1. Enhancing the effectiveness of health care for Ontarians through research CONFIDENTIAL - NOT FOR DISTRIBUTION Predicting the Growth in Dialysis Services in Ontario, Canada 2007-2011 Rob Quinn MD FRCPC Clinical Associate Sunnybrook Health Sciences Centre CIHR Institute for Health Services & Policy Research (IHSPR) Fellow & PhD Candidate Department of Health Policy, Management & Evaluation, University of Toronto December 13, 2007 Rob Quinn MD FRCPC Clinical Associate Sunnybrook Health Sciences Centre CIHR Institute for Health Services & Policy Research (IHSPR) Fellow & PhD Candidate Department of Health Policy, Management & Evaluation, University of Toronto December 13, 2007

2. Enhancing the effectiveness of health care for Ontarians through research 2 Outline of Presentation Background (Renal 101) Data Sources & Terminology Brief Overview of Statistical Methods “The First 90 Days” Provincial Results Making Sense of Data at the LHIN Level Interpretive Cautions Conclusions Background (Renal 101) Data Sources & Terminology Brief Overview of Statistical Methods “The First 90 Days” Provincial Results Making Sense of Data at the LHIN Level Interpretive Cautions Conclusions

3. Enhancing the effectiveness of health care for Ontarians through research 3 How People with Kidney Failure Present 1.Slowly progressive chronic kidney disease  Often followed in predialysis clinics  Usually start as outpatients 2.Acute kidney injury requiring dialysis  Develop kidney failure after acute illness  Hospitalized; high resource utilization; high mortality rate; high rate of recovery 3.Acute kidney injury in setting of chronic kidney disease  Precipitous decline in kidney function due to acute illness  Usually hospitalized; intermediate mortality & likelihood of recovery 1.Slowly progressive chronic kidney disease  Often followed in predialysis clinics  Usually start as outpatients 2.Acute kidney injury requiring dialysis  Develop kidney failure after acute illness  Hospitalized; high resource utilization; high mortality rate; high rate of recovery 3.Acute kidney injury in setting of chronic kidney disease  Precipitous decline in kidney function due to acute illness  Usually hospitalized; intermediate mortality & likelihood of recovery

4. Enhancing the effectiveness of health care for Ontarians through research 4 Treatment Considerations Transplantation  Preferred therapy (cheapest; best outcomes)  Limited supply of organs Hemodialysis (HD)  Highest annual operating costs  Performed in outpatient units (capital investment) Peritoneal Dialysis (PD)  Lower annual operating costs vs. HD  Capital costs minimal  Home therapy Transplantation  Preferred therapy (cheapest; best outcomes)  Limited supply of organs Hemodialysis (HD)  Highest annual operating costs  Performed in outpatient units (capital investment) Peritoneal Dialysis (PD)  Lower annual operating costs vs. HD  Capital costs minimal  Home therapy

5. Enhancing the effectiveness of health care for Ontarians through research *Canadian Institute for Health Information, CORR Annual Report, 20065 Treatment of Kidney Failure in Canada 31,000 patients required renal replacement therapy (RRT) in Canada by end of 2004*  49% treated with Hemodialysis (HD)  39% alive with a Functioning Transplant  12% treated with Peritoneal Dialysis (PD) 31,000 patients required renal replacement therapy (RRT) in Canada by end of 2004*  49% treated with Hemodialysis (HD)  39% alive with a Functioning Transplant  12% treated with Peritoneal Dialysis (PD)

6. Enhancing the effectiveness of health care for Ontarians through research *United States Renal Data System, Annual Report, 20066 The Cost of Caring for Patients Caring for patients with kidney failure is resource intensive*  0.7% of Medicare population  Consume 5% of annual Medicare budget Population of patients with kidney failure continues to grow Projections of the need for dialysis services required to plan for need for equipment, facilities, personnel Caring for patients with kidney failure is resource intensive*  0.7% of Medicare population  Consume 5% of annual Medicare budget Population of patients with kidney failure continues to grow Projections of the need for dialysis services required to plan for need for equipment, facilities, personnel

