1
|
Cheetham MS, Ethier I, Krishnasamy R, Cho Y, Palmer SC, Johnson DW, Craig JC, Stroumza P, Frantzen L, Hegbrant J, Strippoli GF. Home versus in-centre haemodialysis for people with kidney failure. Cochrane Database Syst Rev 2024; 4:CD009535. [PMID: 38588450 PMCID: PMC11001293 DOI: 10.1002/14651858.cd009535.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
BACKGROUND Home haemodialysis (HHD) may be associated with important clinical, social or economic benefits. However, few randomised controlled trials (RCTs) have evaluated HHD versus in-centre HD (ICHD). The relative benefits and harms of these two HD modalities are uncertain. This is an update of a review first published in 2014. This update includes non-randomised studies of interventions (NRSIs). OBJECTIVES To evaluate the benefits and harms of HHD versus ICHD in adults with kidney failure. SEARCH METHODS We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2022 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. We searched MEDLINE (OVID) and EMBASE (OVID) for NRSIs. SELECTION CRITERIA RCTs and NRSIs evaluating HHD (including community houses and self-care) compared to ICHD in adults with kidney failure were eligible. The outcomes of interest were cardiovascular death, all-cause death, non-fatal myocardial infarction, non-fatal stroke, all-cause hospitalisation, vascular access interventions, central venous catheter insertion/exchange, vascular access infection, parathyroidectomy, wait-listing for a kidney transplant, receipt of a kidney transplant, quality of life (QoL), symptoms related to dialysis therapy, fatigue, recovery time, cost-effectiveness, blood pressure, and left ventricular mass. DATA COLLECTION AND ANALYSIS Two authors independently assessed if the studies were eligible and then extracted data. The risk of bias was assessed, and relevant outcomes were extracted. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Meta-analysis was performed on outcomes where there was sufficient data. MAIN RESULTS From the 1305 records identified, a single cross-over RCT and 39 NRSIs proved eligible for inclusion. These studies were of varying design (prospective cohort, retrospective cohort, cross-sectional) and involved a widely variable number of participants (small single-centre studies to international registry analyses). Studies also varied in the treatment prescription and delivery (e.g. treatment duration, frequency, dialysis machine parameters) and participant characteristics (e.g. time on dialysis). Studies often did not describe these parameters in detail. Although the risk of bias, as assessed by the Newcastle-Ottawa Scale, was generally low for most studies, within the constraints of observational study design, studies were at risk of selection bias and residual confounding. Many study outcomes were reported in ways that did not allow direct comparison or meta-analysis. It is uncertain whether HHD, compared to ICHD, may be associated with a decrease in cardiovascular death (RR 0.92, 95% CI 0.80 to 1.07; 2 NRSIs, 30,900 participants; very low certainty evidence) or all-cause death (RR 0.80, 95% CI 0.67 to 0.95; 9 NRSIs, 58,984 patients; very low certainty evidence). It is also uncertain whether HHD may be associated with a decrease in hospitalisation rate (MD -0.50 admissions per patient-year, 95% CI -0.98 to -0.02; 2 NRSIs, 834 participants; very low certainty evidence), compared with ICHD. Compared with ICHD, it is uncertain whether HHD may be associated with receipt of kidney transplantation (RR 1.28, 95% CI 1.01 to 1.63; 6 NRSIs, 10,910 participants; very low certainty evidence) and a shorter recovery time post-dialysis (MD -2.0 hours, 95% CI -2.73 to -1.28; 2 NRSIs, 348 participants; very low certainty evidence). It remains uncertain if HHD may be associated with decreased systolic blood pressure (SBP) (MD -11.71 mm Hg, 95% CI -21.11 to -2.46; 4 NRSIs, 491 participants; very low certainty evidence) and decreased left ventricular mass index (LVMI) (MD -17.74 g/m2, 95% CI -29.60 to -5.89; 2 NRSIs, 130 participants; low certainty evidence). There was insufficient data to evaluate the relative association of HHD and ICHD with fatigue or vascular access outcomes. Patient-reported outcome measures were reported using 18 different measures across 11 studies (QoL: 6 measures; mental health: 3 measures; symptoms: 1 measure; impact and view of health: 6 measures; functional ability: 2 measures). Few studies reported the same measures, which limited the ability to perform meta-analysis or compare outcomes. It is uncertain whether HHD is more cost-effective than ICHD, both in the first (SMD -1.25, 95% CI -2.13 to -0.37; 4 NRSIs, 13,809 participants; very low certainty evidence) and second year of dialysis (SMD -1.47, 95% CI -2.72 to -0.21; 4 NRSIs, 13,809 participants; very low certainty evidence). AUTHORS' CONCLUSIONS Based on low to very low certainty evidence, HHD, compared with ICHD, has uncertain associations or may be associated with decreased cardiovascular and all-cause death, hospitalisation rate, slower post-dialysis recovery time, and decreased SBP and LVMI. HHD has uncertain cost-effectiveness compared with ICHD in the first and second years of treatment. The majority of studies included in this review were observational and subject to potential selection bias and confounding, especially as patients treated with HHD tended to be younger with fewer comorbidities. Variation from study to study in the choice of outcomes and the way in which they were reported limited the ability to perform meta-analyses. Future research should align outcome measures and metrics with other research in the field in order to allow comparison between studies, establish outcome effects with greater certainty, and avoid research waste.
