Dialysis Care in Canada Pietro Ravani, PhD, MD Professor of Medicine pravani@ucalgary.ca 1
www.health.alberta.ca Full benefits: in-patients / triage / GP / spec / AISH Drug 100% coverage if > 65; 70% if < 65 (subsidy for low income); depending on job benefits ~80-100% Limited benefits: Chiropractic, Dental, Podiatry, Optometry, Physical Therapy 2
3 Key points
4 Geography
Comparisons Total Km2 Water Km2 Pop (M) Pop/Km2 Russia 17,000,000 700,000 146 8.4 Canada 10,000,000 900,000 36 3.6 China 9,600,000 270,000 1,370 142 USA 9,500,000 360,000 320 32.6 Italy 300,000 7,000 61 202
100,000 pop. within 3.6 M Km2 21% of POP <16% of GPs 2.4% of specialists
Health Care System in Canada Canada Health Act criteria: Public Administration Comprehensiveness Universality Portability Accessibility 7
AB study findings Remote-dwellers with DM and CKD were (compared to urban-dwellers): < likely to receive specialist care <likely to have recommended labs <likely to be prescribed appropriate meds >likely to die or be hospitalized <likely to start RRT despite ~ ESRD burden
Risk of death is higher in remote dwelling dialysis patients (HD+PD) Death by Distance to Nephrologist All Patients, Adjusted Hazard Ratio 1.3 1.8 1 1.08 1.10 1.13 0.5 0.7 P for trend 0.0001 <=50 50.1-150 150.1-300 >300 Distance (km) N=26,098
CAN health survey 1. Access to Primary Care Resources & Measures of Health Care Utilization 2. Receipt of Recommended Care 3. Lifestyle Behaviour Change 4. General Barriers to Care 5. Economic Barriers to Care 6. Time and Risk Preference Explaining Behaviour 7. Geographic Barriers to Chronic Disease Care 8. Acceptability of Information Technology
Tech. 1: Tele-health?
What is telehealth?
What is telehealth? our definition: two-way interactions between doctor and patient, which replace a usual clinical encounter
Tech. 2: Mob devices?
SMS (text message) support educate empower send reminders a written record engage our definition: one-way message from provider to patient
Examples US: diagnostics, interventional procedures Clinical assessment (Guided surgery)
Old paradigm (e.g., US) Certified sonographer at the bed-side unavailable in geographically isolated areas Images generation unavailable However, non-radiologist MDs do perform US guided diagnostic and intervention procedures for specific issues
New paradigm Tele-Mentored US imaging: novice US operator generates interpretable (real-time verified) images under the remote guidance of a board-certified sonographer Operator: nurse, MD, any novice; level of care delivery depends on the training Decisions made remotely
TMUS concept Pioneered by Dr. Hamilton et al while with NASA (space medicine) Further proven during Turin Olympics (experts at Henry Ford Hospital) NASA and HFH developed and tested a bilingual training module for training
US examples
From CBC website http://www.cbc.ca/news/canada/saskatch ewan/5-ways-robots-are-delivering-healthcare-in-saskatchewan-1.2966190
TC system in Canada HS connectivity to all locations, still suboptimally used in remote areas Fiber-optic backbones everywhere under 60 LAT Above 60 LAT connectivity increasingly dependent on commercially provided satellite communication and geosynchronous satellite systems
Anik F2 Anik F2 is poised to deliver North America's first commercial satellitebased broadband communications service.
