Funding NHHD

Funding NHHD – How we went about it.

Obtaining ongoing commitment to funding from dialysis providers is the cornerstone to a successful, sustainable and progressive program.

When we in Geelong first determined to set up an NHHD program in 1998, I considered two primary options:

Applications through the research grants process in Australia – primarily the National Health and Medical Research Council (NH&MRC)

or …

Support from the outset from government

The NH&MRC, though a highly competitive process, at first seemed to be the more appealing option due to the relative speed (if successful) of a funding stream. However, grants through the NH&MRC are for a finite period (usually a maximum of 3 years) at the end of which a program, like NHHD, would just be beginning to ‘hit its straps. However, it would have developed little ‘stamina’ and thus would likely be left high and dry without a longer-term funding ‘buy-in’ by ongoing funding agencies (in Australia – government and the public purse).

I chose to seek government support from the outset.

Though the wheels grind a little more slowly and more frustrations emerge when dealing with government departments – sometimes slow in decision-making through their committee processes – in the longer run, government funding for a pilot project seemed the more secure choice. If funded by government and then successful – both from a clinical outcome and a financial aspect – then the longer-term aim of achieving ongoing funding seemed more secure. It would be more difficult, we felt, for an agency to back away from a program it had funded and which had then proven to be successful.

It took 2 years – and much effort.

In the end, due to the weight of circumstantial evidence at the time (albeit from a then relatively small, largely Canadian literature base of small number cohort and observational studies), I achieved support from the Department of Human Services (Victoria) for a 3 year pilot study. I wish to acknowledge here the special contributions of Jan Snell, the Barwon Regional Director, DHS (V) and Gillian Smith, Project Officer, DHS (V) for their assistance throughout.

The project was more successful than even we had expected.

The output of the program, the clinical outcomes and the financial benefits accruing to DHS (V) – particularly should a wider uptake of the program be achieved by other dialysis services – can be appreciated from the following references to publications from our unit. Further, the evidence for a subsequent shift in dialysis practice towards longer and more frequent sessions can be seen in the Table and Graphs that follow the reference list.

ORIGINAL PAPERS AND MANUSCRIPTS FROM THE GEELONG NHHD PROGRAM

NB: the Journal … NEPHROLOGY (Carlton) … is the Official Journal of the Asia Pacific Society of Nephrology and of the Australian and New Zealand Society of Nephrology, is published bi-monthly and is available through Blackwell Asia.

Agar J W M, Somerville CA, Dwyer KM, Simmonds RE, Boddington JM, Waldron CM. Nocturnal Haemodialysis in Australia. haemodialysis International. 7 (4), 278-289. October 2003.

Wiggins KJ, Somerville CA, Knight R, Simmonds RE, Boddington JM, Agar J W M. Intradialytic serum protein concentrations differ between nightly nocturnal and conventional haemodialysis. Nephrology (Carlton) 10 (4): 325-329, August 2005.

Agar JWM. Nocturnal dialysis in Australia and New Zealand. Nephrology (Carlton) 10 (3): 222-230, June 2005

Agar JWM, Mahadevan K, Antonis ML, Somerville CA. ‘Flexible’ or ‘lifestyle’ dialysis: Is this the way forward? Nephrology (Carlton) 10 (5): 525-529, October 2005

Agar JWM, Knight RJ, Simmonds RE, Boddington JM, Waldron CM, Somerville CA. Nocturnal Haemodialysis: An Australian cost comparison with conventional satellite haemodialysis. Nephrology (Carlton) 10 (6), 557-570, December 2005

Kerr PK, Perkovic V, Petrie J, Agar JWM, Disney A. The CARI Guidelines: Dialysis Adequacy (HD) Guidelines. Nephrology (Carlton) 10 (Suppl 4), S61-80, October 2005.

McGregor MS, Agar JWM, Blagg CR. Home Haemodialysis: International Trends and Variation. Neph Dial Transpl. 21: 1934-1945, March 2006.

MahadevanK, PellicanoR, ReidA, KerrP, PolkinghorneK, AgarJWM. A comparison of biochemical, hematological and volume parameters in two treatment schedules of nocturnal home haemodialysis. Nephrology (Carlton) (In Press). June 2006

ABSTRACTS PRESENTED/PUBLISHED AT SCIENTIFIC MEETINGS

Agar J W M, Somerville CA, Simmonds RE, Boddington JM, Waldron CM. Nocturnal dialysis – the 1^st Australian experience. (Abst.) Nephrology (Carlton) 7 (Supp) A54. Sept. 2002.

Agar J W M, Somerville CA, Simmonds RE, Boddington JM, Waldron CM. Nocturnal haemodialysis – A preliminary cost comparison with conventional haemodialysis. (Abst.) Nephrology (Carlton) 7 (Supp) A71. Sept. 2002.

