Vascular Access Audit Report 2012 UK Renal Registry and NHS Kidney Care. Kidney Care. Better Kidney Care for All

Transcription

1 Kidney Care Vascular Access Audit Report 2012 UK Renal Registry and NHS Kidney Care Dr Richard Fluck Mr David Pitcher Mrs Retha Steenkamp Better Kidney Care for All

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3 Contents Page 1 Foreword... 2 Acknowledgements... 3 Executive summary... 4 Introduction... 5 Methodology... 6 Background data... 7 Demographics Age and gender Social deprivation... 8 Referral times... 9 Access at dialysis Type of access at first dialysis Type of access after three months Comparison of access at first dialysis and after three months Determinants of access organisational factors Referral to a surgeon Referral times and access at first dialysis Deprivation and access at first dialysis Access in prevalent HD patients on 31/12/ Discussion Recommendations Data collection Access provision References... Appendix Data submission proforma... Appendix 2 Results reported by centres, by renal network CONTENTS 03

4 1. Foreword This is the second time that the kidney community in England has been asked about the types of vascular access used by patients receiving haemodialysis. There is clearly still work to do, but it is evidence of just how committed kidney units are to their patients vascular access that so many centres have responded again this time. The first report contained data from the first six months of This report is more ambitious and contains data on all patients who started on dialysis during It sets the foundations for a regular collection of vascular access to allow continuous audit of patients in the future. I congratulate all those involved in this important audit and thank them for their efforts, particularly staff at the UK Renal Registry and NHS Kidney Care. Is there scope to improve? Yes there is. Will we achieve improvement? Yes - we are now measuring access for dialysis and we will remain focused on patient choice, and then support patients to achieve their goals, be that dialysis requiring timely formation access, conservative kidney care, or pre-emptive renal transplantation. The timely creation of definitive dialysis access is a matter of careful judgement. The progressive decrease year-on-year of patients who present late requiring dialysis, coupled with the recent introduction of patient decision aids to support shared decision making, should improve experience and outcomes for patients and help clinicians in planning a timely dialysis start. This report was collected using a spreadsheet rather than automated direct electronic capture, to which many units responded by asking why can this not be done by direct electronic extraction? So that s the plan from now on - it will be part of the general return of information to the UK Renal Registry. We may not have solved the issue of vascular access for our patients, but the likelihood of dialysing with an AV fistula or graft has increased to 77.6% in the centres which submitted data in both audits (2005 and 2011data). Some regions are doing better than others, so we need to ask ourselves what and how can we learn from our colleagues? Improving on a national figure of only 43% of patients starting haemodialysis via an AVF and AVG needs to be reviewed by each and every kidney team in the country. Donal O Donoghue National clinical director for kidney care Department of Health 04

5 2. Acknowledgements We would like to thank all the staff in the 45 units who submitted data on behalf of their patients and units. We would also like to thank James Medcalf, clinical lead for NHS Kidney Care, for editorial comments and the following UK Renal Registry staff for their help: Sue Shaw for project management; Fiona Braddon for clinical informatics expertise and data processing; Ron Cullen and Damian Fogarty for editorial comments and management of UKRR input into this project. FOREWORD AND ACKNOWLEDGMENTS 05

6 3. Executive summary There was some evidence of a change in the provision of vascular access for patients commencing haemodialysis in 2011 with definitive access at 42.9% compared to 41% reported in the Kidney Care Vascular Access Audit, covering patients starting dialysis in out of 63 renal centres in England, Wales and Northern Ireland took part in the audit, submitting records on 3,236 patients. Overall data completeness was good ranging from 70% for surgical assessment at 3 months or more prior to commencement of dialysis to 100% for other data items. The median age of patients was 67 years and 64 per cent of patients were male. At first dialysis, 42.9% started with an arteriovenous fistula or graft, 21.3% with a non tunnelled line and 35.8% with a tunnelled line. There was variation across renal networks. After three months, 36% were dialysing via an arteriovenous fistula and 40% of patients were receiving haemodialysis via a tunnelled catheter. There was a proportional increase in deprivation from quintile 1 to 5 and 30% of individuals were in the most deprived group (quintile 5). Significant variation between centres was identified in the funnel plot showing the percentage of patients with late referral by centre size. A lower proportion of patients that were referred late (less than 90 days from seeing a renal physician to dialysis) started dialysis with definitive access. Only 5% of late referrals were referred to a surgeon compared to 30% of those referred between 90 and 365 days and 46% for patients referred more than a year before starting dialysis. Where patients were referred to a surgeon, 75% commenced with an arteriovenous fistula. 40% of patients still commenced dialysis with a venous catheter when they had been seen for a year or more within a renal service. Deprivation appeared to have no effect on access type. The percentage of prevalent HD patients with definitive access increased by 6.9% from 70.7% in 2005 to 77.6% in All centres (except three) that reported data for both years recorded an increase in the percentage of HD patients with definitive access in 2011 compared to 2005 (range 0.4 to 29.9). In the majority of renal networks, late referral (less than 90 days from seeing a renal physician to dialysis) accounted for 30% or less of haemodialysis starters. 06

