Economic evaluations of dialysis treatment modalities. Health Policy. 2008;86:163-180. [PMID: 18243397 DOI: 10.1016/j.healthpol.2007.12.004]

Comparison of direct medical costs between automated and continuous ambulatory peritoneal dialysis

OBJECTIVE

We set out to estimate the direct medical costs (DMCs) of peritoneal dialysis (PD) and to compare the DMCs for continuous ambulatory PD (CAPD) and automated PD (APD). In addition, DMCs according to age, sex, and the presence of peritonitis were evaluated.

METHODS

Our retrospective cohort analysis considered patients initiating PD, calculating 2008 costs and, for comparison, updating the results for 2010. The analysis took the perspective of the Mexican Institute of Social Security, including outpatient clinic and emergency room visits, dialysis procedures, medications, laboratory tests, hospitalizations, and surgeries.

RESULTS

No baseline differences were observed for the 41 patients evaluated (22 on CAPD, 19 on APD). Median annual DMCs per patient on PD were US$15 072 in 2008 and US$16 452 in 2010. When analyzing percentage distribution, no differences were found in the DMCs for the modality groups. In both APD and CAPD, the main costs pertained to the dialysis procedure (CAPD 41%, APD 47%) and hospitalizations (CAPD 37%, APD 32%). Dialysis procedures cost significantly more (p = 0.001) in APD (US$7 084) than in CAPD (US$6 071), but total costs (APD US$15 389 vs CAPD US$14 798) and other resources were not different. The presence of peritonitis increased the total costs (US$16 075 vs US$14 705 for patients without peritonitis, p = 0.05), but in the generalized linear model analysis, DMCs were not predicted by age, sex, dialysis modality, or peritonitis. A similar picture was observed for costs extrapolated to 2010, with a 10% - 20% increase for each component--except for laboratory tests, which increased 52%, and dialysis procedures, which decreased 3%, from 2008.

CONCLUSIONS

The annual DMCs per patient on PD in this study were US$15 072 in 2008 and US$16 452 in 2010. Total DMCs for dialysis procedures were higher in APD than in CAPD, but the difference was not statistically significant. In both APD and CAPD, 90% of costs were attributable to the dialysis procedure, hospitalizations, and medications. In a multivariate analysis, no independent variable significantly predicted a higher DMC.

The choice of peritoneal dialysis catheter implantation technique by nephrologists

Peritoneal dialysis catheter (PDC) is the lifeline of peritoneal dialysis (PD) patients. One of the critical issues for successful PD is a well-functioning PDC which is timely inserted. It is the implantation technique rather than the catheter design that determines the outcome of the catheter. Dedication in acquiring the appropriate technique is vital to the success of a PD program. In this paper, we discuss the pros and cons of various techniques used for PDC implantation. A detailed description of PDC implantation by using the minilaparotomy method is presented. We strongly recommend mini-laparotomy as the method of choice for PDC implantation by nephrologists.

Perfil epidemiológico dos óbitos em terapia renal substitutiva e custo do tratamento

OBJETIVO: Descrever o perfil epidemiológico dos óbitos de pacientes em terapia renal substitutiva e o custo do tratamento. MÉTODOS: Estudo transversal e retrospectivo realizado com os dados da Base Nacional de Terapia Renal Substitutiva. Foram incluídos 2029 óbitos por insuficiência renal. Os dados foram analisados por inferência estatística e estatística não paramétrica. RESULTADOS: Houve maior número de óbitos entre os pacientes do sexo masculino e da raça branca. O custo do tratamento aumentou 6,7% nos gastos do estado e 45,3% no município. CONCLUSÃO: O maior número de óbitos ocorreu no sexo masculino, raça branca, variações bruscas nas taxas de mortalidade hospitalar e aumentou o custo do tratamento nos últimos três anos.