Collapse
Affiliation(s)
- Melissa S Cheetham
- Renal Unit, Sunshine Coast University Hospital, Birtinya, Australia
- Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Isabelle Ethier
- Department of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Health Innovation and Evaluation Hub, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Rathika Krishnasamy
- Renal Unit, Sunshine Coast University Hospital, Birtinya, Australia
- Faculty of Medicine, The University of Queensland, Herston, Australia
- Australasian Kidney Trials Network, Translational Research Institute, Woolloongabba, Australia
| | - Yeoungjee Cho
- Faculty of Medicine, The University of Queensland, Herston, Australia
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Paul Stroumza
- Medical Office, Diaverum Marseille, Marseille, France
| | - Luc Frantzen
- Medical Office, Diaverum Marseille, Marseille, France
| | - Jorgen Hegbrant
- Division of Nephrology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Giovanni Fm Strippoli
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| |
Collapse
|
2
|
Abstract
Patients on chronic hemodialysis are counseled to reduce dietary sodium intake to limit their thirst and consequent interdialytic weight gain (IDWG), chronic volume overload and hypertension. Low-sodium dietary trials in hemodialysis are sparse and mostly indicate that dietary education and behavioral counseling are ineffective in reducing sodium intake and IDWG. Additional nutritional restrictions and numerous barriers further complicate dietary adherence. A low-sodium diet may also reduce tissue sodium, which is positively associated with hypertension and left ventricular hypertrophy. A potential alternative or complementary approach to dietary counseling is home delivery of low-sodium meals. Low-sodium meal delivery has demonstrated benefits in patients with hypertension and congestive heart failure but has not been explored or implemented in patients undergoing hemodialysis. The objective of this review is to summarize current strategies to improve volume overload and provide a rationale for low-sodium meal delivery as a novel method to reduce volume-dependent hypertension and tissue sodium accumulation while improving quality of life and other clinical outcomes in patients undergoing hemodialysis.
Collapse
Affiliation(s)
- Luis M Perez
- Division of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, Denver, CO, USA
- Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Annabel Biruete
- Department of Nutrition and Dietetics, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | |
Collapse
|
3
|
Guía de unidades de hemodiálisis 2020. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
4
|
Ferguson TW, Whitlock RH, Bamforth RJ, Beaudry A, Darcel J, Di Nella M, Rigatto C, Tangri N, Komenda P. Cost-Utility of Dialysis in Canada: Hemodialysis, Peritoneal Dialysis, and Nondialysis Treatment of Kidney Failure. Kidney Med 2020; 3:20-30.e1. [PMID: 33604537 PMCID: PMC7873742 DOI: 10.1016/j.xkme.2020.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Rationale & Objective The kidney failure population is growing, necessitating the expansion of dialysis programs. These programs are costly and require a substantial amount of health care resources. Tools that accurately forecast resource use can aid efficient allocation. The objective of this study is to describe the development of an economic simulation model that incorporates treatment history and detailed modality transitions for patients with kidney disease using real-world data to estimate associated costs, utility, and survival by initiating modality. Study Design Cost-utility model with microsimulation. Setting & Population Adult incident maintenance dialysis patients in Canada who initiated facility-based hemodialysis (HD) or home peritoneal dialysis (PD) between 2004 and 2013. Intervention HD and PD. Outcomes Costs (related to dialysis, transplantation, infections, and hospitalizations), survival, utility, and dialysis modality mix over time. Model, Perspective, & Timeframe The model took the perspective of the health care payer. Patients were followed up for 10 years from initiation of dialysis. Our cost-utility analysis compared the intervention with receiving no treatment. Results During a 10-year time horizon, the cost-utility ratio for all patients initiating dialysis was $103,779 per quality-adjusted life-year (QALY) in comparison to no treatment. Patients who initiated with facility-based HD were treated at a cost-utility ratio of $104,880/QALY and patients who initiated with home PD were treated at a cost-utility ratio of $83,762/QALY. During this time horizon, the total mean cost and QALYs per patient were estimated at $350,774 ± $204,704 and 3.38 ± 2.05) QALYs respectively. Limitations The results do not include costs from the societal perspective. Rare patient trajectories were unable to be assessed. Conclusions This model demonstrates that patients who initiated dialysis with PD were treated more cost-effectively than those who initiated with HD during a 10-year time horizon.
Collapse
Affiliation(s)
- Thomas W. Ferguson
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Reid H. Whitlock
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Ryan J. Bamforth
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Alain Beaudry
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Joseph Darcel
- Department of Medicine, University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Michelle Di Nella
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Claudio Rigatto
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
- Address for Correspondence: Paul Komenda, MD, MHA, Seven Oaks General Hospital, 2LB10-2300 McPhillips Street, Winnipeg, MB, Canada R2V 3M3.
| |
Collapse
|
5
|
Mendelssohn DC, Pierratos A. Reformulating the Integrated Care Concept for the New Millennium. Perit Dial Int 2020. [DOI: 10.1177/089686080202200101] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The concept of integrated care advocates a planned approach to predialysis care. Its components include timely referral to a renal care team, timely preparation for dialysis, and timely initiation of dialysis, with peritoneal dialysis (PD) as the initial therapy for suitable patients. This initial therapy may then be followed by timely transfer to hemodialysis (HD) when residual renal function declines or when other PD-related problems occur. We argue that at least three problems exist with the integrated care approach as it is currently being articulated. They are ( 1 ) an under emphasis on slowing the rate of progression of chronic kidney disease, aggressive management of cardiovascular risk factors and other comorbidities, and pre-emptive live donor transplantation; ( 2 ) a lack of consideration of home HD as an alternate initial therapy; and ( 3 ) a lack of discussion about patient choice. We propose a modified version of integrated care that we believe will optimize modality distribution and patient outcomes, while reducing the relative costs per patient treated, compared to the current situation in most countries.
