between teams and will help secure improvements in outcomes.

Investing the savings made from getting the diet right, in more dietitian time for people with kidney disease

 The National Institute for Health and Clinical Excellence (NICE), the drugs “watchdog” recommended last year that every person with stage 4 or 5 CKD should have a formal dietetic assessment by a specialist renal dietician. This happens for children with CKD but adult practice varies widely. The NICE Clinical Guidelines on the management of Hyperphosphataemia highlighted dietary advice as the first line treatment for the management of hyperphosphataemia rather than straight to pharmacological interventions.

Providing a dietary assessment for all people with stage, 4 and 5 CKD would cost more money than is currently spent on dietetic support. It is thought that only 75% of those at risk routinely receive a specialist renal dietetic assessment. NICE have now produced a consultation document that estimates the cost to increase that figure to 95% of adults with stage 4 or 5 CKD receiving dietary advice. This works out at just under £100,000 per million of the population. Given there are just above 50 kidney units in the country, the population served by many unit is in the region of 1 million. Access to specialist renal dietitians fits completely with the concept of multi-disciplinary team care for those with advance kidney disease. The NICE clinical guideline emphasises both  the direct patient management role  of renal dietitians whose advice then   needs to be reiterated by other team members, monitored and reviewed, as well as pointing out that renal dietitians  have a crucial teaching and development  role to play in supporting the wider disciplinary team, and providing “refresher” courses for existing staff.

We know from the Renal Registry reports that overall, only between 60-70% of people on dialysis achieve serum phosphate levels within the recommended range. Therefore, for most units this guideline should provide a prompt to review practice and consider changes to the low clearance clinic and dialysis multi-disciplinary team working. The goal being to achieve better engagement with patients about their diets, so people with advanced CKD or on dialysis have a deeper understanding of what options are available to them.

How is all of this to be paid for? Especially when the guideline emphasises the importance of starting phosphate binders early when they are needed. The economic analysis at NICE suggests that a shift to calcium acetate or calcium carbonate as a first line phosphate binder could pay  for the extra dietetic personnel costs many times over   by saving upto  £3 million pounds per million of the population. Given the variation in practice at unit level, the assumptions used in the audit tools and the costing template provided by NICE. This should help local kidney communities and their commissioners, fine tune the implementation of this guideline and this can lead to achieving more consistent dietetic support for patients, better phosphate control and  saving money, which can be reinvested in other aspects of kidney care.

So, what will the reformed NHS really be like?

Less than 70 days left to go now until the NHS Commissioning Board assumes control. There is still discussion about senates and networks, uncertainty where some individuals will find themselves working and of course, the whole system is bracing itself for Frances II – the second report by Robert Frances QC on the unforgivable lapses in care at Mid Staffordshire Hospital. Reading the national papers, even the Health Service Journal or the indomitable Roy Lilly’s blog, you might be forgiven for being a bit muddled about how it will all work or indeed will it all work ! Of course, if you are a nurse, doctor, patient, dietitian, carer, and technicians or in some other way involved in receiving or giving care, the world will not look that different this 1^st April from last 1^st April! There is a lot that is constant in the sea of  organisational change. However, the Health and Social Care Act is going affect all of us in the English health system.

Therefore, what will the priority be in the coming year? I have given a clue in my first sentence. The 70-days until the 1^st April include Saturdays and Sundays. NHS services 7-day a week is on the agenda. To find out what else is, have a listen to David Nicholson.

If you do not want to risk missing the wood for the trees , remember our system is based around the outcomes framework; reducing avoidable deaths, improving care for long-term conditions, helping people recover from acute illnesses, radically changing the experience of care and keeping people safe. Add to that the NHS constitution – what are people’s rights, and responsibilities? Moreover, you will have a pretty good idea of what the NHS will look like.

David Nicholson makes the point that patients are at the centre of our system, that professional leadership is not just the doctors, it’s everyone in the multi-disciplinary team and that in the information age, data is king.