Pilot testing
Other remote applications McBeth et al., J Trauma 2011
TH requires An operator (GUI may simply require to hold a probe on a patient) A reliable tool (more or less simple often only a stethoscope) Geosynchronous communication system
Total (2014) 4,100,000 Zones Pop n 1) North 0.5 M 2) Edmonton 1.1 M 3) Central 0.5 M 4) Calgary 1.5 M 5) South 0.5 M 27
28
NARP SARP CKD 29
Administration 30
Ministry of Health Board of the Directors CEO Vice-presidents Care delivery 31
32
SARP (Dec 31, 2014) Method Patients Conventional 729 HD Home 85 In-centre nocturnal 25 PD CAPD 30 CCPD 242 TX Prevalent 833 CKD egfr <30 ml/min 1,498 35
SARP 38 MDs 3 Surgeons (TX/VA) 6 TX nephrology 20 Adult N 7 Children N 2 Adult N in the south 36
SARP FTE Personnel OUT IN TOT NURSES 265 58 323 N aids 45 16 61 Managers 10 3 13 Clerks 40 12 52 Educators 7 1 8 Technicians 9 0 9 Dieticians 6.6 1.6 8.2 Pharmacists 2.4 5.2 7.6 Social w. 8 3.5 11.5 Physio-kinesiol 1 2 3 37
Nursing levels 1. N attendant, HC aids (< 1 yr) 2. Licensed Practical N, some meds / prescriptions (task focus); (1.5 yr) 3. Registered Nurse Problem solving (assessment before/after); (4 yrs) 4. Nurse clinician and Nurse manager of human resources (+ experience) 5. Nurse educator 4 + 2 yr M + 1 yr certificate (every 5 years); 6. Nurse practitioner 4 + 2 M + 1 yr practicing 38
Clinical service 39
Services Clinical Rotations Clinics Lab / chart review Academic Teaching (formal, informal) Research Administrative Protocols Policies 40
Encounters Outpatient On HD (1-3 / w) In clinic (q 1-3 m) Inpatient In U37 In any non-nephro U 41
SARP locations Preventive and treatment care south of Red Deer Calgary & satellites Lethbridge Medicine Hat 42
FMC: Calgary Area Consults PLC: Nephro A HD Consults Nephro C PEX HD HD HD CKD HD HD PD CK RVG: Consults South: HD HD 43 Consults
Calgary Rotations FMC-CO FMC-CH FMC-AC 75 20 90 HD HD HD PD CK HD 60 40 NE 5 MDs / W-Days 2 MDs / WE+N SOUTH HD 60 44
45 Technology
Communication 46
Databases Sunrise Clinical Management Clinical decision making (order entry), Delivery of care (electronic MAR), Review of results (lab, DI etc), Clinical documents Picture Archiving & Communication System Combination of hardware and software for storage, retrieval, management, distribution, and presentation of images http://www.albertanetcare.ca/ Implementation of a single, province-wide EHR: all the projects, processes, products, and services of AHS AB Netcare EHR Portal: tool for physicians, pharmacists and other health service providers, providing up-to-date available information immediately at the point of care 47
PARIS & ALTRAbase Information on demographic, co-morbidity, clinical outcomes (including health-related quality of life), Labs, and Health Care Costs Linked with other available local clinical and administrative databases Opportunities Monitoring the implementation of established clinical practice guidelines Quality assurance initiatives Research opportunities with a minimal need for manual data entry 48
Education 49
Students MEDICINE Rotations (FMC): Consult, Acute, Out-PT At any time: 1 M Clerk & 2 MR 1/2/3 # of 4 W-Block = 2 in 3 years of MR (+ electives) FELLOWS 2 NR1 3 NR2 50
Nephrology Fellowship 26 4w blocks in 2 years (mandatory rotations) 10 4w blocks for electives Structured learning every tuesday afternoon Out-pat clinics with preceptors 3 1/2 days per w Calls: 6 nights in 28 days CSN sets learning objectives -> core document -> RCPSC approval -> PGME supervision National IM (1st year) + Nephro (2nd) exams 51
Research 52
www.akdn.info Mission 53
www.akdn.info/research/research3.php 54
Knowledge Translation 55
Web Resources 56
8 links to PP 24 links to PP 6 links to PP 113 links to PP 52 links to PP 57
58 Key points
Thank you pravani@ucalgary.ca 59