Renal GIRFTLive Donor Renal Transplantation
Emerging Themes
Living Kidney Donor Forum
Graham Lipkin & Will McKane: GIRFT Renal Co-Leads
Getting it Right First Time (GIRFT)
2
A clinically led programme across 40 specialties:
Aims
• Reduce unwarranted variation,
• Improve the quality of patient outcomes
Phases
• Analytics – Opportunities of HES linkage
• 52 Renal Unit Deep Dives & Reports*
• Regional implementation
• National Report (in preparation)
• Library for Peer Assist*
Growth in Transplant & RRT across EnglandWhat is the best way to present rates?
Profound variation in ethnic diversityDeprivation and comorbidity
Virtuous Cycle & Opportunity to Improve LD Transplantation
Regional Transplant Networks
• QI - Training leadership• MPT focus• Peer learning• Operational Delivery+ NHSE Service Specs
+ RSTP+ NHSBT Strategy+NHSE LTP
Data
Emerging Themes; Variation in TransplantationSolutions are in place… somewhere
• Quality Improvement structures - support for Leaders*
• Regional Renal Clinical Networks
• Data for QI: accurate, accessible and timely
• LD Transplantation• Access to transplant waiting list• Access to live kidney donation (UKLDKSS)
• Emergency hospitalisation rates
• Medicines management
• Workforce*• Outpatient-frequency and capacity
• Shared Decision Making
Data Rich – not as good as we aspire to
• Good data to support assurance and QI requires:
• Culture across MPT
• Dedicated renal data manager
• Renal EPR that is fit for purpose/Trust EPR
• Timely transfer of accurate data
• Accessibility- Dashboard
UKRR
NHSBT
Where to focus resource?Transplantation
CKD
Advanced kidney care
clinic
Dialysis
Peritoneal
PD catheter
Haemodialysis
AV Fistula
Transplantation
Pre- dialysis Live Donor Transplant
Pre-dialysis Deceased Donor Transplant List
Conservative Care
AssessmentShared Decision Making
True Choice
Referral & Intervention
Dialysis
Unplanned starter (Transplant focus)
Preparation for RTT: pre-emptive listing & LD?Advanced Kidney Care Clinics
• AKC clinics with enabled Clinical Leadership (medical and MDT)
• Transplant First culture
• Shared decision making embedded
• Adequate live donor coordinators
• MDT review meeting
• Data for QI - real time
• Referring/Tx centre listing Pathway
• Good communication & listing processes
• Prediction of ESRF
AKCC tariff that reflects major investment in clinical input
Missed transplant opportunity-expensive
Access to Renal Transplantation ++Survival advantage of (early) Renal Tx
Wolfe RA. N Eng J Med 1999;341:1725-30
RR at 18months Predicted years
life without Tx
Predicted years of
life with Tx
All recipients 0.32 10 20
NHSBT centre transplant rates PMP*
- not adjusted for ethnicity, postcode allocation or ‘need’
*Adjusted for age, ethnicity, PRD and gender
Pre-emptive listing or Pre-emptive Transplantation- three transplant networks in red, amber, green
Live Donor Transplantation by 2 Years from RRT Start
Pre-emptive LD Transplantation
Access to Transplantation-LD and listingTransplant Vs Referring Centre
Live donor Assessment
Role of LD Coordinators(PMP)
Living Donor Assessment
• Referring centres - lack of tariff for LD assessment
• LD work up variation (assessment time unknown)
• Varying ‘drop out’ rates
Percentage
Living donor
conversion
52%
LD assessment
complete within
18 weeks
44%
Medical Resource: Nephrologists
Surgical Capacity: Transplantation vs Vascular access
Equity of access to transplantation
• We will not solve this unless we have collaborative transplant networks
• Transplant centres recognise their responsibilities to the whole network
• Leadership
• Culture and adequately staffing – Live donor coordination
• What timely data is most helpful to assess this and to drive QI?
Transplant Outpatient Review – 1st 6 monthsWhat is optimum frequency?
OP Follow Up in1st 6 Months
Rea
dm
issi
on
rat
es
Emergency Readmission Rates1st Year
Deceased Donor Live Donor
Re-admission Codes
Access to Clinical Research
• Patient Access to clinical Research an essential element of improving care in the NHS
• There is widespread unwarranted variation in research opportunities, even in large university hospitals for patients including those studies sponsored by NI.
• Opportunities to participate in research should be available to patients
• Inclusion in NIHR research trials should be a metric published annually
Emerging ThemesAccess to Transplantation: ‘biggest bang for the buck’
• All renal centres Transplant First culture and Leadership (LD transplant leads)
• Resource advanced kidney care clinic pathway
• Enable referring Units: Focus on live donor kidney Tx coordinator resource. (Live donor treated as a VIP)
• Mandatory Tariff for LD workup Pathway
• 18 week pathway for LD assessment
• Enhanced Network arrangement for Transplant and referring centres - joint responsibility
• ‘Unplanned starter’: dialysis no transplant decision or listing or LD
• Data: New Dashboard metric
• Transplant HRG & Commissioner interaction
Innovative Community DevelopmentsKeen partners to engage