Collapse
Affiliation(s)
| | - Andreas Pierratos
- Division of Nephrology Humber River Regional Hospital Toronto, Ontario, Canada
| |
Collapse
|
6
|
The Symptoms and Impact of Recurrent Focal Segmental Glomerulosclerosis in Kidney Transplant Recipients: A Conceptual Model of the Patient Experience. Adv Ther 2019; 36:3390-3408. [PMID: 31612357 PMCID: PMC6860472 DOI: 10.1007/s12325-019-01110-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Indexed: 12/25/2022]
Abstract
Introduction We qualitatively examined the symptoms and impact of recurrent primary focal segmental glomerulosclerosis (rpFSGS) in kidney transplant recipients, compared with two related FSGS populations, to characterize the experience of patients with rpFSGS. Methods A literature review identified 58 articles concerning the experience of patients with pFSGS and/or rpFSGS in three groups: pre-transplant pFSGS, post-transplant rpFSGS, or post-transplant non-recurrent pFSGS. Literature findings were used to construct a preliminary conceptual model incorporating the symptoms and impact of rpFSGS, which was refined on the basis of qualitative interviews with clinicians. Twenty-five patients (rpFSGS: n = 15; pre-transplant pFSGS: n = 5; post-transplant non-recurrent pFSGS: n = 5) were interviewed to characterize the experience of patients with rpFSGS and compare it with other FSGS populations, and findings were used to finalize the conceptual model. Results The impact of pFSGS/rpFSGS described in the literature was diverse. Treatment-related symptoms, along with anxiety and depression, were considered important features of rpFSGS in addition to the findings from the literature review, according to clinicians. Patient-reported tiredness and swelling were the most common/disturbing symptoms associated with rpFSGS, while physical activity restrictions and adverse effects on work/social life were considered the most profound impact concepts. The collective disease experience was different for patients with rpFSGS and non-recurrent pFSGS, although psychological impact, including treatment-related anxiety and depression, were common to both groups. Conclusions Post-transplant recipients with rpFSGS display a greater symptom burden and experience a more diverse impact than those with non-recurrent pFSGS, highlighting the importance of effective patient monitoring and introducing effective treatments for the prevention and management of pFSGS recurrence. Funding Astellas Pharma Global Development, Inc. Electronic Supplementary Material The online version of this article (10.1007/s12325-019-01110-5) contains supplementary material, which is available to authorized users.
Collapse
|
7
|
Krahn MD, Bremner KE, de Oliveira C, Dixon SN, McFarlane P, Garg AX, Mitsakakis N, Blake PG, Harvey R, Pechlivanoglou P. Home Dialysis Is Associated with Lower Costs and Better Survival than Other Modalities: A Population-Based Study in Ontario, Canada. Perit Dial Int 2019; 39:553-561. [PMID: 31582466 DOI: 10.3747/pdi.2018.00268] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/05/2019] [Indexed: 12/19/2022] Open
Abstract
Background:How and where to initiate dialysis are policy challenges with enormous economic and health consequences. Initiating with home hemodialysis (HD) or peritoneal dialysis (PD) may reduce costs and improve outcomes but evidence is conflicting.Methods:We conducted a population-based study in patients aged ≥ 18 years who initiated chronic dialysis in the province of Ontario, Canada from 2006 to 2014 (N = 12,691) using linked administrative data. Patients were grouped by initial modality: facility HD, facility short daily or slow nocturnal (SD/SN) HD, PD, home HD. We estimated publicly-paid healthcare costs (2015 Canadian dollars; 1 = 0.947 US dollar) and survival, from dialysis initiation to March 2015.Results:By 5 years after dialysis initiation, mean 30-day costs (as-treated) for patients receiving PD and home HD were 50% and 64% lower, respectively, than for facility HD patients ($11,011). Approximately 50% of costs were unrelated to dialysis, reflecting high comorbidity in these patients. With covariate adjustment, mean 5-year cumulative costs were similar for initiators of home HD and PD ($304,178 and $349,338) and higher for facility HD initiators ($410,981). The highest 5-year unadjusted survival was for home HD patients (80%), followed by PD (52%), SD/SN HD (50%), and facility HD (42%).Conclusions:This study in a large cohort over 9 years provides new population-based evidence suggesting that initiating dialysis at home is cost-effective, with lower costs and better survival, than starting with facility HD. Survival differences persisted after adjustment for baseline characteristics but we could not adjust for functional status or severity of comorbidities.
