The Burden, Impact and Costs of Dialysis

- The Data Viewpoint

Dr Shona Methven

Senior Clinical Research Fellow

UK Renal Registry

Aim

To implement and evaluate a quality improvement programme toidentify patients at high risk of progressive renal decline, usingeGFR graph reports sent to primary care in sites across the UK

P - Patient population

I - Intervention

C - Comparator

O - Outcome

S - Study Design

Patients with CKD not yet referred to nephrology

Graph of eGFR over time with individualised advice

Routine care

Late referral rate to nephrology

Step Wedge RCT

• Improve outcomes

– Reduce avoidable late presentation

– Reduce ESKD

• Improve equity of access

• Reduce costs

– For individuals

– For society

• Improve outcomes

– Reduce avoidable late presentation

– Reduce ESKD

• Improve equity of access

• Reduce costs

– For individuals

– For society

• Improve outcomes

– Reduce avoidable late presentation

– Reduce ESKD

• Improve equity of access

• Reduce costs

– For individuals

– For society

Comparative audit of all UK Renal Units

- Quality assurance

- Dashboard indicators

- Commissioning data

- Efficient clinical trials

UK Renal Registry 18th Annual Report

Percentage of people presenting late (2013/2014)

Inequity of Access

to Specialist Services

Late presentation of ESKD

• Unavoidable

vs

• Avoidable

Acute Diagnoses Group

Crescentic GN/ anti GBM disease

Cisplatin Nephrotoxicity

Malignant Hypertension

Polyarteritis/ GPA/ cryoglobulinaemia

Myeloma/ LCDD

Systemic sclerosis

Cortical necrosis/ irreversible ATN

Surgery/trauma

Late presentation of ESKD

• Unavoidable

vs

• Avoidable

UK Renal Registry 18th Annual Report

BurdenImpact

Costs

Consequences of late presentation

Low prevalence of permanent access

Delayed referral for transplant

Greater initial hospitalisation rate

Higher mortality

Reduced patient choice of RRT modality

Anaemia and bone disease

Severe hypertension & fluid overload

Worse psychosocial adjustment

Consequences of late presentation

Low prevalence of permanent access

Delayed referral for transplant

Greater initial hospitalisation rate

Higher mortality

Reduced patient choice of RRT modality

Anaemia and bone disease

Severe hypertension & fluid overload

Worse psychosocial adjustment

Consequences of late presentation

Low prevalence of permanent access

Delayed referral for transplant

Greater initial hospitalisation rate

Higher mortality

Reduced patient choice of RRT modality

Anaemia and bone disease

Severe hypertension & fluid overload

Worse psychosocial adjustment

Consequences of late presentation Benefits of early presentation

Low prevalence of permanent access Greater proportion with permanent access

Delayed referral for transplant Reduced need for urgent dialysis

Greater initial hospitalisation rate Reduced hospital LOS and costs

Higher mortality Improved survival

Reduced patient choice of RRT modality Greater choice of treatment options

Anaemia and bone disease Improved nutrition

Severe hypertension & fluid overload Better CVD and comorbidity management

Worse psychosocial adjustment Delay need to initiate RRT

Overall 2-fold increased risk of

death in group referred late (Chan Am J Med 2007)

UK Renal Registry 18th Annual Report

Survival of incident patients (unadjusted), 1997–2013

Burden

ImpactCosts

Quality of Life with CKD

0% 20% 40% 60% 80% 100%

Mobility

Self-care

Usual Activities

Pain or Discomfort

Anxiety or Depression

Absent Mild Moderate Severe Overwhelming

Data from Transforming Participation in CKD

Burden

Impact

Costs

Costs attributable to CKD (to the nearest £million), 2009–10.

Marion Kerr et al. Nephrol. Dial. Transplant. 2012;27:73-80

Estimated annual cost of direct CKD

care, RRT and non-RRT patients.

Marion Kerr et al. Nephrol. Dial. Transplant. 2012;27:73-80

Do NothingDo Nothing

DANGER

Maintain Invest

Do Nothing MaintainMaintain Invest

Do Nothing Invest

To Save

Maintain

Estimated annual cost of direct CKD

care, RRT and non-RRT patients.

Marion Kerr et al.

Nephrol. Dial. Transplant.

2012;27:73-80

Evaluation using Mixed Methods Approach

Quantitative• 1y outcome uses routinely collected data

• Efficacy of the intervention

• Balancing measure of OP appt activity

Qualitative• Acceptability

• Barriers and facilitators to spread

• Advanced Kidney Disease

– Burden

– Impact

– Costs

• By working together we can show the worth of the ASSIST-CKD intervention

Thank you to you and your colleagues for taking part in this

project