Quality Initiative to Grow Home Therapies is On Track

A quick post to acknowledge and thank our outstanding FHA renal team for their contribution to a recent quality initiative to support & grow home dialysis.  The initiative was launched this summer.

Since July 2015,

– Home Hemodialysis (HHD) has grown from 3% to 3.4% prevalence
– Peritoneal Dialysis (PD) has grown from 26.4% to 27.9% prevalence
– Overall, independent dialysis has grown from 29.4% to 31.3% prevalence

This is a phenomenal amount of growth in a very short period of time.

Remember, this isn’t about just moving a number.

We know that

– independent dialysis is associated with better outcomes than facility HD
– up to 50% of patients want independent dialysis so this accommodates patient choice & values
– patient we divert to urgent start PD instead of HD with a CVC avoid a therapy associated with increased morbidity/mortality
– independent therapy is less costly and lets us invest in better care throughout the rest of the program/health authority

Looking forward to us hitting our 33% target for independent modalities over the next year!

 

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A New BP Target in Chronic Kidney Disease?

In this brief piece which summarizes the recent rounds I presented on Nov 13, 2015 at Royal Columbian Hospital internal medicine rounds, I indicate why the results of SPRINT will change the targeted blood pressure for many of my patients with chronic kidney disease.

View Slides & Summary

 
 
 

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Fraser Health wins people’s choice award at 2015 BC Kidney Days

BC Kidney Days 2015 was a successful event that attracted a significant amount of local research, including several submissions from Fraser Health.  This year’s research award recipients are listed here.

Fraser Health’s Robin Cho et al were the recipient of the People’s Choice award for the poster entitled “Evaluation of Vancomycin Dosing Practices and Attainment of Target Pre-Dialysis Trough Levels in Hemodialysis Patients.”

Have a look at the poster here: Vancomycin in HD Poster

 

 

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Preventative Foot Care Project May Reduce Amputations, Hospitalization and Length of Stay in ESRD

At the 2015 BC Kidney Days, Dr. Shaoyee Yao and Sarah Lacroix present the preliminary results from a quality improvement project designed to reduce preventable complications from lower extremity wounds in patients on dialysis.

It has been know for some time that foot wounds are very common in patients on hemodialysis and peritoneal dialysis, affecting up to 30-40% patients.

In addition, lower limb disease is associated with an increase risk of death, with 5 year survival decreasing from 46% in those without lower limb disease, to 23% in those with disease.

The Fraser Health Renal program designed a CQI project to establish a multidisciplinary approach to early detection and treatment of lower limb lesions in patients with ESRD.

This project was funded via our discretionary fund for just these type of projects, in addition to funding from Amgen Canada.

We elected to roll out the pilot at the Abbotsford Regional Hospital (ARH) and compare outcomes in 2 ways.  We performed an observational analysis of patients outcomes, comparing outcomes at the same site the year prior to the intervention vs the year during the intervention.  Given some concerns over a possible Hawthorne effect or that foot care might have just improved due to general medical progress, we also elected to compared outcomes at control sites that were only offering routine foot care (Surrey Memorial Hospital and Royal Columbian Hospital).

Have a look at the slide deck included on this page (below).

Fraser Health Foot Care Project Shows Reduced Amputation, Hospitalization and Length of Stay in Dialysis Patients from Daniel Schwartz

In addition, Sarah Lacroix presents an excellent overview of the program and more details on our outcomes.

BC Kidney Days 2015 – Foot Care Nursing Breakout Session from Daniel Schwartz

Results

In brief, our raw data comparing pre/post outcomes at ARH suggests that:

a) Amputations were reduced from 2.6% to 1.6% (RRR 38%)
b) Days in hospital were reduced from 9.0 to 5.6 per patient (RRR 38%)
c) Hospitalization for infection was reduced from 8.9% to 4.4% (RRR 51%), overall hospitalization rate was reduced from 18.9% to 17.5% (RRR 7.4%) and total length of stay was reduced

Raw data comparing outcomes at ARH (active intervention) vs SMH/RCH (control sites) suggest that:

a) Amputations were reduced from 3% to 1.6% (RRR 47%)
b) Days in hospital were reduced from 9.9 to 5.6 per patient (RRR 43%)
c) Hospitalization for infection was reduced from 8.5% to 4.4% (RRR 48%), overall hospitalization rate was reduced from 24.2% to 17.5% (RRR 28%) and total length of stay was reduced

It’s interesting to note that we saw an increase in hospitalization for peripheral vascular disease but less amputations and lower admissions for lower limb infections, suggesting that we were intervening earlier in the disease process.  This is also supported by a much lower length of stay in hospital overall.  This suggests that intervening earlier results in earlier revascularization and overall better outcomes.