Collapse
Affiliation(s)
- Murray D Krahn
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Karen E Bremner
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Claire de Oliveira
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Stephanie N Dixon
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - Amit X Garg
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Division of Nephrology, London Health Sciences Centre, Victoria Hospital and University Hospital, London, ON, Canada
| | - Nicholas Mitsakakis
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Peter G Blake
- Ontario Renal Network, Toronto, ON, Canada.,Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | | |
Collapse
|
8
|
Huang B, Lai B, Xu L, Wang Y, Cao Y, Yan P, Chen J. Low employment and low willingness of being reemployed in Chinese working-age maintained hemodialysis patients. Ren Fail 2018; 39:607-612. [PMID: 28805490 PMCID: PMC6446148 DOI: 10.1080/0886022x.2017.1361834] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
AIM Returning to society plays an important role in improving the quality of life in maintenance hemodialysis (MHD) patients, and retention of employment is one of the core enablers. The study is to assess the employment status and to determine the variables for unemployment in Chinese MHD patients. METHODS Prevalent MHD patients from four dialysis centers in Shanghai China were enrolled. We assessed patients' employment status, current social functioning, hemodialysis modality, annual income and general health condition. Among current unemployed working-age patients, the reasons of quitting jobs and willingness of being reemployed were evaluated. RESULTS A total of 231 patients were studied, among which 114 patients were unemployed 1 year before hemodialysis. Among 117 employed patients, 16 patients quitted jobs before dialysis inception, while 49 patients quitted jobs at the initiation of HD, and 26 patients followed after a few months' HD. The main reasons for ceasing employment were physical insufficiency, conflict between dialysis and work schedules, lack of support from employers and resistance from family members. Among the 166 patients who were in their working age, 26 patients were employed. The unemployed patients had the characters of elder age, lower education level, higher annual family income, higher female ratio, lower blood flow, lower physical functioning, and social functioning and lower frequency of weekend hemodialysis and HDF/HF. Among the 140 unemployed patients, only 47 patients had the willingness of being reemployed. Their unemployment status was positively associated with elder age ((OR) 3.13, 95% CI, 1.08-9.1), lower education level ((OR) 1.97, 95% CI, 1.05-5.92), and higher family income ((OR) 7.75, 95% CI, 2.49-24.14). CONCLUSION Ratio of employment and willingness of being reemployed was low in MHD working-age patients. Lack of social and family's support also hampered patient's returning to society except for the HD treatment quality.
Collapse
Affiliation(s)
- Bihong Huang
- a Department of Nursing , Huashan Hospital Fudan University , Shanghai , China
| | - Bihong Lai
- b Department of Nursing , Pudong Hospital, Fudan University , Shanghai , China
| | - Ling Xu
- c Department of Nursing , Shanghai Fifth Hospital, Fudan University , Shanghai , China
| | - Ying Wang
- d Department of Nursing , The 455th Hospital of PLA , Shanghai , China
| | - Yanpei Cao
- a Department of Nursing , Huashan Hospital Fudan University , Shanghai , China
| | - Ping Yan
- e Department of Cardiology , Huashan Hospital Fudan University , Shanghai , China
| | - Jing Chen
- f Department of Nephrology , Huashan Hospital Fudan University , Shanghai , China
| |
Collapse
|
9
|
Miller BW, Himmele R, Sawin DA, Kim J, Kossmann RJ. Choosing Home Hemodialysis: A Critical Review of Patient Outcomes. Blood Purif 2018; 45:224-229. [PMID: 29478056 DOI: 10.1159/000485159] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIM Home hemodialysis (HHD) has been associated with improved clinical outcomes vs. in-center HD (ICHD). The prevalence of HHD in the United States is still very low at 1.8%. This critical review compares HHD and ICHD outcomes for survival, hospitalization, cardiovascular (CV), nutrition, and quality of life (QoL). METHODS Of 545 publications identified, 44 were not selected after applying exclusion criteria. A systematic review of the identified publications was conducted to compare HHD to ICHD outcomes for survival, hospitalization, CV outcomes, nutrition, and QoL. RESULTS Regarding mortality, 10 of 13 trials reported 13-52% reduction; three trials found no differences. According to 6 studies, blood pressure and left ventricular size measurements were generally lower in HHD patients compared to similar measurements in ICHD patients. Regarding nutritional status, conflicting results were reported (8 studies); some found improved muscle mass, total protein, and body mass index in HHD vs. ICHD patients, while others found no significant differences. There were no significant differences in the rate of hospitalization between HHD and ICHD in the 6 articles reviewed. Seven studies on QoL demonstrated positive trends in HHD vs. ICHD populations. CONCLUSIONS Despite limitations in the current data, 66% of the publications reviewed (29/44) demonstrated improved clinical outcomes in patients who chose HHD. These include improved survival, CV, nutritional, and QoL parameters. Even though HHD may not be preferred in all patients, a review of the literature suggests that HHD should be provided as a modality choice for substantially more than the current 1.8% of HHD patients in the United States.
Collapse
|
10
|
Cost analysis of substitutive renal therapies in children. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2018. [DOI: 10.1016/j.jpedp.2017.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
11
|
Camargo MFCD, Barbosa KDS, Fetter SK, Bastos A, Feltran LDS, Koch-Nogueira PC. Cost analysis of substitutive renal therapies in children. J Pediatr (Rio J) 2018; 94:93-99. [PMID: 28750890 DOI: 10.1016/j.jped.2017.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 04/19/2017] [Accepted: 02/27/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE End-stage renal disease is a health problem that consumes public and private resources. This study aimed to identify the cost of hemodialysis (either daily or conventional hemodialysis) and transplantation in children and adolescents. METHODS This was a retrospective cohort of pediatric patients with End-stage renal disease who underwent hemodialysis followed by kidney transplant. All costs incurred in the treatment were collected and the monthly total cost was calculated per patient and for each renal therapy. Subsequently, a dynamic panel data model was estimated. RESULTS The study included 30 children who underwent hemodialysis (16 conventional/14 daily hemodialysis) followed by renal transplantation. The mean monthly outlay for hemodialysis was USD 3500 and USD 1900 for transplant. Hemodialysis costs added up to over USD 87,000 in 40 months for conventional dialysis patients and USD 131,000 in 50 months for daily dialysis patients. In turn, transplant costs in 50 months reached USD 48,000 and USD 70,000, for conventional and daily dialysis patients, respectively. For conventional dialysis patients, transplant is less costly when therapy exceeds 16 months, whereas for daily dialysis patients, the threshold is around 13 months. CONCLUSION Transplantation is less expensive than dialysis in children, and the estimated thresholds indicate that renal transplant should be the preferred treatment for pediatric patients.
