Provincial Dialysis Capacity Assessment 2011-2020 Executive Summary April 2012
Table of Contents Introduction... 2 Planning Process... 2 Methodology... 3 Dialysis Planning Support Model... 3 Data... 3 Maps... 4 Fallback... 4 Results... 4 Capacity Assessment... 4 Patient Travel Time... 5 Occupancy Rate... 5 Impact of ICU Service Use by Chronic Dialysis Patients... 6 Summary... 6 Appendix... 7 Maps... 7 Terminology... 11 1
Introduction In June 2010, the Ontario Renal Network (ORN) completed Ontario s first comprehensive Provincial Dialysis Capacity Assessment. To achieve this, the ORN assessed existing dialysis capacity and planned future expansions for each of Ontario s 26 Regional Chronic Kidney Disease (CKD) Programs. The Provincial Dialysis Capacity Assessment 2009-2013 resulted in a baseline snapshot of dialysis capacity pressures and opportunities across Ontario. In 2012, building on the initial assessment, the ORN completed the Provincial Dialysis Capacity Assessment 2011-2020. This update includes a refresh of each regional assessment to reflect changes in patient demand, dialysis station supply as well as assumptions regarding home dialysis rates, patient travel patterns and CKD program operating models. This update provided an opportunity to incorporate improvements in methodology and content. The updated regional assessments serve as the foundation for collaborative decision making among the Regional CKD Programs, Independent Health Facilities (IHF), Ministry of Health and Long-Term Care (MOHLTC), Local Health Integration Networks (LHINs) and the ORN regarding capital and operational investments. The Provincial Dialysis Capacity Assessment 2011-2020 provides an overview of the following in each region: demand for dialysis services in 2011 and forecast demand out to 2020 capacity to support dialysis patients in 2011 and planned capacity out to 2020 intensive care unit (ICU) use by chronic dialysis patients anticipated future resource requirements, including facilities and hemodialysis (HD) stations This executive summary provides an overview of the planning process, methodology and results. Planning Process In January 2011, the ORN commenced the planning process in collaboration with the ORN Regional Directors. From March 2011 to July 2011, the ORN worked with the Centre for Research in Healthcare Engineering (CRHE) at the University of Toronto to develop a Dialysis Planning Support Model to estimate annual facility level demand for dialysis services in Ontario to 2020. From November 2011 to March 2012 the ORN Regional Directors chaired one to two regional planning meetings with representatives from the Regional CKD Program(s), directly funded satellites (where applicable), IHFs (where applicable), and the LHIN. The purpose of these meetings was to establish a common understanding of the supply and demand for dialysis services across each region in 2011 and out to 2020. The transparent provincial approach used ensures that all patients are accounted for but minimizes the risk of funding surplus capacity by double-counting patients. The timeline below outlines the key processes involved in the assessment development: Jan-11 - Feb-11 Review and collection of data Mar-11 - Jul-11 Model Development Nov-11 - Mar-12 Regional Capacity Planning Meetings Provincial Dialysis Capacity Assessment Jan-11 Apr-11 Jul-11 Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Apr-13 Provincial Dialysis Capacity Assessment development Ongoing use of planning tools 2
Methodology Dialysis Planning Support Model The ORN s capacity planning work is supported by tools that are developed in collaboration with CRHE. The model developed for this assessment enables regional and provincial planners to analyze different scenarios and assumptions regarding system organization and performance. This model uses prevalent patient volumes as a baseline, and applies sublhin dialysis patient growth. Target home dialysis rates obtained from each Regional CKD Program are applied to the forecasted growth to calculate the in-facility patient demand and the number of patients who will be receiving dialysis at home, lessening the burden on in-facility stations. The model helps to inform a number of key planning considerations including, the impact of a growing population requiring renal replacement therapies and increasing rates of home modalities on dialysis demand at a facility, regional and provincial level. While the current model focuses on dialysis care, expanded models are planned to address the full spectrum of CKD care, including the associated health human resources. These tools will continue to serve as a critical decision aid in the ORN s mandate to ensure that the Ontario renal system has the capacity that patients require. Data Dialysis patient data: Ontario Renal Reporting System's (ORRS) April 2011 monthly data submission of all prevalent dialysis patients