7 4. Introduction Vascular access for haemodialysis (HD) patients continues to be an important area of risk. Evidence of variation in provision between centres continues, with the recent Kidney Care Vascular Access Audit reporting outcomes for incident haemodialysis patients [1]. This report highlighted that 59% of HD starters used a venous catheter as their first access. It also confirmed that at three months, there had been little improvement in the access pattern. EXECUTIVE SUMMERY AND INTRODUCTION 07

8 5. Methodology The Vascular Access Audit, managed by The UK Renal Registry (UKRR), collected vascular access data for 2011 as a continuation of the National Kidney Care Audit (Vascular Access for 2009 and 2010 data) which was managed by the NHS Information Centre in 2010 and The data collected for the Dialysis Access Audit 2012 was based upon the data items already collected within the National Kidney Care Audit Vascular Access Report 2011 [1] and covered all patients commencing dialysis in At year end 2011, all renal centres in England, Wales and Northern Ireland were asked to complete an excel spreadsheet (appendix 1) which was submitted directly to the UKRR using secure data transfer procedures. In contrast to the prior audits, all new patients commencing dialysis for the first time during the whole of 2011 were the intended participants. These data items cover basic patient demographic information and specific facts about the patient s treatment, which included: the type of access used at first dialysis the date of the patient s first dialysis session the date the patient was first seen by a renal physician the access type in use three months following the patient s first dialysis session whether the patient was referred to a surgeon at least three months before the patient s first dialysis session. during 2011). After validation there remained 4,099 records for patients starting on either haemodialysis or peritoneal dialysis. The 863 patients who commenced RRT on peritoneal dialysis were excluded from this analysis of vascular access unless stated otherwise. Referral time was defined as the time between the date of first being seen by a renal physician and the date of commencing dialysis. A valid referral time was calculated for a patient if they had both dates recorded and if the date of first being seen by a renal physician was no later than the date of commencing dialysis. Two centres had no valid referral times calculated for any of their patients due to poor data completion. If a patient did not have the date that they were first seen by a renal physician available, then the data field should have been left blank. However, patients from London St Barts & The London Hospital for whom this date was unavailable had had this date recorded as the date they started dialysis. For this reason, when the data were validated, all 96 patients from London St Barts & The London Hospital who had matching dates for these two data fields had the date that they were first seen by a renal physician set to missing. This might have caused an under estimation of the number of late referrals at London St Barts & The London Hospital as some dates that were changed might have been accurate. Upon receipt of the data each file was checked to ensure that the expected patient numbers based on previous years take-on figures were in line with actual numbers received. The records collected by the questionnaires were matched with the UK Renal Registry database allowing identification of unreported deaths within three months of commencing dialysis and patients who had previously received RRT. During validation of the data, 281 records were excluded (144 for being duplicates, and 137 for failing to match the inclusion criteria of commencing dialysis for the first time 08