Mesenchymal stem cell therapy promotes renal repair by limiting glomerular podocyte and progenitor cell dysfunction in adriamycin-induced nephropathy

We previously reported that in a model of spontaneously progressive glomerular injury with early podocyte loss, abnormal migration, and proliferation of glomerular parietal epithelial progenitor cells contributed to the formation of synechiae and crescentic lesions. Here we first investigated whether a similar sequence of events could be extended to rats with adriamycin (ADR)-induced nephropathy. As a second aim, the regenerative potential of therapy with bone marrow-derived mesenchymal stem cells (MSCs) on glomerular resident cells was evaluated. In ADR-treated rats, decrease of WT1(+) podocyte number due to apoptosis was associated with reduced glomerular expression of nephrin and CD2AP. As a consequence of podocyte injury, glomerular adhesions of the capillary tuft to the Bowman's capsule were observed, followed by crescent-like lesions and glomerulosclerosis. Cellular components of synechiae were either NCAM(+) parietal progenitor cells or nestin(+) podocytes. In ADR rats, repeated injections of MSCs limited podocyte loss and apoptosis and partially preserved nephrin and CD2AP. MSCs attenuated the formation of glomerular podocyte-parietal epithelial cell bridges and normalized the distribution of NCAM(+) progenitor cells along the Bowman's capsule, thereby reducing glomerulosclerosis. Finding that MSCs increased glomerular VEGF expression and limited microvascular rarefaction may explain the prosurvival effect by stem cell therapy. MSCs also displayed anti-inflammatory activity. Coculture of MSCs with ADR-damaged podocytes showed a functional role of stem cell-derived VEGF on prosurvival pathways. These data suggest that MSCs by virtue of their tropism for damaged kidney and ability to provide a local prosurvival environment may represent a useful strategy to preserve podocyte viability and reduce glomerular inflammation and sclerosis.

Global trends in rates of peritoneal dialysis

Although there is a perception that the use of peritoneal dialysis is declining worldwide, compilations of global data are unavailable to test this hypothesis. We assessed longitudinal trends in the use of peritoneal dialysis from 1997 to 2008 in 130 countries. The preferred data sources were renal registries, followed by nephrology societies, health ministries, academic centers, national experts, and industry affiliates. In 2008, there were approximately 196,000 peritoneal dialysis patients worldwide, representing 11% of the dialysis population. In total, 59% were treated in developing countries and 41% in developed countries. Over 12 years, the number of peritoneal dialysis patients increased in developing countries by 24.9 patients per million population and in developed countries by 21.8 per million population. The proportion of all dialysis patients treated with peritoneal dialysis did not change in developing countries but significantly declined in developed countries by 5.3%. The use of automated peritoneal dialysis increased by 14.5% in developing countries and by 30.3% in developed countries. In summary, the number of patients treated with peritoneal dialysis rose worldwide from 1997 to 2008, with a 2.5-fold increase in the prevalence of peritoneal dialysis patients in developing countries. The proportion of all dialysis patients treated with this modality continues to decline in developed countries.

Inhibiting angiotensin-converting enzyme promotes renal repair by limiting progenitor cell proliferation and restoring the glomerular architecture

We previously reported that angiotensin-converting enzyme inhibitor (ACEi) renoprotection in Munich Wistar Frömter (MWF) rats, which develop progressive glomerular injury, was associated with podocyte repopulation and preservation of glomerular architecture. Here, we studied the time course of the lesions, their cellular components, and the effect of ACEi. Early glomerular lesions were synechiae, followed by extracapillary crescents and glomerulosclerosis. The majority of cells forming crescents were claudin1(+) parietal epithelial cells and, to a lesser extent, WT1(+) podocytes, both in active proliferation. In crescents, cells expressing the metanephric mesenchyme marker NCAM were also found. Three distinct populations of parietal epithelial cells were identified in the rat Bowman's capsule: NCAM(+)WT1(-) cells, also expressing progenitor cell marker CD24, and NCAM(+)WT1(+) and NCAM(-)WT1(+) cells, the latter population representing parietal podocytes. After exposure to inductive medium, cultured parietal epithelial cells that were obtained by capsulated glomeruli generated podocytes, documenting their progenitor nature. Mitotic activity of cultured renal progenitors was induced by angiotensin II through the down-regulation of cell cycle inhibitor C/EBPδ expression. Treatment with ACEi reduced number and extension of crescents and glomerulosclerosis in MWF rats. Renoprotection was accomplished through the limitation of NCAM(+) progenitor proliferation via the modulation of C/EBPδ. Thus, chaotic migration and proliferation of the Bowman's capsule progenitor cells pave the way to crescent formation and subsequent sclerosis. ACEi, by moderating progenitor cell activation, restores glomerular architecture and prevents renal disease progression.

