Renal Association, CD Forum, Guy’s, March 2010
Home Dialysis – Operational and
Financial Aspects
Roger Greenwood
Lister Renal Unit
Stevenage, UK
Renal Association, CD Forum, March 08
15% HD Patients at Home
is Realistic
Greenwood
vs
Raftery
Growth of the UK dialysis population 1982-2002
Fig 17.5 Prevalent patients, percentage by each dialysis modality
UK Renal Registry 9th Annual Report 2006
Survival on RRT – Lister Renal Unit 1999
1.0
Cumulative Survival
Transplants
.9
.8
.7
PD
.6
.5
.4
HD
.3
.2
.1
0.0
0
12
24
36
48
60
72
Months on Dialysis
84
96
108
120
Cost Utility Analysis, USA
Utilometer
Bell et al. Med Decision Making ,2001, 21, 288
Dialysis Patients Remain in Stage 4/5 CKD
I
II
III
Dialysis Initiation
IV
V
“GFR”
Residual Renal
Function
Delivering More Dialysis by Increasing:
Time
Power
Frequency
Impact of Power: HEMO Trial (USA 2002)
Impact of Frequency: Standard Kt/V (stdKt/V)
Gotch, 1999
TM0065 Rev BNxStage has prepared
Day-of-Week, Association with Mortality
•
•
•
•
•
DOPPS study, 1996-2004
18,000 patients in USA and Europe
All had 2 consecutive days without dialysis
Death significantly higher after ‘long break’
Death from cardiovascular event
Zhang H et al, American Society of Nephrology, Philadelphia, Nov 2008
‘GFR’ Replacement Therapy
I
II
Transplant
HD x 6
III
HD x 4
IV
HD x 3
V
In Centre
?Home
Home HD - Distribution of time & frequency
Guys &St Thomas, London, 09
Mobile HD Machines – At Last!
Home
Travel
TM0065 Rev BNxStage has prepared
NxStage: Simple-to-use supplies
Drop-in, disposable cartridge
Portable Fluids
Disposable Purification Pack
Disposable
Dialysate
Sack
Can we afford daily dialysis?
TM0065 Rev BNxStage has prepared
Purification Pack (good for 6-12 weeks)
Purification Pack
Sediment UV Light
Filter
Carbon
Resin
Dual-bed
Resin X3
Mixed-bed
DI Resin
Ultrafilter
X2
0.2 micron
filter
Dialysate
Sack
Water
KDF
Media
Ultrapure
Water
Sensor 1
Sensor 2
Similarities APD and NxStage
APD
NxStage
Mobile cycler
Mobile cycler
‘Fully saturated’ dialysate
‘Fully saturated’ dialysate
Healthy membrane
Dwell time
High blood flow
Low dialysate flow*
115-140 L lactate/wk
100-180 L lactate/wk
7 divided doses
5/6 divided doses
Daily disposables
Daily disposables
* Different from traditional HD
TM0065 Rev BNxStage has prepared
Dialysis Reference Costs, 16 NHS Trusts, 2008
Home HD brings less income to the Trust
£
• Centre HD
23,868
• Home HD (3 X weekly)
12,948
• PD
20,805
NHS Kidney Care, PbR Working Group, 2008
Home Dialysis – Operational Aspects
•
•
•
•
•
•
Promote frequent dialysis to optimise health prospects
Self-care first policy
Dialysis initiation with APD, including late presenters
4.5 sessions weekly using traditional machines
5.5 sessions weekly NxStage
Expect significant demand for mobile machines
• NxStage
• Quanta
• Deka (Baxter)
EAST OF ENGLAND SCG – Strategy and Capacity Plan - 2008
Sites for New Renal Units
Identified
Expansion of HD Stations by PCT
Assumptions in EoE Strategy and Capacity Plan
•
•
•
•
•
5% annual growth in dialysis (NSF 2004/5)
2.4% annual growth in transplant procedures
3.8% annual growth in functioning transplants
PD up to national average (10.7% RRT) by 2015
10% HD patients self-caring on Home HD by 2015
Business case to Board of E&N Herts NHS Trust
Scenario 1
• Total Dialysis Annual Growth 5%
• 10% HD Patients Self Caring by 2015
• PD increase to 15% all dialysis by 2015
Scenario 2
• Total Dialysis Annual Growth 5%
• Limit Home HD to 5 Patients
• PD continues to decline (current 9.7%)
Assume 50% HHD patients will choose NxStage
Projected Patients and Extra Staff Required from 2009 - 2015
Scenario 1: Aspire to EoE strategy to promote home therapies
4/09
4/10
4/11
4/12
4/13
4/14
4/15
HD (all)
365
378
392
406
422
439
458
HD (Centre) - CHD
364
369
375
381
389
399
412
6
61
5.9
63
5.8
65
5.6
68
5.4
72
5.2
77
5
82
2
5
9
14
19
10
28
49
71
97
7
12.5
17.7
20.8
29.3
Pts/CHD station
Total CHD stations required
CHD stations required in new units in Beds and Herts
Patients treated in new units
Total staff req. for CHD
Home HD
1
9
17
25
33
40
46
% HD patients at home
0.3
2.4
4.3
6.2
7.8
9.1
10
Total staff req for HHD
1
2.3
2.5
2.5
3
4
4
PD
% Total dialysis on PD
38
9.4
45
10
52
11
60
12
67
13
74
14
81
15
Total staff req. for PD
TOTAL DIALYSIS PATIENTS
2
403
3
423
3.5
444
4.5
466
5.25
489
5.5
513
5.5
539
Projected Patients and Extra Staff Required from 2009 - 2015
Scenario 2: Current trends in dialysis case mix continue
4/09
4/10
4/11
4/12
4/13
4/14
4/15
HD (all)
365
387
410
435
461
487
516
HD (Centre) - CHD
364
382
405
