Sandip Mitra
Central Manchester University Hospitals Foundation Trust
Worldwide surge in chronic kidney disease & ESRD Expanding dialysis population, an evolving disease Impressive and worrying mortality on dialysis Poor quality of life
1998 - 2008
Pat
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Dialysis
ESRD
A Sound Alternative:
Home HaemodialysisHome Haemodialysis
•Cost Effectiveness Home Haemodialysis
Home Haemodialysis
•Better
Patient
Outcomes
Toyota Production System
“the number of life years saved could be doubled if resources were reallocated
to more cost-effective interventions” . . .
Home haemodialysis annual sessions based on 4x weekly therapy.
Dialysis Cost Comparison NHS
PbR for Kidney Dialysis Project Group Report June 2009
Treatment (£ Aug 1990)
Cholesterol testing and diet therapy only (all adults aged 40-69) 220Neurosurgical intervention for head injury 240Advice to stop smoking from general practitioner 270Neurosurgical intervention for subarachnoid haemorrhage 490Antihypertensive treatment to prevent stroke (ages 45-64) 940Pacemaker implantation 1 100Hip replacement 1 180Valve replacement for aortic stenosis 1 140Cholesterol testing and treatment 1 480Coronary artery bypass graft (left main vessel disease, severeangina) 2 090Kidney transplant 4 710Breast cancer screening 5 780Heart transplantation 7 840Cholesterol testing and treatment (incrementally) of all adultsaged 25-39 14 150Home haemodialysis 17 260Coronary artery bypass graft (one vessel disease, moderateangina) 18 830Continuous ambulatory peritoneal dialysis 19 870Hospital haemodialysis 21 970Erythropoietin treatment for anaemia in dialysis patients(assuming 10% reduction in mortality) 54 380Neurosurgical intervention for malignant intracranial tumours 107 780Erythropoietin treatment for anaemia in dialysis patients(assuming no increase in survival) 126 290
Dept of Health Economics Research , York
QALYs generated and costs accrued
McFarlane PA et al. Kidney Int 2006; 69:798-805.
Group QALYs Cost ($)
Reference case (IHD) 5.31 543 602
Reference case (HNHD) 5.79 538 094
No transplantation (IHD) 2.78 370 047
No transplantation (HNHD) 3.25 363 206
HNHD as initial modality (IHD) 5.31 543 602
HNHD as initial modality (HNHD) 6.30 534 484
Initial HNHD and no transplantation (IHD) 5.48 730 590
Initial HNHD with no transplantation (HNHD)
7.22 692 658
HNHD=home nocturnal hemodialysisIHD=In-hospital dialysis
Staff – clinical lead (1 PA),
training staff
Flexible Training Centre
Use of existing HD stations with adaptations
Pro rata water and electricity
rates
Machine with basic interface, high
reliability (F4008 home)
Philosophy
Cost per therapy package (Rx cost, machine lease cost, supplies)
Cabin installation (£12000) funding routes
Standard conversion
charge (£3000 - £5000)
Emergency helpline
24/7
In-House technical
team
Integrated Community
support ( HHD 1:20patients)
Social worker , Clinical
Psychologist time
Education and staff training package
Dedicated clinic
Carer support (Carer Grant)
An Environment for Learning
Training activity (2004-2010)
Total patients 171Age 53 yrs (range 22 – 73 yrs)Trained 140Failed 8 , Tx 3, Retrained 11,
training 16AVF : 85 %Diabetes 11 %
Home Haemodialysis Uptake
Manchester , 12% of HD
Pa
tien
ts =
n
Manchester Point prevalence
Improving standards
-0.1
0.4
0.9
1.4
1.9
2.4
PD conventional HD 5-6hr thrice wkly
alternate day nocturnal/daily
preD phosphate
Manchester Feb 2010
Set up Location at Home
Home conversions cabin installation 10 % patients
Phone calls (2009-2010)
Total 69
Clinical / Tech
46 / 23
Weekend 9
After 9 pm 7
Mon 18
Tue 12
Wed 11
Thurs 9
Fri 9
17
05 000
10 00015 00020 00025 00030 00035 00040 00045 00050 000
HHD n=23 SHD n= 28
Other
Installations
Assistant reimb.
Medication
Travel
Radiology
Lab (primary care)
Lab (hosp)
Surgical proc.
Hospitalizations
Out-patient visits
Dialyses
Home HD
Hosp HD Savings /pt
Total Cost (£)
68284 89029 -20745
Capital costs(£)
8886 7918 969
Staff costs (£)
14736 30033 -15297
Cost per QALY
2.42 2.04 0.38
Cost per QALY - Home HD dominates
10 yr savings (50pts) > £ 1 million
CEP 10063, 2010
National Information Center on Health Services Research and Health Care Technology (NICHSR)
Hosp HD
Different Types of Economic Analysis
Home Haemodialysis : Home Haemodialysis : A Neglected OpportunityA Neglected Opportunity
Thank You