The Quality Agenda for UK nephrology

Charlie Tomson

President, Renal Association

SpR club meeting, London, Saturday 18th September 2010

Conflicts of interest

• No financial or other relationships with pharmaceutical companies for at least the last 5 years, in particular no– Directorships– Advisory boards– Free trips to conferences– Free lunches or dinners

• ACCEA Silver award

Outline

• Dimensions of quality

• Quality improvement in healthcare

• The political context, 2010

• Quality in nephrology

• QI in nephrology

Why am I here?

• (because I was hoping to get to the Saturday night SpR club drinking session)

• Social and Political Science part II • Long involvement in RA standards and

guidelines (including CKD guidelines)• 1y Health Foundation Quality

Improvement Fellowship at Institute for Healthcare Improvement

• 4y as UKRR chairman

Dimensions of quality

• Safe – no needless harm• Timely – no needless waits• Efficient – maximise health gain per £• Effective – evidence-based• Equitable – irrespective of race, literacy, income,

BMI• Patient-centred – the patient at the centre• Sustainable – meet the needs of today without

compromising the ability of future generations to meet their needs

Quality Improvement mantras

• If you can’t measure it, you can’t improve it• Every system is perfectly designed to

deliver the results it delivers• Human beings make mistakes, and

attention to human factors can reduce risk• Achieving change in complex

organisations requires ‘profound knowledge’ as well as subject matter knowledge

Appreciation of a System

Understanding Variation

Theory of Knowledge Psycholog

y

V

alues

The political context

• Darzi ‘Next Stage Review’ – focus on clinical dimensions of quality (safe, effective, patient-centred)

• Quality, Innovation, Prevention, Productivity programme

• ‘Flat cash’ funding

• Coalition White Paper – ‘nothing about me without me

Byrne C et al. UKRR 12th Annual Report, Chapter 4. Nephron Clin Pract 2010;115 (suppl 1): c41-c68

Rising numbers, flat cash: a perfect storm

Andrew Lansley: priorities

• Patients: no decision about us without us

• Focus on outcomes, not process targets

• Empower professionals to deliver

• Prioritise prevention to reduce inequity

• Integrate health and social care

http://www.dh.gov.uk/en/MediaCentre/Speeches/DH_116643

DH/IC Indicators for Quality Improvement

LT12 % of all dialysis patients aged <55y on Tp WL

13 Timely referral to kidney unit

14a HD patients with Hb 10.5-12.5

14b PD patients with Hb 10.5-12.5

15 HD patients with adequate URR

16 Survival (after 90 days) ????

17 HD patients with PO4 1.1-1.8

18 PD patients with PO4 1.1-1.8

19 RRT patients with MRSA blood stream infections ???

20 BP for PD and transplant pts <130/80

21 HD patients with HCO3 within lab NR

22 PD patients with HCO3 within lab NR

Q: What’s this got to do with me?

• I’m a renal SpR, not a manager

• I’m not the Clinical Director

• If they want better care, they need to spend more money

• My responsibility is to the patient in front of me

A:

• “It is not necessary to change. Survival is not mandatory”

W. Edwards Deming

Quality of renal care

• Safe

• Timely

• Efficient

• Effective

• Equitable

• Patient-Centred

• Sustainable

Safety of renal care

• (covered by Simon Watson last SpR club)• NPSA signals – mostly related to HD,

equipment• Drug interactions• Drug-induced leucopenia• In-hospital pulmonary oedema• Anticoagulation control• Infection control – C Diff, line infections,

pneumonia

Timeliness of renal care

• Multiple clinic visits– Nephrology– Vascular mapping– Vascular access– Education– Psychology– Transplant assessment– + all the other specialties involved

Effectiveness of renal care

• Evidence-based care: reliable implementation of available evidence

• Dialysis dose

• ?phosphate control?

• Protocol-based management of vasculitis according to RCT evidence

• Protocol-based transplant management

Efficiency in kidney care?

• Increasing focus on who starts RRT and when– Benefits amongst elderly pts with co-

morbidity/nursing home residents?– eGFR at start (including pre-emptive Tp)

• Increasing focus on reducing waste in each clinical pathway

• Alternative: go back to overt or covert rationing

Efficiency of renal care

• Reducing cost per case

• Complicated by primary/secondary care funding split– Payment per episode– Higher payments for RRT vs conservative– Higher payments for admissions with

complications vs no complications

• 80% of NHS costs are salaries

Guy’s/RA: reducing costs of kidney care: 17th Sept 2010

• Nick Richards (Fresenius): – achieve adequate URR by increasing t and Qb;

reduce clinical waste; stop employing ‘co-ordinators’ and talk to each other; link payments to outcome measures

• Lisa Burnapp (DH, Guy’s)– Do more pre-emptive LRD transplants

• Patrick Harnett (Southend)– Rationalise use of ambulance transport for dialysis

• Richard Fluck (Derby)– Reduce access-related infections, pneumonia

Guy’s/RA: reducing costs of kidney care: 17th Sept 2010 - 2

• Sandip Mitra (Manchester)– Expand use of home HD

• Peter Rutherford (Baxter)– Increase use of PD as initial therapy by working on

shared decision-making• Charlie Tomson (Bristol)

– Reduce low-added-value OP appointments• Frances Mortimer (Campaign for Greener HC)

– Reduce Carbon and save money• Jane Macdonald (Hope)

– Reduce use of bank nurses and reduce long-term sickness absence

Rosansky SJ. Kidney International 2009; 76: 257-261

“Rising tide” of ESRD due to earlier start?