7. Enhancing the effectiveness of health care for Ontarians through research 7 Limitations of Existing Literature Only included “chronic dialysis patients”  Based on registry data and do not capture all patients (“90-day rule”)  Often ignore patients with a history of transient dialysis treatment or prior transplant  Ignores the impact of patients with acute kidney injury requiring dialysis Only included “chronic dialysis patients”  Based on registry data and do not capture all patients (“90-day rule”)  Often ignore patients with a history of transient dialysis treatment or prior transplant  Ignores the impact of patients with acute kidney injury requiring dialysis

8. Enhancing the effectiveness of health care for Ontarians through research 8 Objectives 1.Identify all patients who received dialysis treatment in the province between July 1, 1998 and December 31, 2005 2.Describe the disposition of this cohort 90 days following the initiation of therapy 3.Use time series analysis to model historical data and make projections about the need for dialysis services in the province 4.To determine the proportion of dialysis activity that was attributable to hospitalized patients with acute renal failure to quantify the potential impact of this group on resource utilization 1.Identify all patients who received dialysis treatment in the province between July 1, 1998 and December 31, 2005 2.Describe the disposition of this cohort 90 days following the initiation of therapy 3.Use time series analysis to model historical data and make projections about the need for dialysis services in the province 4.To determine the proportion of dialysis activity that was attributable to hospitalized patients with acute renal failure to quantify the potential impact of this group on resource utilization

9. Enhancing the effectiveness of health care for Ontarians through research 9 Data Sources Registered Persons Database (RPDB) Ontario Health Insurance Plan (OHIP) physician billing claims Ontario Diabetes Database (ODD) Canadian Institute for Health Information (CIHI) – Discharge Abstracts Database (DAD) Registered Persons Database (RPDB) Ontario Health Insurance Plan (OHIP) physician billing claims Ontario Diabetes Database (ODD) Canadian Institute for Health Information (CIHI) – Discharge Abstracts Database (DAD)

10. Enhancing the effectiveness of health care for Ontarians through research 10 Data Sources Administrative Health Data  Collected for purposes other than research  Already exists; no further expense to collect  Allows access to information for entire province; can highlight regional differences  Often use surrogate measures for variables of interest  Validation required  Time delays Administrative Health Data  Collected for purposes other than research  Already exists; no further expense to collect  Allows access to information for entire province; can highlight regional differences  Often use surrogate measures for variables of interest  Validation required  Time delays

11. Enhancing the effectiveness of health care for Ontarians through research 11 Data Sources LHIN 10 (South East)  Alternative funding arrangement  Primary clinical data provided on prevalent outpatient HD and PD patients  Billing data looks reliable by July/Sept 2005  Assumed rate of dialysis in Kingston had a constant relationship with the provincial rate  Generated expected values of variables for time period of interest in order to make forecasts LHIN 10 (South East)  Alternative funding arrangement  Primary clinical data provided on prevalent outpatient HD and PD patients  Billing data looks reliable by July/Sept 2005  Assumed rate of dialysis in Kingston had a constant relationship with the provincial rate  Generated expected values of variables for time period of interest in order to make forecasts

12. Enhancing the effectiveness of health care for Ontarians through research 12 Terminology “Incident Dialysis Patients” All NEW dialysis patients during the time period of interest “Incident Dialysis Patients” All NEW dialysis patients during the time period of interest

13. Enhancing the effectiveness of health care for Ontarians through research 13 Terminology “Prevalent Patients” ALL PATIENTS that you are providing dialysis therapy to at a given point in time “Prevalent Patients” ALL PATIENTS that you are providing dialysis therapy to at a given point in time

14. Enhancing the effectiveness of health care for Ontarians through research 14 Terminology “Prevalent Outpatients”  Prevalent Outpatients – HD  Prevalent Outpatients – PD Patients that are the responsibility of the outpatient dialysis units You need a “spot” for them “Prevalent Outpatients”  Prevalent Outpatients – HD  Prevalent Outpatients – PD Patients that are the responsibility of the outpatient dialysis units You need a “spot” for them