9 6. Background data A total of 45 centres returned information on incident patients commencing haemodialysis. There were a total of 3,236 individual cases. Renal centres reported on a range of between 12 and 214 patients (table 1). Results are not presented by centre routinely in the main part of this report, but are available in appendix 2 of this report for reference. The completeness of patients reported on by centre who commenced HD in 2011 was evaluated against the 2010 incident numbers [2]. There was a small decrease (1.8%) in the number of HD patients commencing HD in 2011 in the 45 centres that returned vascular access data to the UK Renal Registry compared to the 2010 incident numbers for these same centres. Although there might well be under-reporting of patients for some centres, the total number of patients reported to have started on HD in 2011 (3,236) seems reasonable compared to previous years. Centre name Number Antrim Hospital 19 Bangor- Gwynedd Hospital 15 Belfast City Hospital 81 Birmingham - Heartlands Hospital 89 Birmingham - Queen Elizabeth Hospital 163 Bradford - St Luke's Hospital 40 Brighton - Royal Sussex County Hospital 82 Bristol - Southmead Hospital 96 Cardiff - University Hospital of Wales 139 Chelmsford - Broomfield Hospital 30 Clwyd - Glan Clwyd Hospital 12 Colchester General Hospital 43 Derby - Royal Derby Hospital 36 Doncaster Royal Infirmary 31 Dudley - Russells Hall Hospital 16 Exeter - Royal Devon and Exeter Hospital 127 Gloucester Royal Hospital 42 Hull Royal Infirmary 59 Kent and Canterbury Hospital 94 Leeds - St James's University Hospital and Leeds General Infirmary 119 Leicester General Hospital 181 Liverpool - University Hospital Aintree 56 London - Royal Free Hospital 127 London - St Barts and The London Hospital 214 London - St Helier Hospital, Carshalton 139 Manchester - Hope Hospital 91 Middlesbrough - James Cook University Hospital 73 Newcastle - Freeman Hospital and Royal Victoria Infirmary 68 Newry - Daisy Hill Hospital 27 Nottingham City Hospital 71 Oxford Radcliffe Hospital 99 Plymouth - Derriford Hospital 24 Portsmouth - Queen Alexandra Hospital 148 Preston - Royal Preston Hospital 104 Sheffield - Northern General Hospital 105 Southend Hospital 18 Stevenage - Lister Hospital 30 Stoke - University Hospital of North Staffordshire 53 Sunderland Royal Hospital 43 Swansea - Morriston Hospital 90 Truro - Royal Cornwall Hospital 23 Tyrone County Hospital 14 Wolverhampton - New Cross Hospital 56 Wrexham Maelor Hospital 16 York District General Hospital 33 Total 3,236 METHODOLOGY AND BACKGROUND DATA Table 1. Patient records by participating centre 09

10 Overall data completeness was good (table 2). Access at first dialysis, date of first dialysis, gender and postcode had a 98% to 100% data return. NHS number was returned in 92% of cases and the access in use at 3 months in 85% of cases. Only 70% completed the record for surgical assessment at 3 months or more prior to commencement of dialysis. Data field Number of records completed Percentage of records completed NHS number 2, Access at first dialysis 3, Access at 3 months 2, Date first seen by physician a 2, Date of first dialysis 3, Assessed by surgeon 2, Gender 3, Postcode 3, a Date first seen by a physician was set to missing for some patients at London St Barts as outlined in the methodology Table 2. Data completeness for the 3,236 patient records submitted 10

11 7. Demographics 7.1 Age and gender There was a predominance of male patients in the sample size (male n=2,074, female n=1,162) (figure 1).The peak age range for incident patients was between 65 and 79 for both males and females. The median age by renal centre ranged from 60 to 77 (figure 2) Number of patients DEMOGRAPHICS Age Group Female Male Figure 1. Age and gender of patients submitted to audit 11

12 12 Figure 2. Median age of HD patients at first dialysis by renal centre

13 7.2 Social deprivation There was a proportional increase in deprivation from quintile 1 to 5 (5 being the most deprived) and 30% of individuals were in quintile 5 (figure 3) Percentage Quintile 1 - Least deprived Most deprived DEMOGRAPHICS Figure 3. Deprivation quintile profile for HD patients resident in England Note: Based on 2,745 patient records (patients resident in England with a valid postcode) The deprivation quintiles were calculated using the English Indices of Deprivation 2010 which measured relative levels of deprivation in small areas of England called Lower Layer Super Output Areas [3]. These 32,482 areas were ranked from least deprived to most deprived and then split into equal quintiles. The patient records were matched to an area, and accordingly a deprivation quintile, by postcode. Only patients resident in England with a valid postcode were included in the analyses involving deprivation quintiles. 13

14 Deprivation by renal network is shown in figure 4. Cheshire and Merseyside, London, the North East and the West Midlands had the greatest level of deprivation with greater than 40% of patients in the most deprived category. In contrast, in the East Midlands, East of England, South Central, South East Coast and South West the distribution was either flat or tended to be less deprived Least deprived 15 2 Percentage Cheshire & Merseyside (54) Cumbria & Lancashire (90) East Midlands East of (283) England (94) Greater Manchester (91) London (472) North East (183) South Central (245) South East Coast (306) South West (175) West Midlands (371) Yorkshire & the Humber (380) Most deprived Network (England only) Figure 4. Deprivation quintile profile for HD patients resident in England by renal centre attended Note: Number of patients at each network listed in brackets 14

15 8. Referral times Referral interval from time of first consultation with a renal physician to the time of first dialysis could be assessed in 3,023 available records. Figure 5 provides referral time banded in three categories - less than 90 days; 90 days to one year; and greater than one year. In the majority of renal networks, late referral contributed 30% or less of haemodialysis starters. There were no under 90 day starters in the Greater Manchester area but the sample size was small from that region. REFERRAL TIMES Figure 5. Referral time from physician to first dialysis by renal network Note: Number of patients with data returned by network name (number with missing data in brackets) 15