Collapse
Affiliation(s)
| | | | | | - Ana Bastos
- Hospital Samaritano, São Paulo, SP, Brazil
| | | | | |
Collapse
|
12
|
Walker RC, Howard K, Morton RL. Home hemodialysis: a comprehensive review of patient-centered and economic considerations. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:149-161. [PMID: 28243134 PMCID: PMC5317253 DOI: 10.2147/ceor.s69340] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Internationally, the number of patients requiring treatment for end-stage kidney disease (ESKD) continues to increase, placing substantial burden on health systems and patients. Home hemodialysis (HD) has fluctuated in its popularity, and the rates of home HD vary considerably between and within countries although there is evidence suggesting a number of clinical, survival, economic, and quality of life (QoL) advantages associated with this treatment. International guidelines encourage shared decision making between patients and clinicians for the type of dialysis, with an emphasis on a treatment that aligned to the patients’ lifestyle. This is a comprehensive literature review of patient-centered and economic impacts of home HD with the studies published between January 2000 and July 2016. Data from the primary studies representing both efficiency and equity of home HD were presented as a narrative synthesis under the following topics: advantages to patients, barriers to patients, economic factors influencing patients, cost-effectiveness of home HD, and inequities in home HD delivery. There were a number of advantages for patients on home HD including improved survival and QoL and flexibility and potential for employment, compared to hospital HD. Similarly, there were several barriers to patients preferring or maintaining home HD, and the strategies to overcome these barriers were frequently reported. Good evidence reported that indigenous, low-income, and other socially disadvantaged individuals had reduced access to home HD compared to other forms of dialysis and that this situation compounds already-poor health outcomes on renal replacement therapy. Government policies that minimize barriers to home HD include reimbursement for dialysis-related out-of-pocket costs and employment-retention interventions for home HD patients and their family members. This review argues that home HD is a cost-effective treatment, and increasing the proportion of patients on this form of dialysis compared to hospital HD will result in a more equitable distribution of good health outcomes for individuals with ESKD.
Collapse
Affiliation(s)
- Rachael C Walker
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia; Hawke's Bay District Health Board, Hastings, New Zealand
| | - Kirsten Howard
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Sydney Medical School, University of Sydney, Sydney, Australia
| |
Collapse
|
13
|
Affiliation(s)
- Emilie Trinh
- Division of Nephrology; University Health Network; Toronto Ontario Canada
| | | |
Collapse
|
14
|
Nickel M, Rideout W, Shah N, Reintjes F, Chen JZ, Burrell R, Pauly RP. Estimating patient-borne water and electricity costs in home hemodialysis: a simulation. CMAJ Open 2017; 5:E61-E65. [PMID: 28401120 PMCID: PMC5378499 DOI: 10.9778/cmajo.20160108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Home hemodialysis is associated with lower costs to the health care system compared with conventional facility-based hemodialysis because of lower staffing and overhead costs, and by transferring the treatment cost of utilities (water and power) to the patient. The purpose of this study was to determine the utility costs of home hemodialysis and create a formula such that patients and renal programs can estimate the annual patient-borne costs involved with this type of treatment. METHODS Seven common combinations of treatment duration and dialysate flows were replicated 5 times using various combinations of home hemodialysis and reverse osmosis machines. Real-time utility (electricity and water) consumption was monitored during these simulations. A generic formula was developed to allow patients and programs to calculate a more precise estimate of utility costs based on individual combinations of dialysis intensity, frequency and utility costs unique to any patient. RESULTS Using typical 2014 utility costs for Edmonton, the most expensive prescription was for nocturnal home hemodialysis (8 h at 300 mL/min, 6 d/wk), which resulted in a utility cost of $1269 per year; the least expensive prescription was for conventional home hemodialysis (4 h at 500 mL/min, 3 d/wk), which cost $420 per year. Water consumption makes up most of this expense, with electricity accounting for only 12% of the cost. INTERPRETATION We show that a substantial cost burden is transferred to the patient on home hemodialysis, which would otherwise be borne by the renal program.
