1. Sandip Mitra Central Manchester University Hospitals Foundation Trust

2.  Worldwide surge in chronic kidney disease & ESRD  Expanding dialysis population, an evolving disease  Impressive and worrying mortality on dialysis  Poor quality of life 1998 - 2008 Patients pmp worldwide Dialysis ESRD

3. A Sound Alternative: Home Haemodialysis Cost Effectiveness Home Haemodialysis Better Patient Outcomes

4. What do they have in common? Toyota Production System

5. VALUE = QUALITY * ACCESS COST “the number of life years saved could be doubled if resources were reallocated to more cost-effective interventions”...

6. Pricing Human Life(-Years)

7. Home haemodialysis annual sessions based on 4x weekly therapy. Dialysis Cost Comparison NHS PbR for Kidney Dialysis Project Group Report June 2009

8. Cost - benefit league table [Cost/QALY] Treatment (£ Aug 1990) Cholesterol testing and diet therapy only (all adults aged 40-69) 220 Neurosurgical intervention for head injury 240 Advice to stop smoking from general practitioner 270 Neurosurgical intervention for subarachnoid haemorrhage 490 Antihypertensive treatment to prevent stroke (ages 45-64) 940 Pacemaker implantation 1 100 Hip replacement 1 180 Valve replacement for aortic stenosis 1 140 Cholesterol testing and treatment 1 480 Coronary artery bypass graft (left main vessel disease, severe angina) 2 090 Kidney transplant 4 710 Breast cancer screening 5 780 Heart transplantation 7 840 Cholesterol testing and treatment (incrementally) of all adults aged 25-39 14 150 Home haemodialysis 17 260 Coronary artery bypass graft (one vessel disease, moderate angina) 18 830 Continuous ambulatory peritoneal dialysis 19 870 Hospital haemodialysis 21 970 Erythropoietin treatment for anaemia in dialysis patients (assuming 10% reduction in mortality) 54 380 Neurosurgical intervention for malignant intracranial tumours 107 780 Erythropoietin treatment for anaemia in dialysis patients (assuming no increase in survival) 126 290 Dept of Health Economics Research, York

9. QALYs generated and costs accrued McFarlane PA et al. Kidney Int 2006; 69:798-805. GroupQALYsCost ($) Reference case (IHD)5.31543 602 Reference case (HNHD)5.79538 094 No transplantation (IHD)2.78370 047 No transplantation (HNHD)3.25363 206 HNHD as initial modality (IHD)5.31543 602 HNHD as initial modality (HNHD)6.30534 484 Initial HNHD and no transplantation (IHD)5.48730 590 Initial HNHD with no transplantation (HNHD) 7.22692 658 HNHD=home nocturnal hemodialysis IHD=In-hospital dialysis

10. Manchester Home Business Model Staff – clinical lead (1 PA), training staff Flexible Training Centre Use of existing HD stations with adaptations Pro rata water and electricity rates Machine with basic interface, high reliability (F4008 home) Philosophy Cost per therapy package (Rx cost, machine lease cost, supplies) Cabin installation (£12000) funding routes Standard conversion charge (£3000 - £5000) Emergency helpline 24/7 In-House technical team Integrated Community support ( HHD 1:20patients) Social worker, Clinical Psychologist time Education and staff training package Dedicated clinic Carer support (Carer Grant)

11. An Environment for Learning

12. Training activity (2004-2010) Total patients 171 Age 53 yrs (range 22 – 73 yrs) Trained 140 Failed 8, Tx 3, Retrained 11, training 16 AVF : 85 % Diabetes 11 %

13. Home Haemodialysis Uptake Manchester, 12% of HD Patients = n Manchester Point prevalence

14. Improving standards Manchester Feb 2010

15. Set up Location at Home Home conversions cabin installation 10 % patients

16. Emergency Helpline 24/7 Phone calls (2009-2010) Total69 Clinical / Tech46 / 23 Weekend9 After 9 pm7 Mon18 Tue12 Wed11 Thurs9 Fri9

17. 17

18. Home HDHosp HDSavings /pt Total Cost (£) 6828489029-20745 Capital costs(£) 88867918969 Staff costs (£) 1473630033-15297 Cost per QALY 2.422.040.38 Cost per QALY - Home HD dominates 10 yr savings (50pts) > £ 1 million CEP 10063, 2010

19. Quadrants of Cost Effectiveness National Information Center on Health Services Research and Health Care Technology (NICHSR) Hosp HD

20. Different Types of Economic Analysis Home Haemodialysis : A Neglected Opportunity VALUE = QUALITY * ACCESS COST

21. Thank You