16 Figure 6 shows the number of patients with late referral to HD (<90 days) by number of patients per renal centre. As can be expected there is a strong correlation between the numbers of patients referred late and overall patient numbers by centre. A funnel plot was used to identify significant centre variation (figure 7). Number of patients where referral period from physician to first haemodialysis is <90 days Number of patients with data per renal centre Figure 6. Number of patients with late referral to haemodialysis (<90 days), by number of patients per renal centre Note: Total patients per renal centre do not include patients who do not have a valid value for referral time. Two centres have been excluded as they do not have any patients with a valid referral time 16

17 60 Solid lines show 95% limits Dotted lines show 99.9% limits 50 Percentage with referral <90days REFERRAL TIMES Number of patients in centre Figure 7. Funnel plot showing the percentage of patients with late referral by centre size For any number of patients in the cohort (x-axis) one can identify whether the percentage of patients referred within < 90 days (y-axis) falls within, plus or minus two standard deviations (SDs) from the national mean (solid lines, 95% limits) or three SDs (dotted lines, 99.9% limits). With 45 centres included in the analysis, it would be expected by chance that two centres would fall outside the 95% (1 in 20) confidence limits. The results have to be cautiously interpreted due to the extent and variation in missing data, small numbers of patients in some centres and non-adjustment for any patient related factors. For these reasons outlying centres were not identified in this report but as the vascular access data collection and quality improves, outlying centres will in future be identified and reported on. The funnel plot (figure 7) identifies significant outliers by centre. Three centres had a significantly higher than average percentage of late referrals (referral <90 days before start of HD) and were outside the 95% limits, with one centre above the 99% limit. The four centres with a higher than average percentage of patients referred late had a relatively high proportion of patients where the date of starting HD and the date of referral to a physician were the same. Four centres had a significantly lower than average proportion of late referred patients and were outside the 95% limits. Two centres had no patients reported as referred < 90 days and one centre had a significantly lower than average proportion of late referred patients and were below the 99% limits. 17

18 9. Access at dialysis 9.1 Type of access at first dialysis For the cohort of incident patients, 41.0% commenced with an arteriovenous fistula, 21.3% with a non tunnelled line and 35.8% with a tunnelled line (figure 8). 36% 41% Arteriovenous fistula (1,313) Arteriovenous graft (51) 21% 2% Non-tunnelled line (680) Tunelled line (1,142) Figure 8. Access at first dialysis 18

19 Cheshire and Merseyside Cumbria and Lancashire East Midlands East of England Greater Manchester London North East South Central South East Coast South West West Midlands Yorkshire and the Humber Northern Ireland Arteriovenous fistula Arteriovenous graft Tunnelled line Non-tunnelled line ACCESS AT DIALYSIS Wales Percentage Figure 9. Access at first dialysis, by renal network for haemodialysis patients There was variation across renal networks (figure 9). Cheshire and Merseyside only reported on 55 patients but more than 90% of them started with an arteriovenous fistula. Similarly, Greater Manchester reported 91 cases of which two thirds commenced with an arteriovenous fistula. Northern Ireland and London reported the lowest rates of arteriovenous fistula usage (less than 30% in both regions) and performance across other networks had a range from 33-52% starting HD with an arteriovenous fistula. There was little difference between access at first haemodialysis in those centres that reported significant incident PD patient usage. 19

20 9.2 Type of access after three months Figure 10 shows data were missing for 15% (499) of patients at three months and a further 5% (175) of patients died before three months. Another two patients withdrew or recovered function and five were transplanted. Forty per cent (1,283) of patients were still receiving haemodialysis via a tunnelled catheter. Thirty-six per cent (1,167) were dialysing via an arteriovenous fistula and 2% (54) of patients had changed modality to peritoneal dialysis. 15% Missing (499) 40% Arteriovenous fistula (1,167) Arteriovenous graft (34) Death before 3 months (175) Non-tunnelled line (17) PD catheter (54) Patient withdrew from dialysis (1) 36% Recovered function (1) 0% 0% 0% 2% 1% 5% 1% Transplanted (5) Tunnelled line (1,283) Figure 10. Access or outcome at three months for all patients who started on haemodialysis 20

21 ACCESS AT DIALYSIS Figure 11. Access or outcome at three months for all patients who started on haemodialysis Patterns of access usage at three months by renal network did not show any significant difference from the incident data (figure 11). The lowest use of arteriovenous fistulas was demonstrated in London, the South West and Northern Ireland, and the highest rates in Greater Manchester, East Midlands, Cumbria and Lancashire and Wales. 21