15. Enhancing the effectiveness of health care for Ontarians through research 15 Statistical Analysis All patients who received at least 1 dialysis treatment followed for 90 days We then described:  Distribution of initial treatment modalities  Proportion of patients starting in hospital  Proportion of patients requiring outpatient treatment  Disposition 90 days after starting dialysis All patients who received at least 1 dialysis treatment followed for 90 days We then described:  Distribution of initial treatment modalities  Proportion of patients starting in hospital  Proportion of patients requiring outpatient treatment  Disposition 90 days after starting dialysis

16. Enhancing the effectiveness of health care for Ontarians through research 16 Statistical Analysis The number of patients requiring treatment was determined at regularly spaced, 3- month intervals  Total number of incident dialysis patients  Total number of prevalent patients  Total number of prevalent outpatients  Total number of prevalent outpatient HD  Total number of prevalent outpatient PD The number of patients requiring treatment was determined at regularly spaced, 3- month intervals  Total number of incident dialysis patients  Total number of prevalent patients  Total number of prevalent outpatients  Total number of prevalent outpatient HD  Total number of prevalent outpatient PD

17. Enhancing the effectiveness of health care for Ontarians through research 17 Statistical Analysis Time series techniques were used to model the historical incidence and prevalence counts 4 different Time Series models constructed for each variable in SAS and examined for “fit”  Autoregressive Integrated Moving Average (ARIMA)  Stepwise Autoregressive  Exponential Smoothing  Winter’s Method (seasonality) Models then used to forecast to 2011 Time series techniques were used to model the historical incidence and prevalence counts 4 different Time Series models constructed for each variable in SAS and examined for “fit”  Autoregressive Integrated Moving Average (ARIMA)  Stepwise Autoregressive  Exponential Smoothing  Winter’s Method (seasonality) Models then used to forecast to 2011

18. Enhancing the effectiveness of health care for Ontarians through research 18 Validity of Results No gold standard to compare against Compared projections from previous report to observed data External validation  Compared data to most recent CORR report No gold standard to compare against Compared projections from previous report to observed data External validation  Compared data to most recent CORR report

19. Enhancing the effectiveness of health care for Ontarians through research 19 RESULTS “The First 90 Days”

20. Enhancing the effectiveness of health care for Ontarians through research 20 Initial Form of Dialysis Treatment Based on data from 31,679 patients Hemodialysis 73% Peritoneal Dialysis 12% Continuous Dialysis (CRRT) 15%

21. Enhancing the effectiveness of health care for Ontarians through research 21 The First 90 Days of Dialysis 62% of all new patients start dialysis in hospital  27% die prior to discharge 63% of all new patients will go on to require treatment in an outpatient dialysis facility 62% of all new patients start dialysis in hospital  27% die prior to discharge 63% of all new patients will go on to require treatment in an outpatient dialysis facility

22. Enhancing the effectiveness of health care for Ontarians through research 22 Status at 90 Days Dead 23% Recovered 25% Alive on Dialysis 52%

23. Enhancing the effectiveness of health care for Ontarians through research Impact of Acute Kidney Injury Makes up ~60% of new patients Capture 48% of new patients if wait until 90 days to start counting people Only accounts for 3% of the prevalent population at any point in time  Disproportionate resource utilization  Divert resources from chronic population Makes up ~60% of new patients Capture 48% of new patients if wait until 90 days to start counting people Only accounts for 3% of the prevalent population at any point in time  Disproportionate resource utilization  Divert resources from chronic population

24. Enhancing the effectiveness of health care for Ontarians through research 24 RESULTS Provincial Data: Incidence, Prevalence, and Modality Distribution

25. Enhancing the effectiveness of health care for Ontarians through research 25 The number of patients being treated with dialysis at any point in time is very predictable and is growing in a linear fashion Projected to grow to 11,104 patients by 2011 Confidence intervals (10,931-11,277) or +/- 1.6%

26. Enhancing the effectiveness of health care for Ontarians through research 26 Projections of prevalent dialysis patients provided by quarter DateForecastLower LimitUpper Limit 01/10/2005851684058628 01/01/2006866685448789 01/04/2006879486688919 01/07/2006890287749030 01/10/2006902488959153 01/01/2007917790469308 01/04/2007931991879451 01/07/2007943693029570 01/10/2007953593999670 01/01/2008965295109793 01/04/2008976296159909 01/07/20089877972610027 01/10/200810000984810153 01/01/200910124996910278 01/04/2009102361007910392 01/07/2009103461018810505 01/10/2009104651030510625 01/01/2010105941043210756 01/04/2010107211055710886 01/07/2010108511068311018 01/10/2010109791080911149 01/01/2011111041093111277

