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