22 9.3 Comparison of access at first dialysis and after three months Tables 3, 4 and 5 document first dialysis access and three month dialysis outcome. These data include those patients who commenced dialysis on peritoneal dialysis allowing a more complete overview of how patients switched between modalities. An analysis focusing solely on patients commencing on peritoneal dialysis will be covered in an additional report. Table 3 provides the comparison of access in use at first dialysis and at three months for all patients. Fifty-four patients switched modality to peritoneal dialysis. All but one of those patients had commenced dialysis on a venous catheter. The majority of patients who commenced with a venous catheter continued dialysis with a venous catheter, although most were using tunnelled access. Less than 6% of patients who commenced dialysis with an arteriovenous fistula had switched to a venous catheter and there was little evidence of technique failure for those patients who commenced with an arteriovenous graft. Of the 185 patients who died before three months, 134 of those patients had commenced dialysis via venous catheters. Access at first dialysis Arteriovenous fistula Arteriovenous graft Arteriovenous fistula Arteriovenous graft Tunnelled line Non-tunnelled line Access at 3 months PD catheter Death before 3 months Transplanted Withdrew Recovered Missing , Total Tunnelled line ,142 Non-tunnelled line PD catheter Missing Grand total 1, , ,099 Table 3. Comparison of access at first dialysis and after three months for all patients (HD, PD, unknown dialysis type at first dialysis) 22

23 Access at first dialysis Arteriovenous fistula Arteriovenous graft Arteriovenous fistula Arteriovenous graft Tunnelled line Non-tunnelled line Access at 3 months PD catheter Death before 3 months Transplanted Withdrew Recovered Missing Tunnelled line Total Non-tunnelled line PD catheter Missing Grand total Table 4. Comparison of access at first dialysis and after three months for all patients, where referral from physician to dialysis was less than 90 days (HD, PD, unknown dialysis type at first dialysis) Table 4 gives details of access at first dialysis and at 3 months, for those patients who were referred late (defined as the referral from physician to dialysis interval as less than 90 days). At the point of dialysis commencement, only 27 patients were dialysing via an arteriovenous fistula or graft. 703 patients commenced with tunnelled or non-tunnelled access. After three months, 31 of these patients had continued on haemodialysis but moved to an arteriovenous fistula (n=30) or an arteriovenous graft (n=1), 18 had switched to peritoneal dialysis, and 65 had died. ACCESS AT DIALYSIS 23

24 Access at first dialysis Arteriovenous fistula Arteriovenous graft Arteriovenous fistula Arteriovenous graft Tunnelled line Non-tunnelled line Access at 3 months PD catheter Death before 3 months Transplanted Withdrew Recovered Missing , Total Tunnelled line Non-tunnelled line PD catheter Missing Grand total 1, ,003 Table 5. Comparison of access at first dialysis and after three months for all patients, where referral from physician to dialysis was more than 90 days Table 5 shows access at first dialysis and at three months for those patients in whom the referral interval was timely (defined as the referral from physician to dialysis interval as greater than 90 days). For these patients, 1,233 commenced with an arteriovenous fistula or arteriovenous graft and 1,009 commenced with a tunnelled or non-tunnelled catheter. After three months, 32 of the patients commencing on a venous catheter had switched to peritoneal dialysis and 58 had died. Thirty-one patients commencing dialysis with an arteriovenous fistula died prior to three months. Of the 1,189 patients commencing with an arteriovenous fistula, 69 patients had had access failure and were dialysing using venous catheters. In comparison, of the 1,009 patients who commenced dialysis with venous catheters, 137 had successfully switched to an arteriovenous fistula and five to an arteriovenous graft. 24

25 10. Determinants of access organisational factors 10.1 Referral to a surgeon Cheshire and Merseyside 56 (100%) Cumbria and Lancashire 104 (0%) East Midlands 288 (13%) East of England 121 (36%) Greater Manchester 91 (100%) London 480 (59%) North East 184 (40%) South Central 247 (2%) South East Coast 176 (2%) South West 312 (45%) West Midlands 377 (0%) Yorkshire and the Humber 387 (48%) DETERMINANTS OF ACCESS Northern Ireland 141 (1%) Wales 272 (19%) Yes No UK 3,236 (30%) Percentage Figure 12. Percentage of HD patients assessed by a surgeon at least three months before starting dialysis, by renal network Note: Number of patients in each network listed after name (% missing in brackets) For those patients commencing haemodialysis in a planned timely way, data were requested on whether they had been assessed by a surgeon at least three months before commencement of dialysis. Data were not returned in 968 cases but of the remaining cohort, 1,029 incident haemodialysis patients had been seen by a surgeon and 1,239 had not. There was wide variation by network but these data need to be interpreted with caution due to the extent of, and variation in, missing data and small number reporting (figure 12). Most networks reported between 40% and 60% of patients having been assessed by a surgeon. The exceptions were London, where the reported value was less than 10%, the South East Coast (34.7%) and Wales which exceeded 60%. 25