accessing services in Ontario (9842 patients). More recent ORRS data has been used for some specific regions where capital investment decisions were underway. Hemodialysis station data: ORN Provincial Dialysis Capacity Assessment 2009-2013 and MOHLTC Machine Funding Plan. Each Regional CKD Program validated the number of approved operating HD stations and their current utilization. Home dialysis rates: Each Regional CKD Program provided a home dialysis target for 2013, 2015, 2017 and 2020. Sub-LHIN dialysis growth: The estimated annualized net new dialysis patients for sections of each sub-lhin was calculated using unpublished historical dialysis outpatient OHIP data (1999-2008) from the Institute of Clinical Evaluative Sciences (ICES) 1. Sub-LHIN data was used to obtain a more accurate view of patient growth at a geographic level smaller than the LHIN. Sub-LHIN v.9 crosswalk: The sub-lhin v.9 crosswalk data, provided by the MOHLTC Health Analytics Branch, included a list of Ontario postal codes and their corresponding sub-lhins. The Sub-LHIN v.9 crosswalk was used to assign patient postal codes from ORRS to a sub- LHIN. 1 October 2010 ICES report on Predicting Growth in Dialysis Services in Ontario to 2015 Dialysis growth trends over the past decade (1999-2008) based on ICES analyses show a greater growth than recent trends based on ORRS. The ORN will continue to monitor this apparent decline in dialysis prevalence 3
Maps Microsoft MapPoint 2011 was used to plot each patient s current residence and dialysis facility location. MapPoint was used to calculate drive times and distances from patient s residence to the facility where they are receiving dialysis care. This data enabled the ORN to understand current patient travel patterns and to identify areas of the province that are under-served. This information can be used to make better use of existing capacity in Ontario s renal system. In addition, dialysis patients and HD station information was mapped using ArcGIS (Arc Map 10). Fallback The ORN is in the process of determining an appropriate fallback calculation using ORRS patient data which will take into consideration the home program size as well as the number of satellite patients. In the interim, this assessment used two HD station utilization rates: Regional Centres: 85% HD station utilization rate Satellites: 100% HD station utilization rate Results Capacity Assessment Each Regional CKD Program was categorized under one of the following three categories based on information as of April 1, 2012. A) Capacity Needed: Regional CKD Programs which are operating at maximum capacity and are currently or forecasted to experience a capacity shortage in the near future. These programs may not have adequate fallback capacity. - Programs with future approved HD station expansions: none - Programs without future approved HD station expansions: Sunnybrook Health Sciences Centre B) Future Capacity Needed: Regional CKD Programs that are approaching maximum capacity and are forecasted to experience a capacity shortage greater than 6 HD stations by 2020. - Programs with future approved HD station expansions: The Ottawa Hospital, William Osler Health System, St. Michael s Hospital, Humber River Regional Hospital - Programs without future approved HD station expansions: Grand River Hospital, Niagara Health System, University Health Network, St. Joseph s Health Care, Lakeridge Health, The Scarborough Hospital C) Adequate Capacity: Regional CKD Programs with a sufficient number of approved or built HD stations to meet the forecasted demand for care (out to 2020). - Hotel Dieu Grace Hospital, London Health Sciences Centre, St. Joseph s Heathcare (Hamilton), Halton Healthcare, Credit Valley Hospital, York Central Hospital, Peterborough Regional Health Centre, Kingston General Hospital, Renfrew Victoria Hospital, Orillia Soldiers Memorial Hospital, Timmins and District Hospital, Sault Area Hospital, North Bay Regional Health Centre, Health Sciences North, Thunder Bay Regional Health Sciences Centre. 4
This assessment identified a number of programs which are approaching maximum capacity and are expected to experience a HD station capacity shortage. A portion of these programs have capital projects underway. In addition, programs which are categorized as having adequate capacity are forecasted to require less than 6 HD stations by 2020. It should be noted that the forecasted surpluses or shortages at a regional centre are dependent on the home dialysis rates achieved and the number of patients who are medically suitable for satellite care. As well, this assessment used a utilization rate of 85% to calculate HD station surplus and shortage at the regional centre. This resulted in some regional centres being represented as experiencing a capacity shortage when in reality they are operating within the approved capacity. Changes to patient travel patterns, home