Agar J W M, Somerville CA, Simmonds RE, Boddington JM, Waldron CM. Nocturnal dialysis – the 1^st Australian experience. (Abst.) haemodialysis International. 7(1). 92. March 2003.

Agar J W M, Somerville CA, Simmonds RE, Boddington JM, Waldron CM. Nocturnal haemodialysis – A preliminary cost comparison with conventional haemodialysis. (Abst.) haemodialysis International. 7(1). 94. March 2003.

Agar J W M, Somerville CA, Dwyer KM, Simmonds RE, Boddington JM, Waldron CM. Nocturnal Haemodialysis – Beyond the 1^st year. (Abst.) Nephrology (Carlton) 8 (Suppl.), A65. July 2003.

Wiggins KJ, Somerville CA, Dwyer KM, Simmonds RE, Agar J W M. Contrary to conventional haemodialysis, in nocturnal haemodialysis the serum albumin falls, reflecting normalisation of volume physiology. (Abst.) Nephrology (Carlton) 8 (Suppl.), A83. August 2003. [Awarded best submitted abstract at the ANZSN annual scientific, Perth, WA, August/Sept 2003]

Simmonds RE, Boddington JM, Waldron CM, Somerville C, Agar J W M. Nocturnal haemodialysis – three years experience. (Abst). Proceedings: Ist Home Haemodialysis Symposium. Christchurch, New Zealand. July 2004.

Agar J W M, Mahadevan K, Antonis M, Somerville CA. ‘Flexible Dialysis’ – the way forward. (Abst). Proceedings: Ist Home Haemodialysis Symposium. Christchurch, New Zealand. July 2004.

Pellicano R, Mahadevan K, Polkinghorne K, Agar J W M, Kerr P. A comparison of two treatment schedules in nocturnal haemodialysis. (Abst). ANZSN, Adelaide, Nephrology (Carlton) 9 (Suppl.1): A16, August 2004.

Agar J W M, Mahadevan K, Antonis M, Somerville CA. ‘Flexible Dialysis’ – is this the way forward? (Abst). ANZSN, Adelaide, Nephrology (Carlton) 9 (Suppl.1): A15, August 2004.

Mahadevan K, Agar J W M, Somerville CA, Simmonds RE, Boddington JM, Waldron CM. Comparison of access site infection in nocturnal vs conventional vs daily haemodialysis. (Abst). ANZSN, Adelaide, Nephrology (Carlton) 9 (Suppl.1): A13, August 2004.

Agar J W M, Mahadevan K, Pellicano R, Kerr P. Comparing two nocturnal haemodialysis programs with different frequencies. (Abst. SA-PO456). J Am Soc Nephrol. 15: 403A, October 2004.

Agar J W M. Wiggins K, Somerville CA. The serum albumin rises in conventional haemodialysis but falls in nocturnal haemodialysis, confirming the normal bio-volumetrics of nocturnal haemodialysis. (Abst. SA-PO457). J Am Soc Nephrol. 15: 403A, October 2004.

Agar JWM, Mahadevan K, Knight R, Antonis MA, Somerville CA. ‘Flexible Dialysis’ – moving forward. (Abst). Peritoneal Dialysis International. 25 (Suppl.1): S22. February, 2005.

Reid AB, Mahadevan K, Agar JWM. Beta-2-microglobulin in nocturnal haemodialysis – a comparative study in low and high flux dialysers. (Abst). haemodialysis International. 9(1): 82, January, 2005.

Agar JWM, Mahadevan K, Reid AB, Pellicano R, Kerr PG. Nocturnal dialysis: Comparing six night/week with alternate night therapy. (Abst). haemodialysis International. 9(1): 81-82, January, 2005. [Awarded best scientific abstract at the 11^th International Haemodialysis Symposium, Tampa, Florida Feb/March 2005]

Simmonds RE, Boddington JM, Waldron CM, Somerville CA, Agar JWM. Nocturnal Haemodialysis – the evidence to date … (Abst.) Proceedings and Abstracts: 33^rd Annual Meeting Renal Society of Australasia. P75, Hobart, May 2005

Agar JWM. Enhanced Frequency Haemodialysis. Proceedings and Abstracts: 33^rd Annual Meeting Renal Society of Australasia. P28, Hobart, May 2005

Toussaint N, Simmonds RE, Boddington JM, Waldron CM, Somerville CA, Agar JWM. Changes in bone densitometry on nocturnal haemodialysis. Nephrology (Carlton) 10 (Suppl.3): A401 (PS84), September 2005

Toussaint N, Simmonds RE, Boddington JM, Waldron CM, Somerville CA, Agar JWM. Improvements in calcium phosphate product on nocturnal haemodialysis. Nephrology (Carlton) 10 (Suppl.3): A401 (PS83), September 2005

