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

1998 - 2008

Pat

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Dialysis

ESRD

A Sound Alternative:

Home HaemodialysisHome Haemodialysis

•Cost Effectiveness Home Haemodialysis

Home Haemodialysis

•Better

Patient

Outcomes

Toyota Production System

“the number of life years saved could be doubled if resources were reallocated

to more cost-effective interventions” . . .

Home haemodialysis annual sessions based on 4x weekly therapy.

Dialysis Cost Comparison NHS

PbR for Kidney Dialysis Project Group Report June 2009

Treatment (£ Aug 1990)

Cholesterol testing and diet therapy only (all adults aged 40-69) 220Neurosurgical intervention for head injury 240Advice to stop smoking from general practitioner 270Neurosurgical intervention for subarachnoid haemorrhage 490Antihypertensive treatment to prevent stroke (ages 45-64) 940Pacemaker implantation 1 100Hip replacement 1 180Valve replacement for aortic stenosis 1 140Cholesterol testing and treatment 1 480Coronary artery bypass graft (left main vessel disease, severeangina) 2 090Kidney transplant 4 710Breast cancer screening 5 780Heart transplantation 7 840Cholesterol testing and treatment (incrementally) of all adultsaged 25-39 14 150Home haemodialysis 17 260Coronary artery bypass graft (one vessel disease, moderateangina) 18 830Continuous ambulatory peritoneal dialysis 19 870Hospital haemodialysis 21 970Erythropoietin treatment for anaemia in dialysis patients(assuming 10% reduction in mortality) 54 380Neurosurgical intervention for malignant intracranial tumours 107 780Erythropoietin treatment for anaemia in dialysis patients(assuming no increase in survival) 126 290

Dept of Health Economics Research , York

QALYs generated and costs accrued

McFarlane PA et al. Kidney Int 2006; 69:798-805.

Group QALYs Cost ($)

Reference case (IHD) 5.31 543 602

Reference case (HNHD) 5.79 538 094

No transplantation (IHD) 2.78 370 047

No transplantation (HNHD) 3.25 363 206

HNHD as initial modality (IHD) 5.31 543 602

HNHD as initial modality (HNHD) 6.30 534 484

Initial HNHD and no transplantation (IHD) 5.48 730 590

Initial HNHD with no transplantation (HNHD)

7.22 692 658

HNHD=home nocturnal hemodialysisIHD=In-hospital dialysis

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 (£3000 - £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 (2004-2010)

Total patients 171Age 53 yrs (range 22 – 73 yrs)Trained 140Failed 8 , Tx 3, Retrained 11,

training 16AVF : 85 %Diabetes 11 %

Home Haemodialysis Uptake

Manchester , 12% of HD

Pa

tien

ts =

n

Manchester Point prevalence

Improving standards

-0.1

0.4

0.9

1.4

1.9

2.4

PD conventional HD 5-6hr thrice wkly

alternate day nocturnal/daily

preD phosphate

Manchester Feb 2010

Set up Location at Home

Home conversions cabin installation 10 % patients

Phone calls (2009-2010)

Total 69

Clinical / Tech

46 / 23

Weekend 9

After 9 pm 7

Mon 18

Tue 12

Wed 11

Thurs 9

Fri 9

17

05 000

10 00015 00020 00025 00030 00035 00040 00045 00050 000

HHD n=23 SHD n= 28

Other

Installations

Assistant reimb.

Medication

Travel

Radiology

Lab (primary care)

Lab (hosp)

Surgical proc.

Hospitalizations

Out-patient visits

Dialyses

Home HD

Hosp HD Savings /pt

Total Cost (£)

68284 89029 -20745

Capital costs(£)

8886 7918 969

Staff costs (£)

14736 30033 -15297

Cost per QALY

2.42 2.04 0.38

Cost per QALY - Home HD dominates

10 yr savings (50pts) > £ 1 million

CEP 10063, 2010

National Information Center on Health Services Research and Health Care Technology (NICHSR)

Hosp HD

Different Types of Economic Analysis 

Home Haemodialysis : Home Haemodialysis : A Neglected OpportunityA Neglected Opportunity

Thank You