Collapse
Affiliation(s)
- Matthew Nickel
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| | - Wes Rideout
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| | - Nikhil Shah
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| | - Frances Reintjes
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| | - Justin Z Chen
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| | - Robert Burrell
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| | - Robert P Pauly
- Department of Chemical and Materials Engineering (Nickel, Burrell), University of Alberta; Northern Alberta Renal Program (Rideout, Reintjes, Pauly), Alberta Health Services; Division of Nephrology, Department of Medicine (Shah, Pauly), University of Alberta; Department of Medicine (Chen), University of Alberta, Edmonton, Alta
| |
Collapse
|
15
|
Affiliation(s)
- John W. M. Agar
- Renal Unit; University Hospital; Barwon Health; Geelong Victoria Australia
| | - Dori Schatell
- CEO; Medical Education Institute; Madison Wisconsin USA
| | - Rachael Walker
- Nephrology; Hawkes Bay District Health Board; Hawkes Bay New Zealand
| |
Collapse
|
16
|
Mitra S, Jayanti A. Clinical outcomes and quality of life for home haemodialysis patients. ACTA ACUST UNITED AC 2014. [DOI: 10.12968/jorn.2014.6.5.220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sandip Mitra
- Consultant Nephrologist, Manchester Royal Infirmary and Senior Lecturer, University of Manchester
| | - Anuradha Jayanti
- Clinical Research Fellow, Department of Nephrology, Manchester Royal Infirmary
| |
Collapse
|
17
|
Klarenbach SW, Tonelli M, Chui B, Manns BJ. Economic evaluation of dialysis therapies. Nat Rev Nephrol 2014; 10:644-52. [DOI: 10.1038/nrneph.2014.145] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|
18
|
Walker R, Marshall MR, Morton RL, McFarlane P, Howard K. The cost-effectiveness of contemporary home haemodialysis modalities compared with facility haemodialysis: A systematic review of full economic evaluations. Nephrology (Carlton) 2014; 19:459-70. [DOI: 10.1111/nep.12269] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Rachael Walker
- Renal Department; Hawkes Bay District Health Board; Hastings New Zealand
- Sydney School of Public Health; University of Sydney; Sydney New South Wales Australia
| | - Mark R Marshall
- Faculty of Medical and Health Sciences; University of Auckland; Auckland New Zealand
- Department of Renal Medicine; Counties Manukau District Health Board; Auckland New Zealand
- Australia and New Zealand Dialysis and Transplant Registry (ANZDATA); The Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Rachael L Morton
- Sydney School of Public Health; University of Sydney; Sydney New South Wales Australia
- Health Economics Research Centre; Nuffield Department of Population Health; University of Oxford; Oxford UK
| | - Philip McFarlane
- Division of Nephrology; St Michael's Hospital; Toronto Ontario Canada
- Department of Medicine; University of Toronto; Toronto Ontario Canada
| | - Kirsten Howard
- Sydney School of Public Health; University of Sydney; Sydney New South Wales Australia
| |
Collapse
|
19
|
Jayanti A, Morris J, Stenvinkel P, Mitra S. Home hemodialysis: Beliefs, attitudes, and practice patterns. Hemodial Int 2014; 18:767-76. [DOI: 10.1111/hdi.12176] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Anuradha Jayanti
- Department of Nephrology; Manchester Royal Infirmary; Manchester UK
| | - Julie Morris
- Department of Biostatistics; South Manchester University Hospital; Manchester UK
| | - Peter Stenvinkel
- Division of Renal Medicine; Department of Clinical Science, Intervention and Technology; Karolinska Institute; Stockholm Sweden
| | - Sandip Mitra
- Department of Nephrology; Manchester Royal Infirmary; Manchester UK
| |
Collapse
|
20
|
Chow E, Wong H, Hahn-Goldberg S, Chan CT, Morra D. Inpatient and emergent resource use of patients on dialysis at an academic medical center. Nephron Clin Pract 2014; 126:124-7. [PMID: 24732261 DOI: 10.1159/000360541] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 02/05/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM End-stage renal disease patients require resources for emergent and inpatient care in addition to ambulatory dialysis. There are two dialysis modalities and settings which patients switch between. Our aim was to characterize the patterns and reasons for switching, as well as the emergent and inpatient utilization of these patients at the University Health Network. METHODS Patients who received chronic dialysis between March 1, 2006, and April 30, 2011, were identified. Utilization was measured by emergency department (ED) visits, inpatient hospitalizations, and bed-days occupied per year. RESULTS Out of 576 patients identified, 18.6% switched modality and/or setting. The majority of switches occurred during the first year of dialysis. Patients who switched had increased utilization compared to those on a continuous modality/setting. Overall, patients had a median rate of 0.91 ED visits per patient-year, compared to 1.56 for patients who switched modality and setting. Median inpatient bed resource requirement was 4.46 bed-days/patient-year overall, compared to 8.91 for patients who switched modality and setting. CONCLUSIONS Emergent and inpatient utilization is related to the setting and modality of dialysis, although differences are partly explained by comorbidities. Patients who switch modalities use more resources and may be a prime population for interventions.
Collapse
Affiliation(s)
- Eric Chow
- The Centre for Innovation in Complex Care, University Health Network (UHN), Toronto, Ont., Canada
| | | | | | | | | |
Collapse
|
21
|
Abma I, Jayanti A, Bayer S, Mitra S, Barlow J. Perceptions and experiences of financial incentives: a qualitative study of dialysis care in England. BMJ Open 2014; 4:e004249. [PMID: 24523426 PMCID: PMC3927715 DOI: 10.1136/bmjopen-2013-004249] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/04/2013] [Accepted: 01/10/2014] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The objective of the study was to understand the extent to which financial incentives such as Payment by Results and other payment mechanisms motivate kidney centres in England to change their practices. DESIGN The study followed a qualitative design. Data collection involved 32 in-depth semistructured interviews with healthcare professionals and managers, focusing on their subjective experience of payment structures. PARTICIPANTS Participants were kidney healthcare professionals, clinical directors, kidney centre managers and finance managers. Healthcare commissioners from different parts of England were also interviewed. SETTING Participants worked at five kidney centres from across England. The selection was based on the prevalence of home haemodialysis, ranging from low (<3%), medium (5-8%) and high (>8%) prevalence, with at least one centre in each one of these categories at the time of selection. RESULTS While the tariff for home haemodialysis is not a clear incentive for its adoption due to uncertainty about operational costs, Commissioning for Quality and Innovation (CQUIN) targets and the Best Practice Tariff for vascular access were seen by our case study centres as a motivator to change practices. CONCLUSIONS The impact of financial incentives designed at a policy level is influenced by the understanding of cost and benefits at the local operational level. In a situation where costs are unclear, incentives which are based on the improvement of profit margins have a smaller impact than incentives which provide an additional direct payment, even if this extra financial support is relatively small.