Toussaint N, Simmonds RE, Boddington JM, Waldron CM, Somerville CA, Agar JWM. Erythropoietin requirements on nocturnal haemodialysis. Nephrology (Carlton) 10 (Suppl.3): A414 (PS131), September 2005

Toussaint N, Simmonds RE, Boddington JM, Waldron CM, Somerville CA, Agar JWM. Nocturnal Haemodialysis reduces hospitalisation compared to conventional haemodialysis. Nephrology (Carlton) 10 (Suppl.3): A390 (PS43), September 2005

Agar JWM and Agar NJM. Optimizing haemodialysis: A simple tool including time, frequency, solute clearance and volume. J Am Soc Nephrol. 16. PUB227, 842A, October 2005

Toussaint N, Somerville CA, Agar JWM. Calcium x phosphate and bone mineral density on nocturnal haemodialysis: What dialysate calcium to use? J Am Soc Nephrol. 16.PO751, 282A, October 2005

Clark CJ, Somerville CA, D'Intini V, Simmonds R, Boddington J, Waldron C, Agar JWM. Left Ventricular Hypertrophy in Nocturnal Haemodialysis Patients. Presented: ANZSN, Melbourne 2006 and for publication: Nephrology (Carlton), October 2006

Clark CJ, Somerville CA, D’Intini V, Simmonds R, Boddington J, Waldron C, Agar JWM

CPR in Nocturnal Haemodialysis Patients. Presented: ANZSN, Melbourne 2006 and for publication: Nephrology (Carlton), October 2006

Agar JWM and Moran J. Structural differences between an Australian and a US-based home dialysis program. (Accepted for presentation: ASN, San Diego. 2006 and for publication JASN, November 2006

BOOKS, MANUALS, PUBLIC DOMAIN DOCUMENTS and WEBSITE PUBLICATIONS

Agar J W M: Nocturnal Haemodialysis … an international information website on nocturnal haemodialysis for patients and renal unit staff – located at http://www.nocturnaldialysis.org

Agar J W M: Moving dialysis to the night – the Geelong Experience. Amgen Nephrology, Issue 7, 8-9: 2004.

Quotidian Dialysis: NHHD-prominent experts discuss what they have learned. In-depth interviews with John Agar (Geelong, Australia), Christopher R Blagg (Seattle, Washington State, USA), Robert Lindsay (London, Ontario, Canada), Robert S Lockridge (Lynchburg, West Virginia, USA), and Andreas Pierratos (Toronto, Canada) @ iKidney.com

http://www.ikidney.com/iKidney/InfoCenter/NephrologyIncite/Archive/NHHD13.htm

In particular, you may wish to note the original paper:

This paper, though long and complex, details the comparative cost advantages in the Australian setting of NHHD when compared to outpatient, community-based facility care. It is this paper in particular that encouraged DHS (V) to introduce the incentivizing reimbursements detailed below.

By the end of the DHS(V) pilot project and with generous lectureship support, in particular from Fresenius Medical (Aust), Amgen (Aust), Janssen Cilag (Aust) and Baxter (Aust) for invited lectures (JWMA) given nationally and internationally, the success of the program was disseminated.

Uptake throughout Australia has resulted in the number of patients on longer hour and more frequent dialysis (the majority of whom have switched to overnight therapy) steadily growing. Unfortunately, the ANZ Registry (ANZDATA) has not (until the data collection year in progress) asked the question ‘Is this patient on NHHD?’ The current data set WILL ask this question. It can only be surmised from the data below that the majority of patients undertaking >6-6.5 hrs dialysis are, in fact, on overnight therapy. A phone survey suggests that this IS the case. The following table and two graphs show the change in dialysis patterns of sessional frequency and sessional duration across Australia from 2001 – 2005.

This data alone would suggest an interesting and refreshing wind of change is gently sweeping through ANZ dialysis.

In addition:

From November 2005, a Federal government incentive to home therapies (both HD and PD) was introduced such that through the CMBS reimbursement scheme, physicians now receive a payment incentive for maintaining patients in the home which is not paid if patients remain in facility care.

From February 2006, in the State of Victoria, a DHS(V) incentive for NHHD of $5,000 over and above the reimbursement given to home CHD was introduced.

This Victorian incentive reimbursement decision can be appreciated from visiting the DHS (V) website at:

http://www.health.vic.gov.au/renaldialysis/improving.htm

These dual steps have reinvigorated home therapies in Australia and, in particular, have renewed enthusiasm for home HD … with NHHD increasingly the preferred and incentivized option.

Other countries must find their own ways forward … but a careful examination (beyond the scope of this website) of the steps taken by government and health department agencies in Australia to encourage home HD, and NHHD in particular, may be a good starting point for other regions seeking to embrace this superior form of dialysis.