Longitudinal analysis of market factors associated with provision of peritoneal dialysis services

Despite the appeal of peritoneal dialysis (PD) among patients, payers, and providers, its use in the United States has been limited and declining. Prior research has found that patient factors explain little variation in PD utilization, and little is known about the contribution of dialysis facility factors. The authors examined market factors associated with the provision of PD services in dialysis facilities between 1995 and 2003. Less than half of dialysis facilities offered PD. PD provision was not explained by disease trends or patient characteristics commonly associated with PD use. Facilities were more likely to offer PD in less competitive and less spatially concentrated markets. PD services may not be available to all patients who would benefit from it and there may be insufficient demand, economics of scale, or incentives for facilities to provide PD. These findings warrant further investigation on dialysis facilities' provision of a preferred, potentially beneficial, and cost-effective therapy.

Cost analysis of the Spanish renal replacement therapy programme

BACKGROUND

A cost analysis of the Spanish Renal Replacement Therapy (RRT) programme in the year 2010, for end-stage renal disease (ESRD) patients, was performed from the perspective of the Public Administration.

METHODS

The costs associated with each RRT modality [hemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation (Tx)] were analysed. The Spanish ESRD incidence and prevalence figures in the year 2010 were forecasted in order to enable the calculation of an aggregate cost for each modality. Costs were mainly computed based on a review of the existing literature and of the Official Bulletins of the Spanish Autonomous Communities. Data from Oblikue Consulting eSalud health care costs database and from several Spanish public sources were also employed.

RESULTS

In the year 2010, the forecasted incidence figures for HD, PD and Tx were 5409, 822 and 2317 patients, respectively. The forecasted prevalence figures were 22,582, 2420 and 24,761 patients, respectively. The average annual per-patient costs (incidence and prevalence) were €2651 and €37,968 (HD), €1808 and €25,826 (PD) and €38,313 and €6283 (Tx). Indirect costs amounted to €8929 (HD), €7429 (PD) and €5483 (Tx). The economic impact of the Spanish RRT programme on the Public Administration budget was estimated at ~€1829 million (indirect costs included): €1327 (HD), €109 (PD) and €393 (Tx) million.

CONCLUSIONS

HD accounted for >70% of the aggregate costs of the Spanish RRT programme in 2010. From a costs minimization perspective, it would be preferable if the number of incident and prevalent patients in PD were increased.

Renal replacement therapy review: past, present and future

Support of renal function in modern times encompasses a wide array of methods and clinical scenarios, from the ambulatory patient to the critically ill. The ability to safely and routinely deliver ongoing organ support in the outpatient setting has until recently separated renal replacement therapy from other organ support. Renal replacement therapy (RRT) can be applied intermittently or continuously using extracorporeal (hemodialysis) or paracorporeal (peritoneal dialysis) methods. The purpose of this article is to familiarize the reader with the history, physiology, mode, dose, equipment and future of renal replacement therapy and not to detail the technical methods employed for blood purification.

Determinantes dos gastos com diálises no Sistema Único de Saúde, Brasil, 2000 a 2004

O objetivo deste estudo é comparar os gastos ambulatoriais totais entre hemodiálise e diálise peritoneal, de 2000 a 2004, dos pacientes que iniciaram diálise, em 2000, no Sistema Único de Saúde (SUS). Foi desenvolvida coorte histórica de pacientes que iniciaram diálise em 2000, identificados por pareamento probabilístico na base de dados de Autorização de Procedimentos de Alta Complexidade/Custo (APAC). Utilizou-se modelo de regressão linear múltipla incluindo atributos individuais, clínicos e variáveis de oferta de serviços de saúde. A coorte foi constituída por 10.899 pacientes, 88,5% iniciaram em hemodiálise, e 11,5%, em diálise peritoneal. A modalidade explica 12% da variância dos gastos, os pacientes em diálise peritoneal apresentam um gasto médio anual 20% maior. Os diferenciais nos gastos são explicados pelo estado da federação e nível de oferta de serviços de saúde. As variáveis de risco individual não alteram o poder de explicação do modelo, sendo significativos a idade e a presença de diabetes mellitus. Constata-se a importância do sistema de pagamento do SUS para explicar as diferenças de gastos do tratamento dialítico no Brasil.