27. Enhancing the effectiveness of health care for Ontarians through research 27 The number of prevalent outpatients being treated with dialysis at any point in time is also very predictable and is growing in a linear fashion Projected to grow to 10,796 patients by 2011 Confidence intervals (10,655 – 10,938) or +/- 1.3%

28. Enhancing the effectiveness of health care for Ontarians through research 28 Majority of prevalent patients are on HD so curve resembles that of “all prevalent patients” and “prevalent outpatients” Projected to grow to 9,157 patients by 2011 (85% prevalent outpatients) Confidence intervals (8,999 – 9,316) or +/- 1.7%

29. Enhancing the effectiveness of health care for Ontarians through research 29 PD growth not as predictable, but still allows confident forecasts Projected to grow to 1,629 patients by 2011 (15% of prevalent outpatients) Confidence intervals (1,532 – 1,726) or +/- 5.6%

30. Enhancing the effectiveness of health care for Ontarians through research 30 Incidence counts are more variable, but demonstrate clear trend Projected to grow to 1,605 patients per quarter by 2011 Confidence intervals (1,415 – 1,795) or +/- 11.8%

31. Enhancing the effectiveness of health care for Ontarians through research 31 Proportion of Prevalent Outpatients Treated with PD vs. HD by Year

32. Enhancing the effectiveness of health care for Ontarians through research 32 Provincial Data – Summary Historical, average annual growth rates  Incidence 4.9%  Prevalence 7.2% 4,000 new patients will require outpatient dialysis each year by 2010 Nearly 11,000 prevalent outpatients will require treatment by 2011 (85% HD) Able to make confident forecasts at a provincial level for all variables Historical, average annual growth rates  Incidence 4.9%  Prevalence 7.2% 4,000 new patients will require outpatient dialysis each year by 2010 Nearly 11,000 prevalent outpatients will require treatment by 2011 (85% HD) Able to make confident forecasts at a provincial level for all variables

33. Enhancing the effectiveness of health care for Ontarians through research 33 Accuracy of Projections Forecast of total prevalent dialysis patients in the province on Jan 1, 2005:  Forecasted value (Previous Report): 8,100  Actual value: 8,063  Difference = 37 patients (0.5% absolute error) Short-term projections very accurate Forecast of total prevalent dialysis patients in the province on Jan 1, 2005:  Forecasted value (Previous Report): 8,100  Actual value: 8,063  Difference = 37 patients (0.5% absolute error) Short-term projections very accurate

34. Enhancing the effectiveness of health care for Ontarians through research 34 Consistency of Projections Change in forecast of total prevalent dialysis patients in province Jan 1, 2010:  Forecasted value (Last report): 10,605  Forecasted value (2007 report): 10,594  Difference = 11 patients (0.1%) Additional year of data has not changed forecasts out to 2010 to any significant degree Change in forecast of total prevalent dialysis patients in province Jan 1, 2010:  Forecasted value (Last report): 10,605  Forecasted value (2007 report): 10,594  Difference = 11 patients (0.1%) Additional year of data has not changed forecasts out to 2010 to any significant degree

35. Enhancing the effectiveness of health care for Ontarians through research 35 LHIN Forecasts From a planning perspective, Need to know total number of prevalent patients to understand resources required to treat them (total prevalent patients) “At any given time, how many dialysis patients am I treating?” From a planning perspective, Need to know total number of prevalent patients to understand resources required to treat them (total prevalent patients) “At any given time, how many dialysis patients am I treating?”

36. Enhancing the effectiveness of health care for Ontarians through research 36 LHIN Forecasts From a planning perspective, Need to know total number of prevalent patients who are “property” of the outpatient units (total prevalent outpatients) “How many patients are my outpatient units responsible for, and how many spots do I need to have?” From a planning perspective, Need to know total number of prevalent patients who are “property” of the outpatient units (total prevalent outpatients) “How many patients are my outpatient units responsible for, and how many spots do I need to have?”

