© 2008 fresenius medical care ltd nephrocare is a registered trademark of fresenius medical care...

© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care

Our approach to excellence in patient care

Poacher and Game Keeper Seems To Come to MindHow to Deliver Kidney Care More Cheaply?

Nick Richards

Medical Director Fresenius Medical care


Is This The Correct Question?

• How to improve value for money?• How to improve quality at no additional cost?• How to improve outcomes at no additional cost?• How to invest to improve outcomes and reduce cost?• How to improve the patient experience?

• We should not look to move back to a third world service– Rationing– Short hours and/or reduced frequency– Low flux– Re use– Etc, etc.


Topics

• Quality• Access• Wasting money• Prevention/case finding• Payment/reimbursement systems• ISO 14001• Unnecessary posts


Perverse Incentives in The System

• Separate budgets for drugs and dialysis (EPO, binders)• Separation of Primary and Secondary care• Separation of nephrology funding from dialysis funding• Payment for inpatient and outpatient episodes• No investment in prevention• Cross subsidy between specialities (dialysis “cash cow”)• No focus on quality when purchasing


A New Look at Outcomes and Cost

annual patient cost

morbidity /mortality

dialysis patients

mortality of allESRD patients

i.e. 15%

untreated patients

% CKD5not treated

100 %

i.e. £25,000


A new Look at Outcomes and Cost

annual patient cost


untreated patients

dialysis patients

i.e. 15%

i.e. £25,000

mortality of allESRD patients

% CKD5not treated

100 %


A new Look at Outcomes and Cost

annual patient cost


untreated patients

dialysis patients

Δ cost

Δ m

ort

ality


1st conclusion

More dialysis cost could lead to more mortality,

If

As a consequence, less patients get access to dialysis


2nd conclusion

It is our mission to reduce mortality!

Therefore

We need to constantly reduce cost

and

Share the profit with society


Improve Quality Outcomes and Reduce Cost

• Current HD outcomes are poor• UK has endemic

– short dialysis hours– Low blood flows– Poor access services

• Optimise treatment to address modifiable metrics linked to outcomes

– Time– Blood flow– Access– Hb– Phosphate– Dry weight– eKt/v

Mean Effective Dialysis Time (mins)

190 200 210 220 230 240 250 260

Mea

n B

lood

Flo

w (

ml/m

in)

260

280

300

320

340

360

380

400

No correlation between access and blood flow

15 L

50% Lines Italian mean

UK mean


Optimised Treatment

• On line HDF standard• Minimum 3 x week• Minimum 4 hours effective dialysis time• Minimum 20 L exchanged• Minimum blood flow 350 ml/min• Minimum litres processed 84 L• Optimise dry weight so UF <8 ml/kg/hr• Fistula use >90%

Outcome:Reduced mortalityReduced hospitalisationReduced EPO useImprove phosphate control

Therefore:Improved outcomes for patientsOptimal use of resourceMoney saved


The Effect of Dialysis Prescription on eKt/V

1.1

1.15

1.2

1.25

1.3

1.35

1.4

1.45

1.5

Baseline

Fx 100 Qd 800 Fx 100 &Qd 800

Time 4.5hrs

Qb 400

1.7 m, 70 kg man, 65 yrs, UF volume of 1.5 L, Hct 0.35, Recirc 5%, Alb 40 gm/lBaseline Fx 60, 4 hrs, 3x wk, Qb 300ml/min, Qd 500ml/min

eKt/V

4.7% 4.7%

14.3%

18.3%

7.1%


Rational Dialysis per 100 patients

• 800 ml/min v 500 ml/min+ £12,500 in concentrate+ 1.1 Million L of water

• Large dialyser v normal dialyser+ £72,000

• Extra 30 minutes dialysis+ £2,500 in concentrate+ 240,000 L water

• Increase blood flow to 400 ml/min≈ free

Benefit marginal

Benefit marginal

Benefit significant

Benefit significant


Fistulae 2008 - 2009 Monthly Mean All Clinics

0

10

20

30

40

50

60

70

80

90

100

Jan-08

Feb

-08

Mar-08

Ap

r-08

May-08

Jun

-08

Jul-08

Au

g-08

Sep

-08

Oct-08

No

v-08

Dec-08

Jan-09

Feb

-09

Mar-09

Ap

r-09

May-09

Jun

-09

Jul-09

Au

g-09

Sep

-09

Oct-09

No

v-09

Dec-09

UK

Italy

France

Turkey

Spain

Serbia

Roumania

Ireland

% F

istu

la


Admission Rates and Inpatient Days

Fistula Permanent Line

Temporary Line

Factor

Admn due to Access

0.37 0.88 1.59 X 2.4 (4.3)

