NICE 透析费用指南2011

Costing report Kidney disease: peritoneal dialysis Implementing NICE guidance NICE clinical guideline 125 July 2011 National costing report: Kidney disease – peritoneal dialysis (July 2011) page 2 of 23 This costing report accompanies the clinical guideline: ‘Kidney disease: peritoneal dialysis in the treatment of stage 5 chronic kidney disease’ (available online at www.nice.org.uk/guidance/CG125). Issue date: July 2011 This guidance is written in the following context This report represents the view of the Institute, which was arrived at after careful consideration of the available data and through consulting healthcare professionals. It should be read in conjunction with the NICE guideline. The report and templates are implementation tools and focus on those areas that were considered to have significant impact on resource utilisation. The cost and activity assessments in the reports are estimates based on a number of assumptions. They provide an indication of the likely impact of the principal recommendations and are not absolute figures. Assumptions used in the report are based on assessment of the national average. Local practice may be different from this, and the template can be amended to reflect local practice to estimate local impact. National Institute for Health and Clinical Excellence MidCity Place 71 High Holborn London WC1V 6NA www.nice.org.uk © National Institute for Health and Clinical Excellence, July 2011. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of the Institute. National costing report: Kidney disease – peritoneal dialysis (July 2011) page 3 of 23 Contents Executive summary .......................................................................................... 4  Supporting implementation ...................................................................... 4  Significant resource-impact recommendations ........................................ 4  Total cost impact ..................................................................................... 4  Benefits and savings ............................................................................... 5  Local costing template ............................................................................. 6  1  Introduction .............................................................................................. 7  1.1  Supporting implementation ........................................................... 7  1.2  What is the aim of this report? ...................................................... 7  1.3  Epidemiology of dialysis ............................................................... 8  1.4  Models of care .............................................................................. 8  2  Costing methodology ............................................................................... 9  2.1  Process ........................................................................................ 9  2.2  Scope of the cost-impact analysis .............................................. 10  2.3  Basis of unit costs ...................................................................... 11  3  Cost of significant resource-impact recommendation ............................ 11  4  Sensitivity analysis ................................................................................ 17  4.1  Methodology ............................................................................... 17  4.2  Impact of sensitivity analysis on costs ........................................ 18  5  Impact of guidance for commissioners .................................................. 18  6  Conclusion ............................................................................................. 19  6.1  Total national cost for England ................................................... 19  6.2  Next steps .................................................................................. 20  Appendix A. Approach to costing guidelines .................................................. 21  Appendix B. Results of sensitivity analysis .................................................... 22  Appendix C. References ................................................................................ 23  National costing report: Kidney disease – peritoneal dialysis (July 2011) page 4 of 23 Executive summary This costing report looks at the resource impact of implementing the NICE guideline ‘Kidney disease: peritoneal dialysis in the treatment of stage 5 chronic kidney disease’ in England. The costing method adopted is outlined in appendix A; it uses the most accurate data available, was produced in conjunction with key clinicians, and reviewed by clinical and financial professionals. Supporting implementation The NICE clinical guideline on peritoneal dialysis is supported by a range of implementation tools available on our website www.nice.org.uk/guidance/CG125 and detailed in the main body of this report. Significant resource-impact recommendations This report focuses on the recommendation that is considered to have the greatest resource impact and that will therefore require the most additional resources to implement or can potentially generate savings. This is:  Consider peritoneal dialysis as the first choice of treatment modality for adults without significant associated comorbidities. Total cost impact The annual changes in revenue costs arising from fully implementing the guideline are summarised in the table below. National costing report: Kidney disease – peritoneal dialysis (July 2011) page 5 of 23 Recurrent annual saving at optimal uptake Current Proposed Change Unit cost Numbers of patients Cost (£000) Numbers of patients Cost (£000s) Numbers of patients Cost (£000s) Home HD 53,367 973 51,944 973 51,944 – – Hospital HD 22,916 16,060 368,036 11,378 260,738 -4682 -107,298 Satellite HD 22,916 17,236 394,988 12,211 279,832 -5025 -115,156 CAPD 17,411 3326 57,902 8494 147,897 5169 89,995 APD 21,071 2920 61,528 7458 157,159 4538 95,631 Totals 40,515 934,398 40,515 897,571 – -36,827 Abbreviations: APD, automated peritoneal dialysis; CAPD, continuous ambulatory peritoneal dialysis; HD, haemodialysis. This is an estimate of the recurrent annual cost after uptake