26 Figure 13 shows the percentage of HD patients assessed by a surgeon at least three months before starting dialysis by referral interval (defined as the referral from physician to dialysis interval). The probability of surgical referral increased based on the time between first physician consultation and first dialysis. For those referred less than 90 days before start of dialysis, less than 5% of patients had seen a surgeon. Of those patients commencing between 90 and 365 days, referral rate to a surgeon was less than 30% and for those greater than a year still a minority (46%) had undergone surgical assessment. If a patient had seen a surgeon three months before starting dialysis, the probability of them commencing on an arteriovenous fistula or graft was considerably higher than if they had not (figure 14). Interestingly, 10% of patients had commenced dialysis from an arteriovenous fistula despite lack of surgical assessment. For those who had seen a surgeon, 75% commenced with an arteriovenous fistula. Number of days between physician visit and first dialysis Figure 13. Referral to surgeon, by referral period 26

27 10.2 Referral times and access at first dialysis Percentage Non-tunnelled line Tunnelled line Arteriovenous graft Arteriovenous fistula DETERMINANTS OF ACCESS Yes (1,029 patients) No (1,201 patients) Missing (956 patients) Surgeon referral Figure 14. Type of access at first dialysis for HD patients, by whether a patient was assessed by a surgeon at least three months before starting dialysis Note: Results based on 3,186 records (excludes 50 records with missing access at first dialysis) 27

28 Figure 15. Referral time from physician to first dialysis by access type, HD starters Note: 326 patients excluded for incomplete data (276 referral time, 50 access when starting dialysis) Overall, even for patients commencing dialysis having been seen for a year or more within a renal service, 40% still commenced with a venous catheter (figure 15). That percentage was higher for the other referral groups, so that for those patients known for greater than 90 but less than 365 days, the probability of catheter usage at the start of dialysis exceeded 65%. 28

29 10.3 Deprivation and access at first dialysis Definitive and non-definitive access use at first dialysis matched the deprivation pattern of the overall incident population, suggesting no influence of deprivation on access provision (figure 16) Percentage Definitive Non Definitive 1 - Least deprived Most deprived DETERMINANTS OF ACCESS Type of access Figure 16. Deprivation by definitive/not definitive access at first dialysis Definitive = arteriovenous graft or fistula Non definitive = non tunnelled line or tunnelled line Results based on 2,702 records (patients resident in England with valid postcode and known access type at first dialysis) 29

30 11. Access in prevalent HD patients on 31/12/2011 Centre Table 6. Access in prevalent HD patients Access in prevalent HD patients on 31/12/2011 Number of HD patients % on HD with AVF % on HD with AVG % on HD with a catheter/ line Antrim Hospital Access in prevalent HD patients on % change of 31/03/2005 a HD patients % on HD with AVF % on HD with AVG % on HD with a catheter/ line with definitive access from Belfast City Hospital Birmingham - Heartlands Hospital Birmingham - Queen Elizabeth Hospital Bradford - St Luke's Hospital Brighton - Royal Sussex County Hospital Bristol - Southmead Hospital Cardiff - University Hospital of Wales Chelmsford - Broomfield Hospital Clwyd - Glan Clwyd Hospital Colchester General Hospital Derby - Royal Derby Hospital Doncaster Royal Infirmary Dudley - Russells Hall Hospital 153 Exeter - Royal Devon and Exeter Hospital Gloucester Royal Hospital Kent and Canterbury Hospital Leeds - St James's University Hospital and Leeds General Infirmary Leicester General Hospital Liverpool - University Hospital Aintree London - Royal Free Hospital Manchester - Hope Hospital Middlesbrough - James Cook University Hospital Newcastle - Freeman Hospital and Royal Victoria Infirmary Newry - Daisy Hill Hospital Nottingham City Hospital Oxford Radcliffe Hospital Plymouth - Derriford Hospital Portsmouth - Queen Alexandra Hospital Preston - Royal Preston Hospital Southend Hospital Stoke - University Hospital of North Staffordshire Truro - Royal Cornwall Hospital Wrexham Maelor Hospital York District General Hospital a Data published by UK Renal Registry [4] Note: AVF=arteriovenous fistula, AVG=arteriovenous graft, definitive access=avf or AVG in use 30

