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 Patients pmp worldwide Dialysis ESRD

A Sound Alternative: Home Haemodialysis Cost Effectiveness Home Haemodialysis Better Patient Outcomes

What do they have in common? Toyota Production System

VALUE = QUALITY * ACCESS COST “the number of life years saved could be doubled if resources were reallocated to more cost-effective interventions”...

Pricing Human Life(-Years)

Home haemodialysis annual sessions based on 4x weekly therapy. Dialysis Cost Comparison NHS PbR for Kidney Dialysis Project Group Report June 2009

Cost - benefit league table [Cost/QALY] Treatment (£ Aug 1990) Cholesterol testing and diet therapy only (all adults aged 40-69) 220 Neurosurgical intervention for head injury 240 Advice to stop smoking from general practitioner 270 Neurosurgical intervention for subarachnoid haemorrhage 490 Antihypertensive treatment to prevent stroke (ages 45-64) 940 Pacemaker implantation Hip replacement Valve replacement for aortic stenosis Cholesterol testing and treatment Coronary artery bypass graft (left main vessel disease, severe angina) Kidney transplant Breast cancer screening Heart transplantation Cholesterol testing and treatment (incrementally) of all adults aged Home haemodialysis Coronary artery bypass graft (one vessel disease, moderate angina) Continuous ambulatory peritoneal dialysis Hospital haemodialysis Erythropoietin treatment for anaemia in dialysis patients (assuming 10% reduction in mortality) Neurosurgical intervention for malignant intracranial tumours Erythropoietin treatment for anaemia in dialysis patients (assuming no increase in survival) Dept of Health Economics Research, York

QALYs generated and costs accrued McFarlane PA et al. Kidney Int 2006; 69: GroupQALYsCost ($) Reference case (IHD) Reference case (HNHD) No transplantation (IHD) No transplantation (HNHD) HNHD as initial modality (IHD) HNHD as initial modality (HNHD) Initial HNHD and no transplantation (IHD) Initial HNHD with no transplantation (HNHD) HNHD=home nocturnal hemodialysis IHD=In-hospital dialysis

Manchester Home Business Model 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 (£ £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 ( ) Total patients 171 Age 53 yrs (range 22 – 73 yrs) Trained 140 Failed 8, Tx 3, Retrained 11, training 16 AVF : 85 % Diabetes 11 %

Home Haemodialysis Uptake Manchester, 12% of HD Patients = n Manchester Point prevalence

Improving standards Manchester Feb 2010

Set up Location at Home Home conversions cabin installation 10 % patients

Emergency Helpline 24/7 Phone calls ( ) Total69 Clinical / Tech46 / 23 Weekend9 After 9 pm7 Mon18 Tue12 Wed11 Thurs9 Fri9

17

Home HDHosp HDSavings /pt Total Cost (£) Capital costs(£) Staff costs (£) Cost per QALY Cost per QALY - Home HD dominates 10 yr savings (50pts) > £ 1 million CEP 10063, 2010

Quadrants of Cost Effectiveness National Information Center on Health Services Research and Health Care Technology (NICHSR) Hosp HD

Different Types of Economic Analysis Home Haemodialysis : A Neglected Opportunity VALUE = QUALITY * ACCESS COST

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