of peritoneal dialysis has reached the optimal level, that is, when the population on dialysis consists entirely of people who have been offered peritoneal dialysis as a first choice where appropriate. It is estimated that it could take approximately 20 years to reach optimal uptake. As NHS organisations budget for the next 3–5 years, we have also estimated the savings that could be realised after 5 years with a conservative increase in the number of people on peritoneal dialysis of 1% each year. Increased uptake of peritoneal dialysis may be delayed initially if additional staff training is needed to enable patients to be supported in carrying out peritoneal dialysis. National costing report: Kidney disease – peritoneal dialysis (July 2011) page 6 of 23 Potential annual saving after 5 years Current Proposed Change Unit cost Numbers of patients Cost (£000) Numbers of patients Cost (£000s) Numbers of patients Cost (£000s) Home HD 53,367 973 51,944 973 51,944 – – Hospital HD 22,916 16,060 368,036 15,083 345,644 -977 -22,391 Satellite HD 22,916 17,236 394,988 16,188 370,957 -1049 -24,031 CAPD 17,411 3326 57,902 4404 76,683 1079 18,781 APD 21,071 2920 61,528 3867 81,485 947 19,957 Totals 40,515 934,398 40,515 926,713 – -7,685 Abbreviations: APD, automated peritoneal dialysis; CAPD, continuous ambulatory peritoneal dialysis; HD, haemodialysis. Benefits and savings Implementing the clinical guideline will bring the following benefits:  Being on dialysis has a substantial effect on patient’s lives. Offering peritoneal dialysis, if it is suitable, gives patients more choice and flexibility.  Implementing the guideline may increase the number of adults starting on peritoneal dialysis each year. If more patients start on peritoneal dialysis this will result in savings. The level of savings will depend on the number of patients who start on peritoneal dialysis.  If the number of adults on peritoneal dialysis in England increases from current levels of approximately 15% (Renal Registry 2010) to the optimal level of 39% (NHS Kidney Care 2009 and expert clinical opinion), there may be annual savings of approximately £37 million nationally. Local costing template The costing template produced to support this guideline enables organisations in England, Wales and Northern Ireland to estimate the impact locally and replace variables with ones that depict the current local position. A sample calculation using this template showed that additional savings of £72,000 could be made for a population of 100,000. National costing report: Kidney disease – peritoneal dialysis (July 2011) page 7 of 23 1 Introduction 1.1 Supporting implementation 1.1.1 The NICE clinical guideline on peritoneal dialysis for people with stage 5 chronic kidney disease is supported by the following implementation tools available on our website www.nice.org.uk/guidance/CG125:  costing tools  a national costing report; this document  a local costing template; a simple spreadsheet that can be used to estimate the local cost of implementation.  baseline assessment tool; assess your baseline against the recommendations in the guidance to prioritise implementation activity, including clinical audit  podcasts; an expert view on implementing the guidance  clinical case scenarios; example cases designed to improve and assess users’ knowledge of the guidance. 1.1.2 A practical guide to implementation, ‘How to put NICE guidance into practice: a guide to implementation for organisations’, is also available to download from the NICE website. It includes advice on establishing organisational level implementation processes as well as detailed steps for people working to implement different types of guidance on the ground. 1.2 What is the aim of this report? 1.2.1 This report provides estimates of the national cost impact arising from implementing guidance on peritoneal dialysis in England. These estimates are based on assumptions about current practice and predictions of how current practice might change following implementation. National costing report: Kidney disease – peritoneal dialysis (July 2011) page 8 of 23 1.2.2 This report aims to help organisations plan for the financial implications of implementing NICE guidance. 1.2.3 This report does not reproduce the NICE guideline on peritoneal dialysis and should be read in conjunction with it (see www.nice.org.uk/guidance/CG125). 1.2.4 The costing template that accompanies this report is designed to help those assessing the resource impact at a local level in England, Wales or Northern Ireland. The costing template may help inform local action plans demonstrating how implementation of the guideline will be achieved. 1.3 Epidemiology of stage 5 chronic kidney disease 1.3.1 In the UK, 400–800 per million of the population at any one time need renal replacement in the form of dialysis. The prevalence of dialysis in the UK is highly age dependent – for people aged 70–80 years it is between 1600 and 2000 people per million. 1.3.2 More than 2% of the NHS budget is spent on renal replacement therapy (dialysis and transplants) for people with established renal failure. 1.4 Models of care 1.4.1 Two main types of dialysis are available, haemodialysis and peritoneal dialysis. The main factors that determine what type of dialysis people choose are lifestyle preferences and feasibility. Factors to take into account include whether the person would prefer to have treatment at home; whether treatment can be delivered at home (not all areas offer home-based options and not all homes are suitable or can be converted to support home dialysis); access for dialysis; travelling distance to the dialysis centre and availability of places in the centre. National costing report: Kidney disease – peritoneal dialysis (July 2011) page 9 of 23 1.4.2 Peritoneal dialysis is administered by the patient, or helper, at home, either overnight while they are asleep (automated peritoneal dialysis [APD] and assisted automated peritoneal dialysis [aAPD]) or continuously (continuous ambulatory peritoneal dialysis [CAPD]). 