31 The majority of centres that returned data had a higher percentage of prevalent HD patients with definitive access in 2011 compared to 2005, although there is wide between centre variation (table 6). Centres that did not return data on prevalent patients in 2011 have been excluded from the table. Ten centres reported an increase of more than 10% in prevalent HD patients with definitive access in 2011 compared to 2005 and of these, two centres reported an increase of more than 20%. The percentage of prevalent HD patients with definitive access in 2011 ranged from 33% to 99%. The percentage of prevalent HD patients that had definitive access increased from 70.7% in 2005 to 77.6% in This is based on patients from 25 centres who contributed data to both years Figure 17 shows the centre level range of percentages of prevalent HD patients with non-definitive access. The crosses represent the centre level means. A paired t-test found there was a significant difference between the means (p=0.0029). Data by access type and centre for prevalent dialysis patients at 31/12/2011 are shown in figure 18. ACCESS IN PREVALENT HD PATIENTS Percentage 10 0 Year Figure 17. Box and whisker plot showing the percentage of prevalent HD patients with non-definitive access on 31/03/2005 and 31/12/2011 Note: Based on 25 centres with prevalent data for 2005 (n=5,827) and 2011 (n=8,312) 31

32 Colchester General Hospital (120) Newry - Daisy Hill Hospital (123) Belfast City Hospital (252) Gloucester Royal Hospital (233) Middlesborough - James Cook University Hospital (335) Manchester - Hope Hospital (629) Cardiff - Uiversity Hospital of Wales (575) London - Royal Free Hospital (787) Chelmsford - Broomfield Hospital (172) Kent and Canterbury Hospital (444) Newcastle - Freeman Hospital and Royal Victoria Infirmary (318) Birmingham - Queen Elizabeth Hospital (1,066) Oxford Radcliffe Hospital (519) Brighton - Royal Sussex County Hospital (436) Exeter - Royal Devon and Exeter Hospital (462) Bradford - St Luke s Hospital (229) York District General Hospital (161) Leicester General Hospital (1,002) Doncaster Royal Infirmary (185) Southend Hospital (138) Leeds - St James s University Hospital and Leeds General Infirmary (605) Preston - Royal Preston Hospital (586) Clwyd - Glan Clwyd Hospital (95) Stoke - University Hospital of North Staffordshire (387) Truro - Royal Cornwall Hospital (176) Plymouth - Derriford Hospital (181) Portsmouth - Queen Alexandra Hospital (620) Birmingham - Heartlands Hospital (498) Wrexham Maelor Hospital (109) Bristol - Southmead Hospital (522) Nottingham City Hospital (491) Derby - Royal Derby Hospital (327) Liverpool - University Hospital Aintree (187) PD AVF AVG Catheter/line Percentage Figure 18. Distribution of prevalent patients on 31/12/2011 by access type and centre Note: Twelve centres excluded for not returning complete prevalent data. Number of patients at each centre in brackets. AVF=arteriovenous fistula, AVG=arteriovenous graft 32

33 12. Discussion There is little evidence of change in the provision of vascular access for patients commencing dialysis in 2011, when compared to the findings of the Kidney Care Vascular Access Audit, published in 2011 using a six month cohort of patients from January to June This audit used the same methodology as the prior work, and allows some comparisons to be made. One year is probably ambitious to expect systematic changes to have occurred, but there are useful points to be made from the new data. First, data collection has been much less problematic. Whilst there is a desire to move away from standalone spreadsheet collection tools, data collection has run quickly and with a high degree of completeness. Fewer centres took part (45 compared to 60) but provided incident data for 12 months and hence more cases. Second, variation in provision by network and by centre is still evident. The Renal Association standard sets a target of 65% for patients to start haemodialysis with either a fistula or a graft if they present more than 90 days before the start of dialysis [5]. The overall figure of 43% starting dialysis with a fistula or graft is almost identical to the figure from the Kidney Care VA audit Fifty-five percent of patients referred more than 90 days before commencing HD started dialysis with a fistula or a graft and again this is similar to the Kidney Care VA audit 2011 results. It is interesting to see that when patients are referred to a surgeon, the probability of starting with a fistula is much higher. The low rate of referral to surgeons suggests recognition or prediction of end stage renal failure still remains an issue. As was discussed in last year s publication, more research is needed to determine how the need for RRT is assessed and predicted. With the publication of the IDEAL trial [6], an understanding of the risks and benefits around dialysis initiation is needed. Vascular access preparedness may be a factor in determining whether to commence haemodialysis and included in scoring criteria to assess a start point [7]. For those presenting at end stage in an unplanned way (defined by no prepared vascular access) there is also the issue of bridging to definitive access. Almost universally, bridging has meant the use of a venous catheter. It is encouraging to see a small proportion of people moving to PD inside three months. The inclusion of PD in this audit is important and PD may have an important role as a bridge [8]. This idea of bridging and unplanned starts needs exploration. In terms of bridging techniques there are options of venous catheters, PD catheters and holding off dialysis initiation whilst access is prepared. The term unplanned start covers those patients who arrived late to the renal team (and that number is falling) and those patients in the renal system for whom preparation has not been started or completed. That latter group now makes up the majority of patients who start haemodialysis with a venous catheter. From this audit, it can be seen that referral to an appropriate vascular access surgeon is not made by renal teams, despite apparent time to do so. This turns the focus back on predicting when access planning should commence. Only 46% of patients in renal clinics for more than one year are referred to surgery, but of those referred, 75% have access in place. In summary, the recommendations from the 2011 Kidney Care Vascular Access audit remain. In particular, recommendations around data collection and access provision require no revision. DISCUSSION 33

