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© 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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of 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.
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
Topics
• Quality• Access• Wasting money• Prevention/case finding• Payment/reimbursement systems• ISO 14001• Unnecessary posts
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
A new Look at Outcomes and Cost
annual patient cost
morbidity /mortality
untreated patients
dialysis patients
i.e. 15%
i.e. £25,000
mortality of allESRD patients
% CKD5not treated
100 %
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
A new Look at Outcomes and Cost
annual patient cost
morbidity /mortality
untreated patients
dialysis patients
Δ cost
Δ m
ort
ality
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
1st conclusion
More dialysis cost could lead to more mortality,
If
As a consequence, less patients get access to dialysis
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
2nd conclusion
It is our mission to reduce mortality!
Therefore
We need to constantly reduce cost
and
Share the profit with society
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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%
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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)
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
Minimum XS Cost of Permanent Lines
£10 Million per year per 1000 patients
Or
£70 Million based on 22,000 patients
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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
© 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care
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