Information, Quality and Values

Donal O’Donoghue National Clinical Director for Kidney Care

Working for better kidney care

UKRR and NHS Kidney Care Information Day

Tuesday 9th October 2012

“Quality is the only organising principle of the NHS”

SustainablePatient Centred

Equitable

Efficient

Effective

Timely

Safe

NHS OUTCOMES FRAMEWORKDomain 1

Preventing people from

dying prematurely

Domain 2Enhancing the quality of life for

people with LTCs

Domain 3Recovery

from episodes of ill health /

injury

Domain 4Ensuring a

positive patient

experience

Domain 5Safe

environment free from avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning Outcomes Framework

Commissioning Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board – certain specialist services and primary care

– all other services

Duty of quality

Du

ty of q

ua

lityDu

ty o

f q

ua

lity

tariffstandard contract

CQUIN QOF

NHS OUTCOMES FRAMEWORKDomain 1

Preventing people from

dying prematurely

Domain 2Enhancing the quality of life for

people with LTCs

Domain 3Recovery

from episodes of ill health /

injury

Domain 4Ensuring a

positive patient

experience

Domain 5Safe

environment free from avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning Outcomes Framework

Commissioning Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board – certain specialist services and primary care

– all other services

Duty of quality

Du

ty of q

ua

lityDu

ty o

f q

ua

lity

tariffstandard contract

CQUIN QOF

CCG

4

Quality Standardsthe evidence base

NICE Quality StandardsBased on evidence of best

practice and an assessment of current care

Summarised evidence- based material: accredited guidance

Primary research evidence is synthesised into other products – guidance, audit and service models

NICE Quality

Standards

Guidance and related

products

Research and audit evidence

Quality StandardsA Quality Standard is a set of specific, concise statements, based on guidance, that act as markers of high-quality, clinical and cost-effective patient care across a pathway or clinical area. There is a maximum of 15 in each set. They are accompanied by quality measures.

Unsafe

Substandard

Adequate

Good Excellent

NICE quality standards

Standard of services

Proportion of services

Registration requirements

Value in Health Care(Porter M: NEJM 363:2477, 2010, Lee: NEJM:363:2481, 2010)

“Measurement of value is challenging…the critical first step is measurement. Provider organisations need to capture data on outcomes that matter to patients and carers.”

Waste

Value

ValueWaste

NHS Atlas of Variation in Healthcare for People with Kidney Disease

Renal Association Conference 2012

The Sage, Gateshead

Thursday 14th June 2012

To download the NHS Atlas of Variation in Healthcare for People with Kidney Disease, visit the Right Care website: http://www.rightcare.nhs.uk/index.php/nhs-atlas/

The Dartmouth Atlas of Healthcare, 1996

To download the NHS Atlas of Variation in Healthcare for People with Kidney Disease, visit the Right Care website: http://www.rightcare.nhs.uk/index.php/nhs-atlas/

To download the NHS Atlas of Variation in Healthcare for People with Kidney Disease, visit the Right Care website: http://www.rightcare.nhs.uk/index.php/nhs-atlas/

Health Survey England 2011

2010/11 CKD prevalence OE ratio

Observed based on QOF 2010/11 prevalenceExpected derived from HSE age and Gender prevalence estimates, applied to 2009 Mid year population estimates (ONS)

Prevalence of CKD:

Figure 1 - Chronic Kidney Disease – QOF Reported Prevalent Cases on CKD Registers – 2006/7 – 2009/10

1,279,246

1,589,353

1,739,4431,817,871

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

2,000,000

2006/7 2007/8 2008/9 2009/10

No.

of P

eopl

e on

CKD

Reg

iste

r

England

Vascular Disease – One Event Leads to Another (REACH Registry)

Original Event = Stroke MI Risk • 2-3 x greater risk Stroke Risk• 9 x greater risk

Original Condition = PAD MI Risk• 4 x greater riskStroke Risk• 2-3 x greater risk

Original Event = MI MI Risk• 5-7 x greater risk• Stroke Risk• 3-4 x greater risk

Diabetes (type 2)Because of the increased risk associated with diabetes, it should be considered a cardiovascular risk equivalent to a non-diabetic patient with previous MI

CKDMI Risk• 2 x greater

riskStroke risk• Up 50%

Trends in Late Referral by Year

Late referral defined as ≤3 months before RRT start

Prevalent patients by treatment

Demand for renal replacement therapy continues to increase

RRT incident rates

but incident rates appear to be reaching a plateau or falling

Percent distribution at initiation by eGFR

The mean eGFR at initiation of RRT in 2009 in the UK was 8.6

The mean eGFR at initiation of RRT in 2008 in the US was 11.1

The mean eGFR at initiation of RRT is rising

1329 1265 1185 12951111 1144 1101 1107 1102 1118

56 85 112147

201 252 313455 515 582

358 372 451463

543671

804

924979

1013

0

200

400

600

800

1000

1200

1400

1600

1800

2000

2200

2400

2600

2800

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Year

Nu

mb

er

DBD donor DCD donor Living donor

Kidney transplants in the UK

Patient Involvement: a Paradigm Shift

Old method New Method

Renal Patient View

“ Grasping what the figures meant enabled us to formulate questions for consultations, to

understand explanations and in some cases, since we were the first to see the figures in

context, to alert consultants to changes as soon as they appeared.

There is a sense that the relationship between the patient and the doctor becomes more

collaborative as soon as the patient understands the figures before the consultation takes place… Because of the service, we feel we benefit more

from consultations.”

Shared Decision Making

The care team communicates to the

patient personalised information about the options, outcomes, probabilities and scientific uncertainties of the various treatments.

“is a fundamental part of care planning and promotes the best choice in what otherwise can be a complex and overwhelming situation.”

The patient communicates his or her values and relative importance he or she places on the potential benefits and harms.

Patient Decision Aids

http://sdm.rightcare.nhs.uk/

http://sdm.rightcare.nhs.uk/