34 13. Recommendations (Taken from National Kidney Care Vascular Access Audit Report 2011) 13.1 Data collection 1. Data items relevant to the audit of vascular access in haemodialysis should be reviewed with a view to simplification. The key mandatory item should be access type in use at each dialysis session. 2. Individual dialysis centres should review data collection and extraction to the UK Renal Registry. 3. The UK Renal Registry should collect data on vascular access and return data quality reports to centres prior to analysis. Correction and improvement of data quality should remain the responsibility of the provider centre. 4. Centres and commissioners should develop data items to enable local and regional audit of process and outcomes related to vascular access Access provision 1. Late referral should be minimised by joint working with primary and secondary care to identify progressive chronic kidney disease. 2. When patients present late, requiring renal replacement therapy, alternative therapies should be considered to allow time for the formation of vascular access. 3. When patients commence dialysis with a venous catheter, a root cause analysis should be undertaken to determine the reasons and to improve the process. 4. Research and development into the prediction of dialysis start dates and the optimal timing of access placement is urgently required. 5. A unified standard for patients commencing all forms of renal replacement therapy, including peritoneal dialysis and transplantation should be developed in collaboration with the Renal Association, the British Renal Society and the British Transplantation Society. This would provide a better measure of clinical care when assessing centre performance. 34

35 14. References 1. National Kidney Care Audit Vascular Access Report 2011, NHS Information Centre. 2. UK Renal Registry 14th Annual Report. Chapter 1: UK RRT Incidence in 2010: national and centre-specific analyses. Gilg J, Castledine C, Fogarty D., UK Renal Registry, English Indices of Deprivation UK Renal Registry 13th annual report. Chapter 7: The Relationship between the type of Vascular Access used and Survival in UK RRT Patients in Castledine C, van Schalkwyk D, Feest T. UK Renal Registry; Renal Association Clinical Practice Guideline on vascular access for haemodialysis. Fluck R, Kumwenda M. Nephron ClinPract. 2011;118 Suppl 1:c A randomized, controlled trial of early versus late initiation of dialysis. Cooper BA, Branley P, Bulfone L, et al. for the IDEAL Study group. NEngl J Med Aug 12;363(7): 'Ideal criteria' for starting chronic hemodialysis: numbers, symptoms or an alerting 'traffic light' system? Arici M. Nephron ClinPract. 2012;120(1):c Epub 2011 Dec Transitions in care: what is the role of peritoneal dialysis? Fluck R. Perit Dial Int Nov-Dec;28(6): RECOMMENDATIONS AND REFERENCES 35

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37 Appendix Data Submission Proforma Audit data item Mandatory/Optional Definition ID O Hospital number UKRR dataset specification code IDN04 Forename M Forename IDN02 Surname M Surname IDN01 DoB M Date of Birth IDN03 Gender M Sex PAT00 NHS number M 'New' NHS number PAT13 Post Code M The postcode of the patient's usual address PAT23 Treatment Centre Code for dialysis M Code of the centre where the patient dialyses. Renal registry code PAT01 Primary Renal Diagnosis M EDTA Diagnosis code ERF04 BMI Date first seen by Renal Physician O M Body Mass Index = Weight in Kg / height in m 2 The date the patient was first seen by a renal physician. Outpatient or Inpatient nephrology. PAT33 APPENDIX 1 Date of first ever RRT M Date of very first dialysis session in 2011 ERF00 Dailysis Modality at First RRT M Dialysis modality used at First ever RRT above (HD, PD, TX) First Dialysis Access M Access type in use at first dialysis ERF12 Assessed by Surgeon for an AVF, AVG or peritoneal dialysis catheter at least 3 months before dialysis O Was the patient seen by a surgeon regarding dialysis access at least 3 months before their first dialysis date Yes/No Access in use at 3 months O The Access in use 3 months after the start of first dialysis 37

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