1.4.3 Haemodialysis is usually administered in a hospital or satellite unit and takes about 4 hours (perhaps more), three times a week. In some cases, haemodialysis is administered at home. 1.4.4 The proportion of people with chronic kidney disease (CKD) starting treatment on home- or hospital-based dialysis, and peritoneal or haemodialysis treatment, varies considerably. The proportion of people with chronic kidney disease using in-centre haemodialysis ranges from 60–100%. It is likely that this variability represents variation in local practice, resources, and in particular the development of aAPD and home haemodialysis programmes. 1.4.5 There is currently no national guidance in England and Wales on supporting people in making informed decisions about renal replacement therapy. 2 Costing methodology 2.1 Process 2.1.1 We use a structured approach for costing clinical guidelines (see appendix A). 2.1.2 We had to make assumptions in the costing model. We developed these assumptions and tested them for reasonableness with members of the Guideline Development Group (GDG) and key clinical practitioners in the NHS. 2.1.3 Because it is estimated that it may take 20 years to reach optimal uptake and the NHS budgets for the next 3–5 years, the costing template estimates both the potential national savings on full implementation and the potential savings after 5 years if the National costing report: Kidney disease – peritoneal dialysis (July 2011) page 10 of 23 number of people on peritoneal dialysis were to increase by 1% each year. 2.2 Scope of the cost-impact analysis 2.2.1 The guideline offers best practice advice on the care of people with a diagnosis of stage 5 chronic kidney disease who need or who are receiving renal replacement therapy (specifically peritoneal dialysis). 2.2.2 The guidance does not cover people who need or are receiving renal replacement therapy for conditions other than stage 5 chronic kidney disease. Therefore, these issues are outside the scope of the costing work. 2.2.3 We worked with the GDG and other professionals to identify the recommendations that would have the most significant resource impact (see table 1). Costing work has focused on these recommendations. Table 1 Recommendations with a significant resource impact High-cost recommendation Recommendation number Offer all people with stage 5 chronic kidney disease a choice of peritoneal dialysis or haemodialysis, if appropriate, but consider peritoneal dialysis as the first choice of treatment modality for:  children 2 years old or younger  people with residual renal function  adults without significant associated comorbidities. 1.1.9 2.2.4 We have limited the consideration of costs and savings to direct costs to the NHS that will arise from implementation. We have not included consequences for the individual, the private sector or the not-for-profit sector. Where applicable, any realisable cost savings arising from a change in practice have been offset against the cost of implementing the change. National costing report: Kidney disease – peritoneal dialysis (July 2011) page 11 of 23 2.3 Basis of unit costs 2.3.1 The way the NHS is funded has undergone reform with the introduction of ‘Payment by results’, based on a national tariff. The national tariff will be applied to all activity for which Healthcare Resource Groups (HRGs) or other appropriate case-mix measures are available. If a national tariff price or indicative price exists for an activity this has been used as the unit cost; this has then been inflated by the national average market forces factor. 2.3.2 Using these prices ensures that the costs in the report are the cost to the primary care trust (PCT) of commissioning predicted changes in activity at the tariff price, but may not represent the actual cost to individual trusts of delivering the activity. 2.3.3 For new or developing services, for which there is no national average unit cost, organisations already undertaking this activity have been asked their current unit cost. 3 Cost of significant resource-impact recommendation Recommendation Offer all people with stage 5 chronic kidney disease a choice of peritoneal dialysis or haemodialysis, if appropriate, but consider peritoneal dialysis as the first choice of treatment modality for:  children 2 years old or younger  people with residual renal function  adults without significant associated comorbidities. Background 3.1.1 The previously strong presence of peritoneal dialysis in the UK has fallen in the last decade (first modality peritoneal dialysis reduced from 40% to 21%). There is wide variation around the country both National costing report: Kidney disease – peritoneal dialysis (July 2011) page 12 of 23 in the number of patients on peritoneal dialysis and in the types of dialysis available. It has been shown that 50% of patients given free choice will choose peritoneal dialysis, but the percentage on peritoneal dialysis at 90 days ranges from 0–60% (NHS Kidney Care 2009). 3.1.2 Implementation of the recommendation to consider peritoneal dialysis as a first choice for new patients, if it is appropriate, may result in an increase in the number of new dialysis patients starting on peritoneal dialysis each year. Because peritoneal dialysis is estimated to be less expensive than haemodialysis this is likely to result in savings. Assumptions made 3.1.3 It is assumed that peritoneal dialysis is already well established as an option for children, so calculations focus on adults older than 18 years. 3.1.4 The number of people currently on renal dialysis in England is estimated to be 0.0791% using the adult acceptance rate for 2009 (Renal Registry 2010). 3.1.5 The percentage of patients on each modality is also given for each renal centre. The current number of dialysis patients on peritoneal dialysis in England is estimated to be approximately 15%. According to expert opinion, 10–15% of people will not be suitable for peritoneal dialysis. A mid-point of 12.5% has been used. 3.1.6 NHS Kidney Care (2009) suggests that given informed choice, 50% of new patients (for whom peritoneal dialysis is suitable) would opt for peritoneal dialysis. 3.1.7 Some patients who choose peritoneal dialysis will have to move on to haemodialysis after the procedure to create access fails. In addition to the patients who are unable to start on peritoneal dialysis due to