Survival from day 1 vs eGFR at start: EDTA-ERA

Stel V et al. Nephrol Dial Transplant 2009;24; 3175-3182

Stel V et al. NDT 2010; doi 10.1093/ndt/gfq209

eGFR at start in Europe, 1999 and 2003

828 patients with eGFR 10-15 randomised to start at eGFR 10-14 vs 5-7 (+clinical discretion)

Median time from randomisation 1.8 vs 7.4 months

Median eGFR at start 12.0 vs 9.8

NEJM 2010; 363: 609-619

NEJM 2009; 361: 1539-1547

Carson R. CJASN 2009; 4: 1611-1619

Survival from eGFR 10.8 ml/min/1.73m2

Supply-led demand?

• Unused haemodialysis facilities make it difficult to balance the budget

• Commercially provided satellite or main unit HD facilities have a vested interest in keeping patients on satellite or main unit HD

• PbR provides financial incentives for RRT over Maximal Conservative Care

Equity of renal care

• Same opportunity to benefit from healthcare irrespective of – Ethnic origin– Cultural origin– Literacy– Income– Educational status– Social class– Language– Geography

Socioeconomic factors in RRT acceptance rate

N

EW

S

Age-gender standardised rateof RRT per million population

17.88 - 80.1180.11 - 96.3696.36 - 114.45114.45 - 146.39146.39 - 287.43

100 0 100 200 Miles

PCTs with higher deprivation scores have higher RRT acceptance rates

PCTs with higher ethnic minority populations have higher RRT acceptance rates in England, but not in Wales

After adjustment for deprivation and ethnicity, acceptance rate ratio remains significantly higher in Wales, and lower in NW England and Yorkshire/Humberside

Udayaraj U et al. J Epid Comm Health 2010;64:535

Socioeconomic status and access to transplant waiting list

Quintile 1 (least deprived)

reference

Quintile 2 0.93 (0.86-1.00)

Quintile 3 0.83 (0.75-0.93)

Quintile 4 0.70 (0.63-0.78)

Quintile 5 (most deprived)

0.60 (0.54-0.68)

Adjusted for age, gender, PRD, year of start; and for centre effect

N= 9602 - White patients only

Udayaraj U et al. Transplantation 2010; 90: 279-285

Centre variation in access to renal transplantation – longitudinal study

• Objective – to assess whether there is equity in access to renal transplantation in the UK after adjustment for case mix

• Incident patients in 65 centres submitting data to UKRR between 1/03 and 12/05, followed until 12/08 (excluding pts >65y, pts activated and then immediately suspended, patients listed for multi-organ Tp)

• Proportion of incident patients at each centre registered on waiting list, time taken to registration, and proportion subsequently transplanted

Ravanan R et al. BMJ 2010; 341: c3451

Patient experience in renal care

• No validated PROMs for chronic conditions

• Several validated QoL measures, none routinely collected or reported

• No validated measures of satisfaction with OP consultations

Trust in OP medical care

417 patients attending new patient OPA with cardiologist, neurologist, nephrologist, gastroenterologist, rheumatologist

Keating NL. Arch Intern Med 2004; 164: 1015-1020

Summary so far

• 7 dimensions of quality

• Room for improvement in each

• But how?

Original research

Submission

Acceptance

Publication

Bibliographic databases

Review, paper, textbook

Implementation

variable

0.5 years

0.6 years

0.3 years

6-13 years

9.3 years

Negative results

Lack of numbers

Inconsistent indexing

Translating research into care

Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70

Clinical research to clinical practice: lost in translation?

• US life expectancy lower than 22 other countries despite $250bn NIH investment since 1950– lack of improvement due to

failure to translate the findings of clinical investigations into the practice of medicine at the community level

– from the translational highway to the smaller avenues and lanes of the microsystems that deliver care

Lenfant C. Shattuck Lecture. N Engl J Med 2003; 349: 868

QI: implementation science

• Establish the need for improvement

• Establish a measure

• Agree a SMART aim

• Find a change package– From the literature– From high performing centres

• Do multiple PDSA cycles

Understanding high performance

• Structure + Process = Outcome• Learning from high-performing units requires

– Identifying them reliably– Finding out how they achieve their results

• A detailed understanding of HOW care is delivered, as well as WHAT care is delivered, is critically important for understanding how different centres achieve different results

Collecting information on causes of centre variation

• Anecdote

• Ask the high performers– But they won’t have any idea how their

practice differs from ‘poor’ performers

• Ask people who’ve worked elsewhere – e.g. rotation SpRs!!

• Design a questionnaire – Delphi technique

• Administer a questionnaire

Thank you

Charlie.tomson@nbt.nhs.uk