Economic consequences of an increased number of patients on outgoing dialysis

OBJECTIVE

During the past 10 years the number of prevalent patients on dialysis treatment has doubled in Denmark and the number is expected to increase further. The majority of Danish patients on dialysis receive haemodialysis at a hospital-based centre, and increasing patient numbers will put pressure on these dialysis centres. In order to reduce this pressure, more patients will need to be offered dialysis as outgoing treatment. The aim of this study was to analyse the economic consequences of an increased number of patients on outgoing dialysis in a Danish setting.

MATERIAL AND METHODS

A Markov model using Danish cost estimates and clinical parameters from the Danish National Registry was developed and used to simulate changes of dialysis modalities, exits to transplantation or death as well as entry of new incident patients over a period of 10 years.

RESULTS

The development in total annual costs over a 10-year period showed that an increased number of patients on outgoing dialysis will lead to total savings of approximately €9.6 million.

CONCLUSIONS

The estimated savings of approximately €9.6 million only constitute 0.6% of the total cost of dialysis. In terms of cost over time, therefore, an increased number of patients on outgoing treatment will not lead to an increase in costs; the total cost of treatment will probably be unchanged or slightly reduced. The results were sensitive to inclusion of capital costs and exclusion of costs associated with complications or comorbidity.

Dialysis facility and patient characteristics associated with utilization of home dialysis

BACKGROUND AND OBJECTIVES

Nonmedical factors influencing utilization of home dialysis at the facility level are poorly quantified. Home dialysis is comparably effective and safe but less expensive to society and Medicare than in-center hemodialysis. Elimination of modifiable practice variation unrelated to medical factors could contribute to improvements in patient outcomes and use of scarce resources.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Prevalent dialysis patient data by facility were collected from the 2007 ESRD Network's annual reports. Facility characteristic data were collected from Medicare's Dialysis Facility Compare file. A multivariate regression model was used to evaluate associations between the use of home dialysis and facility characteristics.

RESULTS

The utilization of home dialysis was positively associated with facility size, percent patients employed full- or part-time, younger population, and years a facility was Medicare certified. Variables negatively associated include an increased number of hemodialysis patients per hemodialysis station, chain association, rural location, more densely populated zip code, a late dialysis work shift, and greater percent of black patients within a zip code.

CONCLUSIONS

Improved understanding of factors affecting the frequency of use of home dialysis may help explain practice variations across the United States that result in an imbalanced use of medical resources within the ESRD population. In turn, this may improve the delivery of healthcare and extend the ability of an increasingly overburdened medical financing system to survive.

Geographic and temporal trends in peritoneal dialysis services in the United States between 1995 and 2003

BACKGROUND

Peritoneal dialysis (PD) is the preferred dialysis modality for many patients with end-stage renal disease (ESRD) in the United States. However, in sharp contrast to the high rates of PD use in other industrialized countries, PD use in the United States is low and decreasing. PD availability is a necessary condition for PD use; however, little is known about the availability and geographic distribution of PD services. This study describes trends in the regional supply of PD services in dialysis facilities between 1995 and 2003.

STUDY DESIGN

Longitudinal cohort study.

SETTING & PARTICIPANTS

Nonfederal outpatient dialysis facilities treating patients with ESRD in the United States using data from the US Renal Data System.

PREDICTORS

Annual ESRD patient and dialysis facility composition in hospital referral regions.

OUTCOME

Annual proportion of dialysis facilities offering PD treatment services in hospital referral regions.