In fact, this intervention resulted in approximately 3.4-4.2 less days of hospitalization for each patient in our program.

Impact

Extrapolating to our entire program (were we able to roll this out more widely across the health authority), with a ‘back of the napkin’ calculation:

a) Approximate number of patients with ESRD at FHA: ~1100
b) Approximate cost per hospitalization day (as per CIHI report) : ~$1000 per day
c) Approximate reduction in length of hospital stay per patient (mean of pre/post & active/control results): 3.8 days

1100 patients X 3.8 hospital day reductions/patient X $1000 per day

= $4, 180, 000

The financial investment to achieve these outcomes was relatively modest, with total expenditure of $80 888.76 during the period for which we report outcomes.

So that’s a potential $4,180,000 saved per year as a result of preventative foot care in ESRD.

Next step is to perform appropriate statistical testing and an economic analysis.  We are hopeful that we will confirm this intervention is highly cost saving, while at the same time showing an improvement in patient outcomes; essentially that it is cheaper to provide better care.

If we are able to demonstrate that the results are both statistically significant and economically advantageous, we will go back to funders to seek support for a widespread implementation of this preventative care program across the region, and hopefully the province.

What can we take away from this project?

a) Pending our statistical and economic analysis, it appears that investing in preventative care may result in better patient outcomes at markedly lower cost
b) Our discretionary project funds, in addition to industry sponsorship, can provide an amazing opportunity to explore new methods of improving outcomes (we are unique within FHA in that we have access to such funds)
c) Creating high quality project proposals is an important first step in identify projects that are set up for success.  While brief and simple, the foot care proposal we reviewed addressed the following:
a) the problem you’re trying to solve ie why does this matter?
b) what you’re going to do ie what’s the intervention?
c) how you’re going to define and measure success ie how will we know if we’ve succeeded?
d) what it’s going to cost
Have a look at the original proposal – it’s a great template for those considering future submissions.
View Foot Care Project Proposal

 
 

References

 
Ndip A1, Lavery LA, Lafontaine J, Rutter MK, Vardhan A, Vileikyte L, Boulton AJ. High levels of foot ulceration and amputation risk in a multiracial cohort of diabetic patients on dialysis therapy. Diabetes Care. 2010 Apr;33(4):878-80. PMID: 20067975.
 
Orimoto Y1, Ohta T, Ishibashi H, Sugimoto I, Iwata H, Yamada T, Tadakoshi M, Hida N. The prognosis of patients on hemodialysis with foot lesions. J Vasc Surg. 2013 Nov;58(5):1291-9. PMID: 23810259.
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Quality/Program targets

As members of the FHA renal team will see in this week’s “Program Update”, we will be focusing renewed attention to a few of our key program priorities.

As we’ve prioritized before, we will continue to focus on increasing uptake of independent modalities and decreasing the number of central venous catheters in use in our HD units.

Our goal for independent modalities is to reach a combined Peritoneal Dialysis and Home Hemodialysis rate of 33%.  We are currently at 30%, so have a bit of work ahead of us and will be calling on the entire program to support those patients wishing to transition to home dialysis.

We have been very successful in reducing our  PD peritonitis rates and are currently seeing patients, on average, with one episode every 43 months. Our goal here is to preserve this performance and target better than 1 episode in 40 months.

Lastly, for patients who have been on hemodialysis for more than six months, we are targeting an AVF/AVG prevalence rate of 63%. We are currently at 60%. We believe this can be achieved with the ongoing support of our teams.

We want to achieve these goals by August 31, 2016.  While these are certainly achievable goals, they will require focused attention and effort.

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