BC Experience with Assisted PD: 12 month pilot results, evaluation implications and future directions

Assisted Peritoneal Dialysis: A Patient-Centered Approach to Support Self Management Dr. Micheli Bevilacqua, MD, FCRPC Quality Forum 2017 BC Provincial Renal Agency

Outline

• Background of the PD Assist (PDA) pilot project

• Review outcomes of the 12-month PDA pilot

• Discuss tips to contextualize outcomes of a patient-centred chronic disease support program

Disclosures

• Evaluation of PD Assist is one of several projects I am involved in with at BC Renal Agency for which I am paid a salary unrelated to the outcomes of PD Assist (or any other project)

• I have no other relevant financial or non-financial interests to disclose

Acknowledgments • PD patients advocating for and willing to be involved in this

new program

• PD units in the pilot areas

• Those involved in planning and evaluation of PD assist: Paul Taylor, Linda Turnbull, Sue Saunders, Penny Hill, Lee Er, Erlyn Amano, Suneet Singh and anyone else I may have left out!

Thanks to BC Patient Safety and Quality Council for recognizing our program!!

Background • Peritoneal dialysis (PD) is a treatment

modality for ESRD

• Compared to other treatment choices, there are some superior clinical outcomes, improved quality of life and cost savings

• PD is a home based therapy; patients themselves or family members/caregivers perform treatment independently

Background

• There were previously no supports available to assist patients/families who were struggling with self-care PD

• Benefits of PD are especially important for those most likely to struggle: • Avoiding transport, minimal disruption to daily routine,

independence, especially at end of life

• Supporting independence in these patients is patient-centered,

equitable and may increase overall penetrance of PD

Assisted PD Experience in other jurisdictions

• Europe: France, Germany, Denmark –all with decades of experience

• Canada: Ontario has several programs with varying levels of support • All have found ways to support PD patients • All come at increased cost • Reported outcomes of these programs are variable

PD Assist in BC Details of 12 month PDA pilot

• CCPD patients were identified as ‘at risk’ and in need of support by their PD team. Key areas that were targeted were: • Patient inability/fatigue with setup/dismantling of cycler machine • Care-giver burden related these tasks

• Standardized identification criteria were developed

• Enrolment could be either long-term or temporary (respite)

• Four PD sites in the Lower Mainland were chosen as the pilot centres: St Paul’s Hospital, Vancouver General Hospital, Royal Columbian Hospital and Abbotsford Regional Hospital

PD Assist in BC Details of 12 month PDA pilot

• The program uses a once daily visit by trained care givers to assist individuals in setup/dismantle of CCPD

• Patients/care-givers responsible for other CCPD related tasks • Troubleshooting, choosing dialysate, etc.

• The caregivers are provided by an external health service provider (Nurse Next

Door, NND) at no cost to patients

• NND care providers were trained and had competency assessed by our PD staff

• PDA only provides assistance in CCPD related tasks, not other aspects of care that the patients may need/request (unless privately arranged)

Who are we talking about?

• A 38 year old type 1 diabetic on PD who lives independently and broke his leg

• A 88 year old lady on PD for 6 years with progressive dementia relying entirely on husband to stay out of nursing home and do all the PD • Right now if he couldn’t manage or she needed placement,

she would transition to hemodialysis (costlier, associated with lower QoL)

Results of the 12 month pilot evaluation Temporary (Respite) PDA

Usage and outcomes of PDA respite program

• 1 transferred to HD – would have transferred regardless • 1 death on PD at home then hospice – this was the desired outcome • The other 7/9 returned to PD at home and avoided long admissions

Reasons for respite service Frequency Duration of respite required (days)

Primary caregiver away travelling 2 pts x 2

2 pts x 1

13, 16, 2,2

3, 32

Fall – fractured wrist 1 pt 40

Hand injury 1 pt 14

Fall – fractured tibia 1 pt 40 (remains on respite)

Neuro issues with self-care 1 pt 1 (transferred to HD)

Palliative support prior to hospice 1 pt 12 (deceased following)

Surveillance for weakness 1 pt 55 (remains on respite)

Fractured arm 1 pt 70

Cost of respite PDA

0

2000

4000

6000

8000

10000

12000

14000

16000

PD on PDA Transfer to HD PD in hospital

Options for patients temporarily unable to perform self care PD (29 days- median of pilot)

Hospital Costs

PDA

Dialysis costs

The cost of the median duration of PD respite (29 days) is $1250 or approx. 1 day in hospital!