Collapse
Affiliation(s)
- Inger Abma
- Imperial College Business School, South Kensington Campus, London, UK
| | - Anuradha Jayanti
- Manchester Institute of Nephrology & Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - Steffen Bayer
- Duke-NUS Graduate Medical School Singapore, Singapore, Singapore
| | - Sandip Mitra
- Manchester Institute of Nephrology & Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - James Barlow
- Imperial College Business School, South Kensington Campus, London, UK
| |
Collapse
|
22
|
Polaschegg HD. Hemodialysis machine technology: a global overview. Expert Rev Med Devices 2014; 7:793-810. [DOI: 10.1586/erd.10.54] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
23
|
Klarenbach S, Tonelli M, Pauly R, Walsh M, Culleton B, So H, Hemmelgarn B, Manns B. Economic evaluation of frequent home nocturnal hemodialysis based on a randomized controlled trial. J Am Soc Nephrol 2013; 25:587-94. [PMID: 24231665 DOI: 10.1681/asn.2013040360] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Provider and patient enthusiasm for frequent home nocturnal hemodialysis (FHNHD) has been renewed; however, the cost-effectiveness of this technique is unknown. We performed a cost-utility analysis of FHNHD compared with conventional hemodialysis (CvHD; 4 hours three times per week) from a health payer perspective over a lifetime horizon using patient information from the Alberta NHD randomized controlled trial. Costs, including training costs, were obtained using microcosting and administrative data (CAN$2012). We determined the incremental cost per quality-adjusted life year (QALY) gained. Robustness was assessed using scenario, sensitivity, and probabilistic sensitivity analyses. Compared with CvHD (61% in-center, 14% satellite, and 25% home dialysis), FHNHD led to incremental cost savings (-$6700) and an additional 0.38 QALYs. In sensitivity analyses, when the annual probability of technique failure with FHNHD increased from 7.6% (reference case) to ≥19%, FHNHD became unattractive (>$75,000/QALY). The cost/QALY gained became $13,000 if average training time for FHNHD increased from 3.7 to 6 weeks. In scenarios with alternate comparator modalities, FHNHD remained dominant compared with in-center CvHD; cost/QALYs gained were $18,500, $198,000, and $423,000 compared with satellite CvHD, home CvHD, and peritoneal dialysis, respectively. In summary, FHNHD is attractive compared with in-center CvHD in this cohort. However, the attractiveness of FHNHD varies by technique failure rate, training time, and dialysis modalities from which patients are drawn, and these variables should be considered when establishing FHNHD programs.
Collapse
Affiliation(s)
- Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | | | | | | | | |
Collapse
|
24
|
|
25
|
Nesrallah GE, Mustafa RA, MacRae J, Pauly RP, Perkins DN, Gangji A, Rioux JP, Steele A, Suri RS, Chan CT, Copland M, Komenda P, McFarlane PA, Pierratos A, Lindsay R, Zimmerman DL. Canadian Society of Nephrology Guidelines for the Management of Patients With ESRD Treated With Intensive Hemodialysis. Am J Kidney Dis 2013; 62:187-98. [DOI: 10.1053/j.ajkd.2013.02.351] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 02/14/2013] [Indexed: 11/11/2022]
|
26
|
Fischer MJ, Porter AC, Lash JP. Treatment of depression and poor mental health among patients receiving maintenance dialysis: are there options other than a pill or a couch? Am J Kidney Dis 2013; 61:694-7. [PMID: 23582252 DOI: 10.1053/j.ajkd.2013.02.347] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 02/11/2013] [Indexed: 11/11/2022]
|
27
|
Hornberger J, Hirth RA. Financial Implications of Choice of Dialysis Type of the Revised Medicare Payment System: An Economic Analysis. Am J Kidney Dis 2012; 60:280-7. [DOI: 10.1053/j.ajkd.2012.03.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Accepted: 03/13/2012] [Indexed: 11/11/2022]
|
28
|
Tennankore KK, Chan CT, Curran SP. Intensive home haemodialysis: benefits and barriers. Nat Rev Nephrol 2012; 8:515-22. [DOI: 10.1038/nrneph.2012.145] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
29
|
Zhang H, Schaubel DE, Kalbfleisch JD, Bragg-Gresham JL, Robinson BM, Pisoni RL, Canaud B, Jadoul M, Akiba T, Saito A, Port FK, Saran R. Dialysis outcomes and analysis of practice patterns suggests the dialysis schedule affects day-of-week mortality. Kidney Int 2012; 81:1108-15. [PMID: 22297673 PMCID: PMC3365564 DOI: 10.1038/ki.2011.481] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The risk of death for hemodialysis patients is thought to be highest on the days following the longest interval without dialysis (usually Mondays and Tuesdays); however, existing results are inconclusive. To clarify this we analyzed Dialysis Outcomes and Practice Patterns Study (DOPPS) data of 22,163 hemodialysis patients from the United States, Europe, and Japan. Our study focused on the association between dialysis schedule and day of the week of all-cause, cardiovascular, and noncardiovascular mortality with day-of-week coded as a time-dependent covariate. The models were adjusted for dialysis schedule, age, country, DOPPS phase I or II, and other demographic and clinical covariates, and compared mortality on each day to the 7-day average. Patients on a Monday-Wednesday-Friday (MWF) schedule had elevated all-cause mortality on Mondays, and those on a Tuesday-Thursday-Saturday (TTS) schedule had increased risk of mortality on Tuesdays in all three regions. The association between day-of-week mortality and schedule was generally stronger for cardiovascular than noncardiovascular mortality, and was most pronounced in the United States. Unexpectedly, Japanese patients on a MWF schedule had a higher risk of noncardiovascular mortality on Fridays, and European patients on a TTS schedule experienced an elevated cardiovascular mortality on Saturdays. Thus, future studies are needed to evaluate the influence of practice patterns on schedule-specific mortality and factors that could modulate this effect.
