Renal Replacement Therapy (RRT) Services

Client

East Midlands Specialised Commissioning Group and the East Midlands Renal Network

Background

The annual acceptance rates into programmes of renal replacement therapy (RRT) and the incidence and prevalence of established renal failure (ERF) have increased significantly over the past decades and continue to rise. The patients who are now being treated are older with more co-morbidity. Given the continued shortage of kidneys for transplantation, the expansion of RRT in the last decade has largely been in dialysis. Most of the expansion has been in hospital haemodialysis (HD), increasingly delivered in renal satellite units (RSUs). Home haemodialysis (HHD) and peritoneal dialysis (PD and CAPD) are alternatives to in hospital haemodialysis, which make up a small proportion of total cases.

Modelling future demand is a complex activity, relying on a variety of variables in relatively small populations and how these will change over time. There are a number of potential factors that might contribute to changing demand for RRT. One possibility is that improved detection of early stages of chronic kidney disease (CKD) might lead to increased numbers of referred patients from primary care. Alternatively, it is possible that early detection may improve management so that fewer patients progress to stage 5 CKD. The overall effect of these competing influences is uncertain. Changing incidences of the underlying causes and risk factors for chronic kidney disease, such as diabetes or BP, are other factors that are known to influence the number of people with ERF.

The problem

A coherent approach to planning and commissioning of RRT across the East Midlands was necessary, and robust data is required to inform long-term planning for the dialysis service. There are three main renal centres in East Midlands; Derby, Nottingham and Leicester with satellite provision by a total of nine RSUs: seven RSUs in Lincolnshire and Northamptonshire (covered from Leicester) and two RSUs covered by Nottingham. Two RSUs (in Kettering and Northampton) plan to become autonomous within the network.

The objectives of the project were:

to map the geographical variation in need across the East Midlands (age/sex and ethnicity)
to report on capacity and provision of dialysis services by provider and compare this to need
to qualitatively describe any pressures within the system.

An output is an estimate of the number of people likely to need RRT (principally haemodialysis) in the future according to provider unit and geographical areas.

Our solution

To meet the objectives we developed an interactive demand and capacity model that achieved the following ends:

it informed the planning process at a detailed level
it was adjustable to allow for potential variations due to factors such as changes in practice
it assumed a contingency that provides some surplus capacity to cope with short term fluctuations in demand
it provided a geographical overlay that allowed matching of the services at a local level

The figure below shows an overview of the model and of the transition probabilities between different states.

RRT Model

The outcome (view a demo here)

The renal clinicians use the interactive model to plan capacity within their dialysis service and to assess the potential impact of service configuration changes to the flow of patients through the system. The commissioners use the model to allocate their budget within the RRT service. The model acts as a common framework for shared decision making between commissioners and clinicians.