The pandemic has highlighted the need to re-evaluate renal referral pathways and improve care closer to home through the identification and treatment of chronic kidney disease (CKD).
It has also underlined the importance of earlier recognition of kidney deterioration, which will precipitate the need for renal replacement therapy (RRT) or a renal transplant.
A key area for review in this regard is in the management of patients who are either unsuitable for a renal transplant or lack a donor.
Unique methodology
Wilmington Healthcare has used its unique behavioural methodology, Costed Integrated Patient Scenarios, to help identify a best practice pathway for CKD by exploring the effects of planned, proactive RRT, compared with unplanned, reactive RRT.
The work included an analysis of whole system costs for both RRT options which is critical given the move towards integrated healthcare systems, with joined-up finances, which are looking for new ways to improve services and save money across whole care pathways.
A key part of the Costed Integrated Patient Scenario process involved a multidisciplinary team (MDT) stakeholder review, covering all aspects of the current pathway, from the presentation of an individual with CKD through to specialist intervention and managed care in the community.
A straw man pathway
To help guide the process, the team created a straw man pathway involving a fictitious patient – a 65-year-old man called ‘Sid’ who developed hypertension and type 2 diabetes and was later diagnosed with stage 4 CKD.
The straw man was debated by the key stakeholder group to determine what was important for Sid, his family and the NHS and to help define two scenarios – a suboptimal and an optimal treatment pathway.
The suboptimal pathway often results when insufficient planning is given to patient management and the patient ‘crash lands’ in hospital needing renal dialysis. The Delphi academic process was used to gain agreement on the critical optimal pathway steps.
One particularly interesting feature of the work was the identification of a critical window of opportunity to improve outcomes for the patient. This occurred when Sid was found to have a low glomerular filtration rate (eGFR), which indicated CKD.
Missed opportunity
In the suboptimal scenario, Sid’s critically low eGFR window was missed. A nephrology referral that was made later clashed with the diabetes clinic, and the appointment was never rescheduled due to an administrative error.
A lack of co-ordinated care meant that pre-existing conditions were not well managed and the patient’s overall health, including CKD, continued to deteriorate. There was an escalation of symptoms, which necessitated multiple and lengthy emergency admissions. A continued lack of patient awareness of CKD options ultimately led to hospital haemodialysis as the only RRT route.
Prompt action
In the optimal pathway there was prompt action because Sid’s eGFR was noted earlier. The opportunity to proactively improve health outcomes, manage pre-existing conditions, increase quality of life and reduce the cost of care was quickly spotted and a secondary care referral was made.
An expedited and proactive risk factor assessment was conducted with ongoing MDT management through a specialist renal service and home dialysis was identified as the preferred option when such treatment became necessary.
A joined-up approach
The two scenarios show that the total financial costs of failing to proactively manage CKD were more than £150,000 per patient for the total CKD journey over the years documented in the Costed Integrated Patient Scenario. These costs were calculated over acute care, the ambulance service, community teams and primary care.
This Costed Integrated Patient Scenario evaluation helps renal commissioners and providers understand the implications of different pathways in terms of quality of care and cost across the whole system, which is vital given the move to integrated, population-based care, and critically it highlights the importance of proactive monitoring of patients at risk of CKD in primary care.
The move to provide more renal replacement therapy closer to home has been a priority for some time and, if it had been implemented, it could have been particularly valuable during the pandemic which has placed huge pressure on renal services.
The Costed Integrated Patient Scenario has now provided economic evidence as to why this change needs to happen not only to save the NHS money, but also to improve patient outcomes and keep patients out of hospital, where possible.
Sue Thomas is a Clinical Consultant, for Wilmington Healthcare. For information on Wilmington Healthcare, visit www.wilmingtonhealthcare.com/patient-scenarios
