Shared learning database

Manchester Royal Infirmary, Central Manchester Foundation Trust
Published date:
February 2011

An innovative approach to dialysis delivery to enable and empower patients to perform Haemodialysis independently at home, avoiding regular visits to hospital for treatment. The model has seen phenomenal success in uptake, achieving NICE recommendations, and has been associated with improvement in patient experience and outcomes.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The aim was to design a home haemodialysis (HHD) program that was fit for purpose & accessible to all those patients who might benefit, in line with NICE guidance. A model of service development was based on the principles of innovation as a continuous process that was applied through regular evaluation of all the components. We hypothesized that a streamlined efficient model with targeted pathway redesign along the three pillars of choice, training and home support, using defined tools and strategies can overcome adoption barriers and improve patient experience & outcomes. We defined a high impact implementation model that required a) an environment of learning of a complex technology and b) a set of well defined program policies, innovative tools and pathway redesign strategies implemented in three steps of training, choice and support. The initiative led by the applicant was fully supported and enabled by the Clinical Director and management team and involved a number of steps of change. Our approach was that anyone who is motivated, willing to learn, wishes to be independent and has suitable living accommodation would be suitable for home haemodialysis. The objectives were to a) overcome adoption barriers and enable independent dialysis for all those who might benefit b) define a cost effective model of dialysis service delivery that combined clinical success & cost-effectiveness with a potential for wider NHS adoption.

Reasons for implementing your project

Despite technical improvements, patient outcomes on hospital haemodialysis remain poor with respect to quality of life (QoL), morbidity and mortality. Adjusted mortality on conventional dialysis is worse than most cancers with 5 year survival less than 50%. Current treatment is expensive with poor QoL (job loss, in-centre visits 3 days per week, dietary/fluid restriction & constant tiredness). The benefits of Frequent Haemodialysis, ideally performed at home, were clear and now shown in many clinical studies (14). Despite the guidance in 2002, the prevalence of HHD had not changed and UK Renal Registry report 2008 showed no change in overall prevalence in this modality in renal units since 2002. (7) With a rising incidence of Chronic kidney disease in the region, there was unmet need for dialysis provision in Manchester in 2004. Most home dialysis programs in the UK offering home haemodialysis had failed to sustain in the 1990s. Manchester's historical Home dialysis program in the 1970s and 80s saw a rapid fall in patient numbers at home, with a hospital closure in 2000. By 2004, PD program had steadily diminished in size although still substantial (140pts), but only 11 patients were on HHD. The Greater Manchester Renal Network (East Sector) serves a population density of 1.5 million with a multicultural, multiethnic population base. These provided new challenges to introducing self care HHD as cultural, social and educational background are potentially significant barriers to self learning. The Home HD prevalence in the North West had varied between 0-5% of all dialysis patients. (10) The emerging data on the inadequacies of standard hospital dialysis, the NICE recommendations & Renal NSF I advocating greater patient choice provided the impetus to a committed clinical team to embark on a more innovative approach to dialysis provision, the NICE way.

How did you implement the project

Step 1. Haemodialysis Training Centre: Aim: To provide an environment conducive to learning for a complex technology through the following changes: - Existing funded HD stations, reconfigured into a training centre, hence patients could learn how to self care whilst on conventional dialysis. - Modular Accelerated HHD learning program Level 1-5 was designed in-house & implemented over 6 months, to improve communication, track progress and accelerate training time. A fast-track training pathway for appropriate learners, new cannulation strategies and tools to measure learning reduced training time. - A novel 2-station 'Step-down'shift allowed fully trained patients to undergo a short period of independent dialysis in-centre without staff- to boost confidence enabling wider choice. - A home installation design template adapted to suit home circumstances. Step 2 Choice strategy. A unique education strategy set up at an early phase of the project, facilitated the dialysis decision-making process. Step 3: Community Support. At home flexible schedules were prescribed with 12 different regimens employed based on patient preferences. The frequency and schedule contributed to better outcomes. As growing numbers of patients were predicted an emergency telephone helpline for 24/7 technical, medical and nursing support was established. Step 4 Technology / Business model. We adopted a technique of self-cannulation (Button-hole technique) which is less painful, easier to learn and preserves vascular access. This allowed fast-track training, and alleviated needle-phobia concerns in many subjects. Additional strategies of needle securement were put in place to allow dialysis at home whilst asleep. A cost-per-therapy approach with machine lease and renewal every 5yrs avoided large capital expenditure. The service delivery model was achieved through investment in a team of existing committed staff that believed in the therapy and inspired patient confidence.

