1. The Quality Agenda for UK nephrology Charlie Tomson President, Renal Association SpR club meeting, London, Saturday 18 th September 2010

2. Conflicts of interest No financial or other relationships with pharmaceutical companies for at least the last 5 years, in particular no –Directorships –Advisory boards –Free trips to conferences –Free lunches or dinners ACCEA Silver award

3. Outline Dimensions of quality Quality improvement in healthcare The political context, 2010 Quality in nephrology QI in nephrology

4. Why am I here? (because I was hoping to get to the Saturday night SpR club drinking session) Social and Political Science part II Long involvement in RA standards and guidelines (including CKD guidelines) 1y Health Foundation Quality Improvement Fellowship at Institute for Healthcare Improvement 4y as UKRR chairman

5. Dimensions of quality Safe – no needless harm Timely – no needless waits Efficient – maximise health gain per £ Effective – evidence-based Equitable – irrespective of race, literacy, income, BMI Patient-centred – the patient at the centre Sustainable – meet the needs of today without compromising the ability of future generations to meet their needs

6. Quality Improvement mantras If you cant measure it, you cant improve it Every system is perfectly designed to deliver the results it delivers Human beings make mistakes, and attention to human factors can reduce risk Achieving change in complex organisations requires profound knowledge as well as subject matter knowledge

7. Appreciation of a System Understanding Variation Theory of Knowledge Psychology Values

8. The political context Darzi Next Stage Review – focus on clinical dimensions of quality (safe, effective, patient-centred) Quality, Innovation, Prevention, Productivity programme Flat cash funding Coalition White Paper – nothing about me without me

9. Byrne C et al. UKRR 12 th Annual Report, Chapter 4. Nephron Clin Pract 2010;115 (suppl 1): c41-c68 Rising numbers, flat cash: a perfect storm

10. Andrew Lansley: priorities Patients: no decision about us without us Focus on outcomes, not process targets Empower professionals to deliver Prioritise prevention to reduce inequity Integrate health and social care http://www.dh.gov.uk/en/MediaCentre/Speeches/DH_116643

11. DH/IC Indicators for Quality Improvement LT12% of all dialysis patients aged <55y on Tp WL 13Timely referral to kidney unit 14aHD patients with Hb 10.5-12.5 14bPD patients with Hb 10.5-12.5 15HD patients with adequate URR 16Survival (after 90 days) ???? 17HD patients with PO4 1.1-1.8 18PD patients with PO4 1.1-1.8 19RRT patients with MRSA blood stream infections ??? 20BP for PD and transplant pts <130/80 21HD patients with HCO 3 within lab NR 22PD patients with HCO 3 within lab NR

12. Q: Whats this got to do with me? Im a renal SpR, not a manager Im not the Clinical Director If they want better care, they need to spend more money My responsibility is to the patient in front of me

13. A: It is not necessary to change. Survival is not mandatory W. Edwards Deming

14. Quality of renal care Safe Timely Efficient Effective Equitable Patient-Centred Sustainable

15. Safety of renal care (covered by Simon Watson last SpR club) NPSA signals – mostly related to HD, equipment Drug interactions Drug-induced leucopenia In-hospital pulmonary oedema Anticoagulation control Infection control – C Diff, line infections, pneumonia

16. Timeliness of renal care Multiple clinic visits –Nephrology –Vascular mapping –Vascular access –Education –Psychology –Transplant assessment –+ all the other specialties involved

17. Effectiveness of renal care Evidence-based care: reliable implementation of available evidence Dialysis dose ?phosphate control? Protocol-based management of vasculitis according to RCT evidence Protocol-based transplant management

18. Efficiency in kidney care? Increasing focus on who starts RRT and when –Benefits amongst elderly pts with co- morbidity/nursing home residents? –eGFR at start (including pre-emptive Tp) Increasing focus on reducing waste in each clinical pathway Alternative: go back to overt or covert rationing

19. Efficiency of renal care Reducing cost per case Complicated by primary/secondary care funding split –Payment per episode –Higher payments for RRT vs conservative –Higher payments for admissions with complications vs no complications 80% of NHS costs are salaries

20. Guys/RA: reducing costs of kidney care: 17 th Sept 2010 Nick Richards (Fresenius): –achieve adequate URR by increasing t and Q b ; reduce clinical waste; stop employing co-ordinators and talk to each other; link payments to outcome measures Lisa Burnapp (DH, Guys) –Do more pre-emptive LRD transplants Patrick Harnett (Southend) –Rationalise use of ambulance transport for dialysis Richard Fluck (Derby) –Reduce access-related infections, pneumonia