RESULTS

The average proportion of facilities offering PD services in hospital referral regions was 56% in 1996, which decreased to 47% in 2003. There was geographic variation in PD services, with greater PD availability in metropolitan cities (compared with rural regions) and the Northeast (relative to the South and Midwest). Variation in PD availability was not explained by disease trends or patient characteristics believed to be important for PD use. An increasing regional presence of chain-affiliated facilities was associated with less PD supply.

LIMITATIONS

Accuracy of patient registry data, inability to account for consolidation of PD services among chain providers, sensitivity of results to definition of regional markets.

CONCLUSIONS

The small and decreasing availability of PD therapy seems counterintuitive given its demonstrated appeal to patients and payers. Further research is needed to investigate dialysis facilities' role in the underuse of a potentially useful therapy.

Ownership patterns of dialysis units and peritoneal dialysis in the United States: utilization and outcomes

BACKGROUND

Peritoneal dialysis (PD) provides outcomes similar to hemodialysis, but its use has decreased in the United States despite its potential for substantial taxpayer savings. We undertook this study to determine the relationship between dialysis unit ownership with PD use and outcomes.

STUDY DESIGN

Observational study.

SETTING & PARTICIPANTS

All incident dialysis patients (1996 to 2004) from the US Renal Data System.

PREDICTOR

Large dialysis organization (LDO), defined as corporations owning 20 or more freestanding dialysis units located in more than 1 state.

OUTCOMES & MEASUREMENTS

Odds for an incident dialysis patient undergoing PD and hazards for death on follow-up in incident PD patients for each of the 5 LDOs (non-LDO as reference).

RESULTS

During the 9-year period, 785,531 patients started maintenance dialysis therapy; the proportion receiving care in LDOs increased from 39% to 63%. There were consistent differences in PD use. It was significantly lower in LDO 2 (adjusted odds ratio [OR], 0.66; 95% confidence interval [CI], 0.64 to 0.68), LDO 3 (OR, 0.82; 95% CI, 0.80 to 0.85), and LDO 4 (OR, 0.96; 95% CI, 0.92 to 0.995) and higher in LDO 1 (adjusted OR, 1.06; 95% CI, 1.02 to 1.11) and LDO 5 (adjusted OR, 1.09; 95% CI, 1.06 to 1.12). Between 2000 and 2004, LDO 2 had the least use and greatest risk of death (hazard ratio, 1.08; 95% CI, 1.02 to 1.14); LDO 1 had greater use and the lowest death risk (hazard ratio, 0.87; 95% CI, 0.78 to 0.96).

LIMITATIONS

Only cross-sectional associations can be described.

CONCLUSIONS

Three of the 5 LDOs had consistently lower PD use. Patients treated in the LDO with the lowest use of PD had the greatest risk of death. Understanding relationships among providers, physicians, and dialysis modality use may help devise strategies for increasing PD use in appropriate patients. This has the potential to reduce the cost of renal replacement therapy and further improve outcomes.

Reimbursement and economic factors influencing dialysis modality choice around the world

The worldwide incidence of kidney failure is on the rise and treatment is costly; thus, the global burden of illness is growing. Kidney failure patients require either a kidney transplant or dialysis to maintain life. This review focuses on the economics of dialysis. Alternative dialysis modalities are haemodialysis (HD) and peritoneal dialysis (PD). Important economic factors influencing dialysis modality selection include financing, reimbursement and resource availability. In general, where there is little or no facility or physician reimbursement or payment for PD, the share of PD is very low. Regarding resource availability, when centre HD capacity is high, there is an incentive to use that capacity rather than place patients on home dialysis. In certain countries, there is interest in revising the reimbursement structure to favour home-based therapies, including PD and home HD. Modality selection is influenced by employment status, with an association between being employed and PD as the modality choice. Cost drivers differ for PD and HD. PD is driven mainly by variable costs such as solutions and tubing, while HD is driven mainly by fixed costs of facility space and staff. Many cost comparisons of dialysis modalities have been conducted. A key factor to consider in reviewing cost comparisons is the perspective of the analysis because different costs are relevant for different perspectives. In developed countries, HD is generally more expensive than PD to the payer. Additional research is needed in the developing world before conclusive statements may be made regarding the relative costs of HD and PD.