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2007 – Commissioners Summary
Renal Registry Annual Report 2007: Executive Summary for Commissioners of Renal Services
The UK Renal Registry produces an annual Report that contains detailed information on the provision and quality of Renal Replacement Therapy (RRT) for Established Renal Failure (ERF) in the UK. Copies of each Report are sent to all specialised commissioners, electronic copies can be downloaded from www.renalreg.org.
This Executive Summary of the 2007 UK Renal Registry Report is designed for commissioners of renal services and the format is similar to the 2006 Executive Summary. It has been developed because of an appreciation of the commissioners’ need for clear information to help drive up the quality and cost effectiveness of the renal services they commission. It is also hoped that it will be useful to patients and others without specialised knowledge of renal services. Appendix C of the main Report ( www.renalreg.org )gives a description of renal services for non-renal physicians.
Data items included in the Report are those that are of ‘headline’ importance to commissioners but do not describe all aspects of the care of patients with ERF; it is hoped that readers of this summary will turn to the full Report for further details.
The Scottish Renal Registry is funded and operated independently of the UK Renal Registry. It assembles a limited dataset with nearly complete data for each item and publishes its own detailed analyses but also sends a dataset to the UK Renal Registry for inclusion in UK-wide analyses.
Paediatric renal centres do not yet submit data electronically to the Registry, as many do not have suitable IT systems. Data on treatment of patients with established renal failure by paediatric renal centres is collected by means of an annual paper-based survey, data from which are then analysed by the Paediatric Registry Committee. None of the analyses presented in this summary report include data from paediatric renal centres.
The UK Renal Registry is working with the East Midlands Public Health Organisation to provide some of this data in the form of interactive maps using GIS software, which will viewable on the web by mid 2008.
Summary data from the UK Renal Registry is sent to other national and international Registries (including the European Dialysis and Transplantation Association – European Renal Association Registry (http://www.era-edta-reg.org ), and the United States Renal Data System (www.usrds.org), to allow comparisons with other countries.
The purpose of the UK Renal Registry is described in full in Appendix A of the full Report, but may be summarised as follows:
- To improve the care of patients with renal disease
- To facilitate comparative audit of outcomes between renal centres and to aid nephrologists in improving their practice and outcomes
- To aid Trust clinical governance departments and contracts managers
- To provide commissioners of renal services with information on the volume, quality, and equity of renal services Caution
There are several dangers in providing the detailed analyses of the outcomes of RRT. Commissioners (and other users of these analyses) should therefore use the variations shown to inform discussions with their providers on the quality of the care provided, rather than draw direct conclusions from them. Several examples are given below.
Some of the analyses presented relate to performance against a ‘standard’ set by the Renal Association. It should be emphasised that failure to achieve this standard in 100% of patients is not necessarily a marker of inferior care. For example, case-mix can influence the achievement of these goals. Achievement of some standards depends on circumstances outside the clinicians’ direct control, for instance because it is affected by patients’ adherence to complex drug treatment regimens.
Many of the analyses are presented in the form of ‘caterpillar plots’, which are akin to league tables. These plots include a measure of renal centre performance (e.g. the median haemoglobin concentration, or the percentage of patients whose haemoglobin concentration is within a certain range). The plots encourage comparisons between renal centres and the conclusion that renal centres whose figures lie at the ‘good’ end of the plot are performing better than those whose figures lie at the other end. However, some of these differences may occur by chance. Whenever two numbers are compared, it is inevitable that one will be larger than another.
The summary measures of centre performance are also presented with a measure of the statistical uncertainty – the 95% confidence interval. Confidence intervals are valuable ways of comparing two estimates of performance: if the confidence intervals do not overlap, the difference between the two estimates is unlikely to have occurred by chance. However, if 80 such comparisons are made, it is highly likely that an apparently ‘significant’ difference between two renal centres will occur by chance. The ‘funnel plots’ presented here are a more statistically acceptable way of presenting differences between renal centres, but have the disadvantage that the points on the graph need to be checked against the tabulated data to identify the individual renal centres.
There is the possibility that commissioners might choose to reduce funding for a particular part of a service if their local renal centre is achieving higher than average standards in that service. In most instances this would be a retrograde step. The analyses presented here contain no analyses of the costs of care; however, it is likely that much of the variation in outcomes is due not to differences in funding but in differences in the efficiency of care processes. Withdrawing funding from high-performing centres risks penalising efficient services, where the correct approach would be to identify the underlying systems and processes that deliver better outcomes and to spread those practices to other areas. In some clinical areas, reduced investment in quality of care would undoubtedly lead to higher costs in other areas: for instance, reduction of expenditure on vascular access surgery in high-performing centres is highly likely to result in increased risk of hospitalisation for complications of failed vascular access, including catheter-related MRSA (and other) bacteraemia.