Summary of PDA Respite

• PDA Respite is an effective method to support patients temporarily unable to perform self care PD

• The vast majority of PDA respite patients returned to self care PD and avoided long hospital stay • Contrast to historical experience where patients remain hospitalized or are

transitioned to HD

• Median duration of respite was 29 days

• PDA respite is cost effective compared to alternatives

Results of the 12 month pilot evaluation Long-term PDA

Long-term PDA usage

• The enrollment period for long term PDA was July 18, 2014 to Mar 9, 2015

• A survey with standardized criteria to identify potential PDA patients was sent to all PD units

• 53 patients from the pilot centres ultimately enrolled in long term PDA

Comparator groups

To evaluate long term PDA, two comparator cohorts were used:

A benchmark PD cohort: All prevalent CCPD patients in BC between July 18 2014 and March 27 2015. A comparable ‘PDA Eligible’ cohort: Based on PD Assist eligibility survey, those who were deemed eligible for PD Assist service but were not on the service

PDA clinical outcomes: technique survival

94.3 100 98.8

92.3 94.4 96

87.7 86.4 83.7

PDA PDA Eligible Benchmark CCPD

Perc

ent

rem

ain

ing

on

PD

1 month 3 month 1 year

Outcomes of PDA patients PD Assist Exit Reasons # Pts Days on PDA

Deceased 9 11, 61, 91, 99, 109, 121,

131, 157, 339

Incompatible schedule; ended PD Assist but

remained on PD 2 8, 13

General weakness; ended PD Assist but

remained on PD 2 120, 147

Inadequate dialysis, transferred to HD 1 18

Social issues, transferred to HD 1 9

Patient preferred HD 2 9, 179

Incapable to perform treatment

independently, transferred to HD 1 45

Sepsis – remained on PD, as inpatient and LTC 1 6

Peritonitis: a common complication of PD

0.18

0.36

0.22

PDA PDA Eligible Benchmark CCPD

Even

ts p

er p

atie

nt

year

Hospitalization

55

35 34

PDA PDA Eligible Benchmark CCPD

Perc

ent

ho

spit

aliz

ed in

pilo

t p

erio

d

Putting it all together Contextualizing results of PDA

Abraham Wald Operational problems versus general statistical problems

Patient-centered outcomes in chronic disease management

Patient-centered outcomes in chronic disease management

Technique survival • Equivalent technique survival is an excellent outcome • Goal is not to turn these patients into ‘well’ PD patients

Deaths on PDA

• This is a good outcome – a supported death at home, without a disruptive modality change

Hospitalization • This likely represents recognition of serious issues: seen in other trials and

anecdotally by our PD units

Patient feedback

Qualitative feedback was collected from patients, PD units and caregivers (NND). Feedback was overwhelmingly positive and supported continuation and expansion of PDA

– "We [My family and I] hope the program continues and I hope that more people get to participate in it…I think it's keeping people out of hospitals and allowing them to stay in their homes longer. Keeping them out of nursing homes and allowing them to stay in their homes longer.“

– “A blessing for many to know that they had an option to help support their family. Definitely helps to relieve the stress and potential burn out for many”

Costs of PDA

• A chronic disease management program such as PDA is best viewed through a cost minimization lens • ESRD patients who wish to have RRT do not have a zero cost option • Goal is to provide care that produces best outcomes at lowest cost

• PDA should be compared to other options for patients failing independent PD, not to self-care PD • Traditionally, these are LTC or HD

PDA ~ $15000 per year LTC ~ $38500 per year Transition to HD is ~ $44000 per year more than PD

Putting it all together

• PDA provides a patient-centered way to support patients on independent modality

• Clinical outcomes are acceptable, especially when viewed in the context of the frail population this program serves

• Costs are acceptable and lower than available alternatives

• Experience among patients, caregivers and PD units in pilot was very positive

Next steps

• The plan has been presented to PHSA leadership, all of whom support the PDA program

• They are highlighting it internally as a model of patient-centered chronic disease management

• PDA has the support of BC Provincial Renal Agency and dedicated funding from PHSA

– A provincial implementation plan is underway

Questions?

If you would like more information about the PDA program or our program evaluation methods, feel free to contact me at:

mike.bevilacqua@bcpra.ca

Thanks to BC Patient Safety and Quality Council for recognizing our program!!