37. Enhancing the effectiveness of health care for Ontarians through research 37 LHIN Forecasts From a planning perspective, Need to know modality mix (PD vs. HD) in prevalent outpatients in order to plan new HD units (total prevalent outpatient HD, PD) “How many outpatient HD spots do I need?” From a planning perspective, Need to know modality mix (PD vs. HD) in prevalent outpatients in order to plan new HD units (total prevalent outpatient HD, PD) “How many outpatient HD spots do I need?”

38. Enhancing the effectiveness of health care for Ontarians through research 38 LHIN Data – Summary Confident in Predictions  Total prevalent patients, prevalent outpatients  Total prevalent outpatient HD Less Confident in Predictions  “SMALL NUMBERS IN SMALL LHINS”  Total prevalent PD patients  Incident patients Confident in Predictions  Total prevalent patients, prevalent outpatients  Total prevalent outpatient HD Less Confident in Predictions  “SMALL NUMBERS IN SMALL LHINS”  Total prevalent PD patients  Incident patients

39. Enhancing the effectiveness of health care for Ontarians through research 39

40. Enhancing the effectiveness of health care for Ontarians through research 40 Interpretive Cautions Identify individuals based on where they live, not necessarily where they seek dialysis treatment A number of patients treated at a given program may live outside current LHIN boundaries LHIN-specific numbers may not reflect practice of particular regional program Identify individuals based on where they live, not necessarily where they seek dialysis treatment A number of patients treated at a given program may live outside current LHIN boundaries LHIN-specific numbers may not reflect practice of particular regional program

41. Enhancing the effectiveness of health care for Ontarians through research 41 Interpretive Cautions HD patients include:  Short, Daily HD  Nocturnal HD  Home HD Prevalence of home-based HD therapies varies from region-to-region HD patients include:  Short, Daily HD  Nocturnal HD  Home HD Prevalence of home-based HD therapies varies from region-to-region

42. Enhancing the effectiveness of health care for Ontarians through research 42 Other Considerations Impact of a regional dialysis program on resource consumption beyond the provision of dialysis services  Personnel  Hospitalization  Invasive procedures (access-related complications) Interventional radiology & surgical support  Provision of home care services  Rehabilitation, long-term care, palliative services  Support for other services Oncology Cardiac Surgery Critical Care Impact of a regional dialysis program on resource consumption beyond the provision of dialysis services  Personnel  Hospitalization  Invasive procedures (access-related complications) Interventional radiology & surgical support  Provision of home care services  Rehabilitation, long-term care, palliative services  Support for other services Oncology Cardiac Surgery Critical Care

43. Enhancing the effectiveness of health care for Ontarians through research 43 Conclusions Growth in dialysis patients is considerable, but fairly predictable at a provincial level All incident patients (including acute renal failure) should be accounted for in the analysis Feasible to develop a plan for expansion that is long-term, transparent, & consistent Growth in dialysis patients is considerable, but fairly predictable at a provincial level All incident patients (including acute renal failure) should be accounted for in the analysis Feasible to develop a plan for expansion that is long-term, transparent, & consistent

44. Enhancing the effectiveness of health care for Ontarians through research 44 Conclusions Must consider need for personnel & other services to support regional programs Need to confirm accuracy of administrative data how it can be used most effectively in planning for provision of renal services Influence of alternative funding arrangements and the potential need for alternative sources of information Must consider need for personnel & other services to support regional programs Need to confirm accuracy of administrative data how it can be used most effectively in planning for provision of renal services Influence of alternative funding arrangements and the potential need for alternative sources of information

45. Enhancing the effectiveness of health care for Ontarians through research 45 Acknowledgements Rahim Moineddin (Statistician) Laurence Chong & Cindy Huo (Analysts) Michael Paterson Jan Hux Matthew Oliver Ginette Daigle Kingston Regional Dialysis Program Rahim Moineddin (Statistician) Laurence Chong & Cindy Huo (Analysts) Michael Paterson Jan Hux Matthew Oliver Ginette Daigle Kingston Regional Dialysis Program