430
456
482
511
6
61
5.9
65
5.8
70
5.6
77
5.4
84
5.2
93
5
102
CHD stations reqd in new units in Beds and Herts
2
7
14
21
30
38
Patients treated in new units
6
40
77
116
154
196
16.3
22.6
35
45.3
60
Pts/CHD station
Total CHD stations required
Total staff req. for CHD
Home HD
3
1
5
5
5
5
5
5
0.3
1.3
1.2
1.1
1.1
1
1
0.25
0.25
0.25
0.25
0.3
0.3
0.25
PD
% Total dialysis on PD
38
9.4
35
8.3
32
7.2
30
6.4
27
5.5
25
4.9
23
4.3
Total staff req. for PD
2
403
2
423
2
444
1.75
466
1.5
489
1.4
513
1.25
539
% HD patients at home
Total staff req. for HHD
TOTAL DIALYSIS PATIENTS
Cumulative (extra) costs by year 2015/16
GBP
GBP
Scenario 1 – 10% HHD
Scenario 2 – Mainly CHD
Pay
1,254,486
2,037,096
Consumables
1,093,293
502,730
Machine Lease Costs
175,478
112,893
Home Conversion
118,688
2,000
Pathology Savings
-34,200
-3,040
Pharmacy Savings
-79,639
18,011
Travel Savings
-44,000
5,500
Holiday Dialysis Saving
-56,700
-5,040
Total Non-Pay
1,172,919
633,054
Total Revenue Costs
2,427,404
2,670,150
*before depreciation and capital charges
Cumulative (extra) costs by year 2015/16
GBP
GBP
Scenario 1 – 10% HHD
Scenario 2 – Mainly CHD
Pay
1,254,486
2,037,096
Total Non-Pay
1,172,919
633,054
Revenue Costs (excl)
2,427,404
2,670,150
Depreciation over 40 yr
200,000
450,000
Capital Charges (3.5%)
280,000
630,000
Total Revenue (incl)
2,907,404
3,750,150
Capital Build
(new centres)
2,000,000
6,000,000
New Dialysis Centres
Reimbursement (PbR), NHS Kidney Care, June 2009
But: Self –Care at home brings less income to the Trust
•
•
•
•
•
Hospital HD
Satellite HD
Home HD (4X weekly)
CAPD
APD
• All HD LC02A
• All PD LC04A
£28,860
£22,152
£17,264
£18,980
£21,900
£23,868
£20,805
Need to test whether Trust can afford a home dialysis
programme by feeding these reimbursement rates
into the model
Cumulative (extra) costs by year 2015/16
Scenario 1 – 10% Scenario 2 –
HHD
Mainly CHD
Compare
Scenarios 1 and
2
Extra Revenue
(expenditure)
2,907,404
3,750,150
842,746
Income (PbR)
12,907,400
13,369,500
462,100
Effective Savings to
Trust
Capital Build
(new centres)
380,646
2,000,000
6,000,000
4,000,000
Business Case – bottom line
• Self-Care will result in costs savings of £842,746 p.a. by 2015
• Self-Care will create a revenue deficit of £462,100
• Current PbR tariffs likely to dampen the enthusiasm
Denoument:
•
•
•
•
Challenge traditional funding model
Patient advocacy - Kidney Alliance, NKF
Work with SCGs, NHS Kidney Care, PbR team at NHS
Pull levers - Payment for Performance, Patient Choice
Kidney Alliance, 09/10
• Mission Statement re Home Therapies
• World Kidney Day, March 2009
– Home HD featured in Commons Terrace reception
• Questions in Commons, Lords, through 09/10
• Patient presence in SCG Strategy meetings
DH, Payment by Results, Draft Guidance, December 2010
Paras 283-292: Renal Non-Mandatory Prices for 2010/11
£
£
Centre HD
Home HD
CAPD/APD
144 session
144 session
48 day
22,464 annum
33,696 annum
17,520 annum
....this recommendation is intended to incentivise an increase in provision
of home dialysis options...
....sessional payment since patients may dialyse 4 or 5 session a week...
....we encourage commissioners, where there are low levels of provision, to
work with their providers to create effective choices…
DH PbR Team 17th Dec 2009
Kidney Alliance Response to PbR Consultation, Jan 10
•
•
•
•
•
•
•
Plea for a soft landing for some Trusts
Don’t over-incentivise HHD, suggest parity with CHD
Clarify tariff includes home conversion costs
Address Assisted PD (aAPD)
Clarify drug in(ex)clusions – anaemia, bone-mineral-metab
‘Unbundling’ exposes Conservative Mgnt, Pre-Dial, Transp w/u, f/u
‘Unbundling’ exposes dietetics, SW and counselling
Commissioning for Quality and Innovation (CQUIN)
• CQUIN part of ‘Payment for Performance’ scheme
• Proportion of provider income conditional on agreed goals
• Worth 0.5% contract value in 09/10 rising to 1.5% in 10/11
EoE Renal CQUIN for 2010/11
‘Providers in EoE to achieve a 10% Home HD rate by April 2015’
...CQUIN monies linked to this indicator will be at risk of being
withdrawn if non-submission of data or failure to achieve
interim targets...
EoE SCG 15th Feb 2010
Summary
•
•
•
•
•
•
•
Rejuvenation of interest in Home HD (HHD)
HHD chief aim is to deliver more (frequent) dialysis
Mobile machines will be in demand
HHD insufficiently incentivised with traditional reimbursement
PbR rates recently proposed will incentivise HHD
HHD can also be incentivised through Payment by Performance
At least 2 English regions have adopted HHD for their renal CQUIN