dialysis utilization, transplant rate, and dialysis growth rate also will affect the results of this assessment and need to be reconsidered regularly. Patient Travel Time One of the key priorities of the ORN is to ensure all Ontarians with end stage renal disease have access to care as close to home as possible. Through our capacity planning work the ORN has captured patient travel time data at a facility, regional program, and provincial level. This information supports our on-going planning efforts to ensure appropriately located capacity exists for patients to receive care closer to home. Based on ORRS April 2011 prevalent patient data, across the province, 79% of patients had a driving travel time of less than 30 minutes, 16% between 30 and 60 minutes, and 5% more than 60 minutes. By planning at the regional and provincial level the ORN aims to reduced travel times and in turn improve the quality of life for dialysis patients. The Ontario Renal Plan 2012-2015 has set out the following target for 2015: more than 80% of facility dialysis patients will travel less than 30 minutes to reach their nearest centre and fewer than 5% will travel more than 60 minutes. Occupancy Rate Occupancy rates measure organizational effectiveness and the ability of dialysis facilities to plan for and deliver dialysis services. This indicator shows whether there is a potential opportunity to create additional capacity by increasing the number of patients per station. This measure is highly sensitive to the size of the patient population, the number of operating stations, the hours of operation per day and the days of operation per week. Occupancy in small or rural units with few stations is impacted by the loss or addition of one or two patients, whereas the loss of the same number of patients in a larger facility does not have the same impact. Availability of health human resources also impacts this measure. Therefore, the occupancy rate must be considered within the context of the dialysis facilities' operating model and resource constraints. This information supports on-going planning efforts to ensure appropriately located capacity exists. The results showed that six programs are operating at or close to maximum capacity. This suggests that these programs may not have adequate fallback capacity. 16 programs have the capacity to expand (i.e. open up additional shifts at certain facilities) whereas the remaining are operating all facilities 6 days/week, 3 shifts per day. The provincial average occupancy rate is 84.0% based on current utilization and 77% based on maximum utilization. 5
Impact of ICU Service Use by Chronic Dialysis Patients The ORN has begun to look at the impact of ICU service use by chronic dialysis patients. Moving forward the ORN will conduct further analysis in this area to support improved planning and funding of this level of care. Summary The Provincial Dialysis Capacity Assessment 2011-2020 resulted in a snapshot of dialysis demand and capacity across Ontario in 2011 and forecasted out to 2020. This assessment will be used as a decision tool to ensure that the Ontario renal system has the capacity that patient will require. For further information, please contact Graham Woodward, Director, Ontario Renal Network (graham.woodward@renalnetwork.on.ca). 6
Appendix Maps Figure 1. Total Number of Approved Operating Hemodialysis Stations, by Facility, April 2012 7
Figure 2. Number of In-facility Hemodialysis Patients, by Facility, April 2011 8
Figure 3. Proportion of In-facility Hemodialysis Patients in Terms of Current Treatment Capacity 9
Figure 4. Facilities Operating Below Standard Station Utilization, April 2012 10
Terminology Home dialysis: The provision of dialysis in the home; includes peritoneal dialysis (in a patients home and in a Long Term Care home) and home hemodialysis. Dialysis station capacity shortage: A dialysis facility that does not have enough hemodialysis stations to support patient demand. Dialysis station capacity surplus: A dialysis facility that has more than enough dialysis stations to support the patient demand. Dialysis patient fallback: Occurs when a dialysis patient is transferred from a satellite dialysis facility and/or from home dialysis to a regional centre in order to receive care. Fallback hemodialysis stations: Hemodialysis stations located at regional centres, that are required to remain idle at all times in order to support fallback patients from dialysis satellites or from home dialysis. These stations are not included in the regional centre dialysis capacity calculation. Approved operating hemodialysis stations: The number of hemodialysis stations that are approved and budgeted to operate by the ORN & MOHLTC. Built hemodialysis stations: The number of physical hemodialysis stations located at a dialysis facility. Not all built stations are necessarily approved for operation by the ORN & MOHLTC. 11