Admn due to sepsis

0.04 0.39 0.70 X 9.8 (17.5)

Days due to access

2.05 4.24 8.71 X 2.1 (4.25)

Days due to sepsis

0.33 4.18 7.56 X 12.7 (22.9)


Minimum XS Cost of Permanent Lines

£10 Million per year per 1000 patients

Or

£70 Million based on 22,000 patients


Late Presentation

• Little in the way of proactive case finding• Inadequate pre-dialysis care

– Education

– Referral guidelines

– Remote IT monitoring

• 22% of patients present < 3 months prior to dialysis• Range 8 - 41%• 11% of late presenters will start PD v 27% otherwise• Late presenters more anaemic 9.5 gm/dl vs 10.5 gm/dl• Majority of late presenter will have a line for 3-6 months

– Higher admission rates

– Higher inpatient days

• 70% of MSRA bacteraemia occurs in patients with lines


ISO 14001 an Environmental Management Policy

• This standard is applicable to any organisation that wishes to: – Implement, maintain and improve an environmental management

system – Assure itself of its conformance with its own stated environmental

policy – Demonstrate conformance – Ensure compliance with environmental laws and regulations – Seek certification of its environmental management system by an

external third party organization


WASTE (Kg/tr) - UK

0.9

1

1.1

1.2

1.3

1.4

1.5

1.6

1.7

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

MONTH

WA

ST

E (

Kg

)

UK 2009

UK 2010

Change in Clinical Waste per Treatment 2009-2010

2 million Kg/year£2 million

Target


Bundle Payments Mechanisms

• Introduced in Portugal 2009• €29,000 per patient per year• Includes

– Dialysis – Drugs

• Antihypertensives• ESAs• Phosphate binders • Vit D analogues• Calcimimetics• Antibiotics• Fibrinolytics

– Medical follow up– Investigations

• X ray• Ultrasound• Echo• Laboratory tests

• Payments linked to outcome– Process indicators

• Hb• Ferritin• Phosphate• Dialysis dose

– 3 x weekly– 12 hours– eKt/v ≥ 1.2

– Outcome indicators• Lab tests performed• Hospitalisations• Mortality

Indicator Reference value

2008 2009

% patients with Hb 10-13g/dl ≥ 70% 73% 74%

% patients with ferritin 200-800 ng/ml ≥ 80% 73% 75%

% patients with phosphate 3.5-5.5 mg/dl ≥ 50% 55% 55%

% patients with 3 dialysis sessions/week ≥ 90% 90% 93%

% patients with total hours of ≥ 12 hours/week ≥ 90% 90% 92%

% of patients with eKt/v ≥ 1.2 ≥ 75% 76% 86%

Failure to meet water standard ≥ 90% 99.8% 99.9%

Hospitalisations/patient/year ≤ 1 0.05 0.07

Annual mortality rate ≤ 20% 11% 12.5%

Outcomes Against Targets


Bundle Payments Mechanisms

• Forces focus on output not input• Requires sophisticated IT links• Drives the need for regular QA/audit• Drives up quality• Caps financial risk• Moves financial risk from payer to provider


Co-ordinators – Non Transplant

Person A Person B

Person C (a co-ordinator)

Originally paid for by the pharmaceutical industry but are now a cost for the NHS. Are they necessary?

Solutions:Move funding back to pharmaceutical industryChange the system (A talks to B)Potential savings > £6 million


Summary - Savings

• Optimise the available resource - Focus on quality• Stop wasting money at the fringe• Invest in a proper access service (in or out of house)• Invest in prevention/case finding• Move to a bundle payment mechanism• Focus on environment (clinical waste, water, electricity)• Stop funding unnecessary posts

© 2008 fresenius medical care ltd nephrocare is a registered trademark of fresenius medical care...

Documents

kidney care

dialysis cost

patient care poacher

dialysis slide

mortality slide

additional cost

quality outcomes

cost current hd outcomes