Key findings

A sustainable model of Home HD provision has resulted in the largest centre of HHD in UK and Europe. The program has had phenomenal success with baseline provision in Manchester (3% in 2004) having risen to 15.7% of all dialysis patients (7 fold greater than the national average of 2% ) who have chosen independent haemodialysis to be established at home to achieve NICE threshold (Fig1,2). The training centre has trained 181 patients with 4%failure rate, of all ages (21-78y) and social backgrounds (33% female, 11% ethnic minority). Flexibility of home schedules underpins the model (18% Nocturnal, 40%alternate day, 26% daily, 16% standard). The service has delivered safe (No water quality failures, bacteremia or needle disconnect, 8 episodes) and superior outcomes (Table1,2, Fig5). The modality has low technique failure (8.3 %) with minimal HD disruption. Impressive reduction in carbon foot print with at least 45084 hrs travel time (0.5 hr per travel) avoided in 5yr period (1878 days equivalent). The model has added dialysis capacity with substantial cost avoidance approx £ 0.66-0.96 million per year (Overall benefit worth approx £5m Table3). The implementation model shows sustainability and is predicted to increase further in size in the next 5 yrs. This has resulted in greater patient choice for independent HD for all those who might benefit, resulting in improved patient experience and superior clinical outcomes including survival when compared to conventional hospital HD. The model has resulted in significant cost avoidance (depending on cost type (Table 3) see Appendix for results . Fig 1 Percentage of Home HD prevalence of all dialysis since 2004. Fig 2 UK Registry data. Fig 3 Model Patient pathway. Fig 4 Predialysis update. Fig 5 Overall survival in Home HD program. Fig 6 Helpline support data. Table 1 Clinical performance A. Table 2 Clinical performance B. Table 3 Projected costs and savings per pt year by modality. Table 4 Patient quotes.

Key learning points

Despite its evidence on clinical superiority, patient acceptance and cost effectiveness, Home Haemodialysis, has an extremely low UK prevalence (1-2%). An innovative approach to redesign existing dialysis provision to incorporate training, learning and promotion of self-confidence has allowed 15.7% dialysis patients in Manchester, the option to perform haemodialysis independently at home, fitting it around their lifestyle. Providing a safe and superior dialytic therapy, this treatment model has offered improved health & longevity with fewer medications and substantial reduction in hospital visits, empowering patients with greater involvement, freedom and flexibility. The Manchester program is the leading home haemodialysis centre in UK & Europe achieving the threshold & NICE recommendations. The current business model demonstrate that this year our HHD program will allow 40% cost benefit compared to hospital HD and 46% cost benefit for satellite dialysis units per patient on treatment at home each year. A prevalence of 70 patients at home offers significant cost avoidance in 2011 alone. This is line with the QIPP agenda for Renal Services.(11) The Manchester model has demonstrated sustained growth and potential for dissemination in the UK. It has been enabled by combining existing resources with innovative tools and strategies for a fundamental transformation of service delivery that is cost effective and results in improved clinical outcomes.

Contact details

Sandip Mitra
Consultant Renal Physician
Manchester Royal Infirmary, Central Manchester Foundation Trust

Secondary care
Is the example industry-sponsored in any way?