21. Guys/RA: reducing costs of kidney care: 17 th Sept 2010 - 2 Sandip Mitra (Manchester) –Expand use of home HD Peter Rutherford (Baxter) –Increase use of PD as initial therapy by working on shared decision-making Charlie Tomson (Bristol) –Reduce low-added-value OP appointments Frances Mortimer (Campaign for Greener HC) –Reduce Carbon and save money Jane Macdonald (Hope) –Reduce use of bank nurses and reduce long-term sickness absence

22. Rosansky SJ. Kidney International 2009; 76: 257-261 Rising tide of ESRD due to earlier start?

23. Survival from day 1 vs eGFR at start: EDTA-ERA Stel V et al. Nephrol Dial Transplant 2009;24; 3175-3182

24. Stel V et al. NDT 2010; doi 10.1093/ndt/gfq209 eGFR at start in Europe, 1999 and 2003

25. 828 patients with eGFR 10-15 randomised to start at eGFR 10- 14 vs 5-7 (+clinical discretion) Median time from randomisation 1.8 vs 7.4 months Median eGFR at start 12.0 vs 9.8 NEJM 2010; 363: 609-619

26. NEJM 2009; 361: 1539-1547

27. Carson R. CJASN 2009; 4: 1611-1619 Survival from eGFR 10.8 ml/min/1.73m 2

28. Supply-led demand? Unused haemodialysis facilities make it difficult to balance the budget Commercially provided satellite or main unit HD facilities have a vested interest in keeping patients on satellite or main unit HD PbR provides financial incentives for RRT over Maximal Conservative Care

29. Equity of renal care Same opportunity to benefit from healthcare irrespective of –Ethnic origin –Cultural origin –Literacy –Income –Educational status –Social class –Language –Geography

30. Socioeconomic factors in RRT acceptance rate PCTs with higher deprivation scores have higher RRT acceptance rates PCTs with higher ethnic minority populations have higher RRT acceptance rates in England, but not in Wales After adjustment for deprivation and ethnicity, acceptance rate ratio remains significantly higher in Wales, and lower in NW England and Yorkshire/Humberside Udayaraj U et al. J Epid Comm Health 2010;64:535

31. Socioeconomic status and access to transplant waiting list Quintile 1 (least deprived) reference Quintile 20.93 (0.86-1.00) Quintile 30.83 (0.75-0.93) Quintile 40.70 (0.63-0.78) Quintile 5 (most deprived) 0.60 (0.54-0.68) Adjusted for age, gender, PRD, year of start; and for centre effect N= 9602 - White patients only Udayaraj U et al. Transplantation 2010; 90: 279-285

32. Centre variation in access to renal transplantation – longitudinal study Objective – to assess whether there is equity in access to renal transplantation in the UK after adjustment for case mix Incident patients in 65 centres submitting data to UKRR between 1/03 and 12/05, followed until 12/08 (excluding pts >65y, pts activated and then immediately suspended, patients listed for multi-organ Tp) Proportion of incident patients at each centre registered on waiting list, time taken to registration, and proportion subsequently transplanted

33. Ravanan R et al. BMJ 2010; 341: c3451

34. Patient experience in renal care No validated PROMs for chronic conditions Several validated QoL measures, none routinely collected or reported No validated measures of satisfaction with OP consultations

35. Trust in OP medical care 417 patients attending new patient OPA with cardiologist, neurologist, nephrologist, gastroenterologist, rheumatologist Keating NL. Arch Intern Med 2004; 164: 1015-1020

36. Summary so far 7 dimensions of quality Room for improvement in each But how?

37. Original research Submission Acceptance Publication Bibliographic databases Review, paper, textbook Implementation variable 0.5 years 0.6 years 0.3 years 6-13 years 9.3 years Negative results Lack of numbers Inconsistent indexing Translating research into care Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70

38. Clinical research to clinical practice: lost in translation? US life expectancy lower than 22 other countries despite $250bn NIH investment since 1950 –lack of improvement due to failure to translate the findings of clinical investigations into the practice of medicine at the community level –from the translational highway to the smaller avenues and lanes of the microsystems that deliver care Lenfant C. Shattuck Lecture. N Engl J Med 2003; 349: 868

39. QI: implementation science Establish the need for improvement Establish a measure Agree a SMART aim Find a change package –From the literature –From high performing centres Do multiple PDSA cycles

40. Understanding high performance Structure + Process = Outcome Learning from high-performing units requires –Identifying them reliably –Finding out how they achieve their results A detailed understanding of HOW care is delivered, as well as WHAT care is delivered, is critically important for understanding how different centres achieve different results

41. Collecting information on causes of centre variation Anecdote Ask the high performers –But they wont have any idea how their practice differs from poor performers Ask people whove worked elsewhere – e.g. rotation SpRs!! Design a questionnaire – Delphi technique Administer a questionnaire

42. Thank you Charlie.tomson@nbt.nhs.uk