What does a Clinical

Director look for in

the Annual Registry Report ?

D Eadington

Hull Royal Infirmary

June 2008 Conflict of Interest;

no longer a Clinical Director

The problem with the post-prandial talk ….

PRIMACY

RECENCY

What do I look for ?

• Feedback – confirm what we know already

- discover what we don’t

- comparison; neighbours, peers

• Stimulus - set priority areas

- educate or re-educate staff

• Things that inform the commissioning process

• Who do we compare ourselves with ?

• What do I look at (or not) ?

• What does the data mean ?

• What else do we do with it ?

• What would I like more of ?

1st HULL

1. Luton

2. Windsor

3. Sunderland

19th Hull

• Population 1.04 million, ~3000 sq m

• 3 peripheral DGHs (~540k)

• Satellites; 1992 Brigg

• 1998 Scarborough

• 2002 Grimsby

• 2007 Scunthorpe (Brigg closed)

• 2008 Bridlington

• 2008 Fresenius partnership (first central unit)Consultant 7 (6 WTE)

[GIM 5/19 + 28 beds]

SpR 6 Renal

1 Acute Medicine

StRs 2

FY 1 + 2 3 + 1

Nurse Specialist 7

York 40 miles

Leeds 65 miles

Sheffield 65 miles

Middlesborough 80 miles

Who are our comparator units ?

• Colleagues; Leeds, Bradford, York

• Neighbours ; Sheffield, Middlesborough

• Peer hospitals; Preston, Newcastle

• “How are they doing that better than us ?”

What do I do with the report ?

• Some; look at quickly – less interest

• Some; look at longer - wonder what it means

• Rest; look at longest - compare with other units, discuss

- where is the widest range ?

• Reflection; What are we not doing well enough ?

- outcomes, data inputs

What is not there at all ?

What else do we do with the reports ?

• Service planning (less than in past)

• Training – junior staff

- nurses

- medical students

• Nursing governance – ‘every data point counts’

• Patients – dietitians, information posters

1. Look at quickly

• Demographics – are take on rates stabilising ?

- more palliation as part of LCC ?

• Items where new action is not a high priority

- Adequacy/URR

- Ferritin

• Not yet a strong evidence base to change practice

- Cholesterol

Be clear what take on rates mean

4.97 m

Hull 1.04m

York 0.39m

Sheffield 1.75m

Bradford 0.60m

Leeds 2.20m

All 5.98m

Be clear what take on rates mean

Which one

is right ?

1.62m

1.27m

0.47m

1.61m

2. Look at longer; what does it mean ?

• Anaemia

• PTH

Adequate

Is it any better ?

(CHOIR/CREATE)

3. Look at longest – comparisons matter

• Phosphate

• Blood pressure

• Survival

0102030405060708090

%

2001 2002 2003 2004 2005 2006 2007

Year

Pre HD phosphate

Hull

Median

Best

All HD phosphate

0

10

20

30

40

50

60

1.1-1.59 1.6-1.79 1.8-1.99 >1.99

Range

%

01020304050607080

%

2000 2001 2002 2003 2004 2005 2006 2007

Year

PD phosphate

Hull

Median

Reviewing serial data would be welcome

Blood pressure – a very wide range

Is data collection standardised ?

Survival is the main outcome Survival is the main outcome

Does deprivation affect ESRD survival ?

61 ( 37% )

71 ( 44% )

45 ( 28% )

78 ( 48% )

0

100 ( 61% )

70 ( 43% )

Inc 61

(37%)

9

(4%)

Empl 71

(44%)

10

(5%)

Health 45

(28%)

3

(2%)

Educ 78

(48%)

10

(5%)

Barriers

** 15

(9%)

Crime 100

(61%)

5

(3%)

Envir 70

(43%)

10

(5%)

SOAs Hull

163

EastY

209

Does the disadvantage of deprivation on health

continue into ESRD ?

OR

Is it neutralised by the severity of other risk factors ?

OR

Something else ?

> 2 SDs poorer > 2 SDs better

Sunderland Royal Free Preston

Middlesborough Ipswich Guys

Airdrie Basildon

What do I look for ?

• Feedback – confirm what we know already

- discover what we don’t

- comparison; neighbours, peers

• Stimulus - set priority areas

- educate or re-educate staff

• Things that inform the commissioning process

Stimulus - what are we not recording well enough ?

Hull

• Transplant blood pressures

• Comorbidity data

• Referral patterns

Crash landers remain too common

What do we have to do for ourself ?

• More interactivity with own data possible ?

• Time - IMPROVEMENT

• Relative position – RATE OF CHANGE

HD URR > 65%

0

20

40

60

80

100

120

2002 2003 2004 2005 2006 2007

Years

%

Hull

Median

Best

0

20

40

60

80

100

%

2002 2003 2004 2005 2006 2007

Years

HD Hb > 10 g/dl

Hull

Median

Best

• Cause of death ; how many withdrawals ?

• Low Clearance Care; how many for palliation ?

evidence for slower progression ?

(CKD5 pilot)

What else is missing ?

How is your commissioning process ?

Save 1 kg paper / copy online

“Wake up, he’s finishing …”

• stimulus to service improvement

• pride in a communal effort

• content far outweighs any shortcomings