1. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Our approach to excellence in patient care Poacher and Game Keeper Seems To Come to Mind How to Deliver Kidney Care More Cheaply? Nick Richards Medical Director Fresenius Medical care

2. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Is This The Correct Question? How to improve value for money? How to improve quality at no additional cost? How to improve outcomes at no additional cost? How to invest to improve outcomes and reduce cost? How to improve the patient experience? We should not look to move back to a third world service –Rationing –Short hours and/or reduced frequency –Low flux –Re use –Etc, etc.

3. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Topics Quality Access Wasting money Prevention/case finding Payment/reimbursement systems ISO 14001 Unnecessary posts

4. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Perverse Incentives in The System Separate budgets for drugs and dialysis (EPO, binders) Separation of Primary and Secondary care Separation of nephrology funding from dialysis funding Payment for inpatient and outpatient episodes No investment in prevention Cross subsidy between specialities (dialysis “cash cow”) No focus on quality when purchasing

5. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care A New Look at Outcomes and Cost annual patient cost morbidity / mortality dialysis patients mortality of all ESRD patients i.e. 15% untreated patients % CKD5 not treated 100 % i.e. £25,000

6. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care A new Look at Outcomes and Cost annual patient cost morbidity / mortality untreated patients dialysis patients i.e. 15% i.e. £25,000 mortality of all ESRD patients % CKD5 not treated 100 %

7. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care A new Look at Outcomes and Cost annual patient cost morbidity / mortality untreated patients dialysis patients Δ cost Δ mortality

8. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care 1st conclusion More dialysis cost could lead to more mortality, If As a consequence, less patients get access to dialysis

9. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care 2nd conclusion It is our mission to reduce mortality! Therefore We need to constantly reduce cost and Share the profit with society

10. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Improve Quality Outcomes and Reduce Cost Current HD outcomes are poor UK has endemic –short dialysis hours –Low blood flows –Poor access services Optimise treatment to address modifiable metrics linked to outcomes –Time –Blood flow –Access –Hb –Phosphate –Dry weight –eKt/v No correlation between access and blood flow 15 L 50% Lines Italian mean UK mean

11. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Optimised Treatment On line HDF standard Minimum 3 x week Minimum 4 hours effective dialysis time Minimum 20 L exchanged Minimum blood flow 350 ml/min Minimum litres processed 84 L Optimise dry weight so UF <8 ml/kg/hr Fistula use >90% Outcome: Reduced mortality Reduced hospitalisation Reduced EPO use Improve phosphate control Therefore: Improved outcomes for patients Optimal use of resource Money saved

12. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care The Effect of Dialysis Prescription on eKt/V 1.7 m, 70 kg man, 65 yrs, UF volume of 1.5 L, Hct 0.35, Recirc 5%, Alb 40 gm/l Baseline Fx 60, 4 hrs, 3x wk, Qb 300ml/min, Qd 500ml/min eKt/V 4.7% 14.3% 18.3% 7.1%

13. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Rational Dialysis per 100 patients 800 ml/min v 500 ml/min +£12,500 in concentrate +1.1 Million L of water Large dialyser v normal dialyser +£72,000 Extra 30 minutes dialysis +£2,500 in concentrate +240,000 L water Increase blood flow to 400 ml/min ≈free Benefit marginal Benefit significant

14. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Fistulae 2008 - 2009 Monthly Mean All Clinics % Fistula

15. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Admission Rates and Inpatient Days FistulaPermanent Line Temporary Line Factor Adm n due to Access 0.370.881.59X 2.4 (4.3) Adm n due to sepsis 0.040.390.70X 9.8 (17.5) Days due to access 2.054.248.71X 2.1 (4.25) Days due to sepsis 0.334.187.56X 12.7 (22.9)

16. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Minimum XS Cost of Permanent Lines £10 Million per year per 1000 patients Or £70 Million based on 22,000 patients

17. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Late Presentation Little in the way of proactive case finding Inadequate pre-dialysis care –Education –Referral guidelines –Remote IT monitoring 22% of patients present < 3 months prior to dialysis Range 8 - 41% 11% of late presenters will start PD v 27% otherwise Late presenters more anaemic 9.5 gm/dl vs 10.5 gm/dl Majority of late presenter will have a line for 3-6 months –Higher admission rates –Higher inpatient days 70% of MSRA bacteraemia occurs in patients with lines

18. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care ISO 14001 an Environmental Management Policy This standard is applicable to any organisation that wishes to: –Implement, maintain and improve an environmental management system –Assure itself of its conformance with its own stated environmental policy –Demonstrate conformance –Ensure compliance with environmental laws and regulations –Seek certification of its environmental management system by an external third party organization

19. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Change in Clinical Waste per Treatment 2009-2010 2 million Kg/year £2 million Target

20. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Bundle Payments Mechanisms Introduced in Portugal 2009 €29,000 per patient per year Includes –Dialysis –Drugs Antihypertensives ESAs Phosphate binders Vit D analogues Calcimimetics Antibiotics Fibrinolytics –Medical follow up –Investigations X ray Ultrasound Echo Laboratory tests Payments linked to outcome –Process indicators Hb Ferritin Phosphate Dialysis dose –3 x weekly –12 hours –eKt/v ≥ 1.2 –Outcome indicators Lab tests performed Hospitalisations Mortality IndicatorReference value 20082009 % patients with Hb 10-13g/dl ≥ 70%73%74% % patients with ferritin 200-800 ng/ml ≥ 80%73%75% % patients with phosphate 3.5-5.5 mg/dl ≥ 50%55% % patients with 3 dialysis sessions/week ≥ 90%90%93% % patients with total hours of ≥ 12 hours/week ≥ 90%90%92% % of patients with eKt/v ≥ 1.2 ≥ 75%76%86% Failure to meet water standard ≥ 90%99.8%99.9% Hospitalisations/patient/year ≤ 10.050.07 Annual mortality rate ≤ 20%11%12.5% Outcomes Against Targets

21. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Bundle Payments Mechanisms Forces focus on output not input Requires sophisticated IT links Drives the need for regular QA/audit Drives up quality Caps financial risk Moves financial risk from payer to provider

22. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Co-ordinators – Non Transplant Person A Person B Person C (a co-ordinator) Originally paid for by the pharmaceutical industry but are now a cost for the NHS. Are they necessary? Solutions: Move funding back to pharmaceutical industry Change the system (A talks to B) Potential savings > £6 million

23. © 2008 Fresenius Medical Care Ltd Nephrocare is a registered trademark of Fresenius Medical Care Summary - Savings Optimise the available resource - Focus on quality Stop wasting money at the fringe Invest in a proper access service (in or out of house) Invest in prevention/case finding Move to a bundle payment mechanism Focus on environment (clinical waste, water, electricity) Stop funding unnecessary posts