Collapse
Affiliation(s)
- Hui Zhang
- University of Michigan-Kidney Epidemiology and Cost Center, Ann Arbor, Michigan 48109, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Ipema KJ, van der Schans CP, Vonk N, de Vries JM, Westerhuis R, Duym E, Franssen CF. A Difference Between Day and Night: Protein Intake Improves After the Transition From Conventional to Frequent Nocturnal Home Hemodialysis. J Ren Nutr 2012; 22:365-72. [DOI: 10.1053/j.jrn.2011.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 08/08/2011] [Accepted: 08/30/2011] [Indexed: 11/11/2022] Open
|
31
|
International practice patterns and factors associated with non-conventional hemodialysis utilization. BMC Nephrol 2011; 12:66. [PMID: 22142369 PMCID: PMC3241205 DOI: 10.1186/1471-2369-12-66] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 12/05/2011] [Indexed: 11/23/2022] Open
Abstract
Background The purpose of our study was to determine characteristics that influence the utilization of non-conventional hemodialysis (NCHD) therapies and its subtypes (nocturnal (NHD), short daily (SDHD), long conventional (LCHD) and conventional hemodialysis (CHD) as well as provider attitudes regarding the evidence for NCHD use. Methods An international cohort of subscribers of a nephrology education website http://www.nephrologynow.com was invited to participate in an online survey. Non-conventional hemodialysis was defined as any forms of hemodialysis delivered > 3 treatments per week and/or > 4 hours per session. NHD and SDHD included both home and in-centre. Respondents were categorized as CHD if their centre only offered conventional thrice weekly hemodialysis. Variables associated with NCHD and its subtypes were determined using multivariate logistic regression analysis. The survey assessed multiple domains regarding NCHD including reasons for initiating and discontinuing, for not offering and attitudes regarding evidence. Results 544 surveys were completed leading to a 15.6% response rate. The final cohort was limited to 311 physicians. Dialysis modalities utilized among the respondents were as follows: NCHD194 (62.4%), NHD 83 (26.7%), SDHD 107 (34.4%), LCHD 81 (26%) and CHD 117 (37.6%). The geographic regions of participants were as follows: 11.9% Canada, 26.7% USA, 21.5% Europe, 6.1% Australia/New Zealand, 10% Africa/Middle East, 10.9% Asia and 12.9% South America. Variables associated with NCHD utilization included NCHD training (OR 2.47 CI 1.25-4.16), government physician reimbursement (OR 2.66, CI 1.11-6.40), practicing at an academic centre (OR 2.28 CI 1.25-4.16), higher national health care expenditure and number of ESRD patients per centre. Hemodialysis providers with patients on NCHD were significantly more likely to agree with the statements that NCHD improves quality of life, improves nutritional status, reduces EPO requirements and is cost effective. The most common reasons to initiate NCHD were driven by patient preference and the desire to improve volume control and global health outcomes. Conclusion Physician attitudes toward the evidence for NCHD differ significantly between NCHD providers and conventional HD providers. Interventions and health policy targeting these areas along with increased physician education and training in NCHD modalities may be effective in increasing its utilization.
Collapse
|
32
|
|
33
|
Cornelis T, Kotanko P, Goffin E, Kooman JP, van der Sande FM, Chan CT. Can Intensive Hemodialysis Prevent Loss of Functionality in the Elderly ESRD Patient? Semin Dial 2011; 24:645-52. [DOI: 10.1111/j.1525-139x.2011.00995.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
34
|
Komenda P, Gavaghan MB, Garfield SS, Poret AW, Sood MM. An economic assessment model for in-center, conventional home, and more frequent home hemodialysis. Kidney Int 2011; 81:307-13. [PMID: 21993583 PMCID: PMC3258566 DOI: 10.1038/ki.2011.338] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
More intensive and/or frequent hemodialysis may provide clinical benefits to patients with end-stage renal disease; however, these dialysis treatments are more convenient to the patients if provided in their homes. Here we created a standardized model, based on a systematic review of available costing literature, to determine the economic viability of providing hemodialysis in the home that arrays costs and common approaches for assessing direct medical and nonmedical costs. Our model was based on data from Australia, Canada, and the United Kingdom. The first year start-up costs for all hemodialysis modalities were higher than in subsequent years with modeled costs for conventional home hemodialysis lower than in-center hemodialysis in subsequent years. Modeled costs for frequent home hemodialysis was higher than both in-center and conventional home hemodialysis in the United Kingdom, but lower than in-center hemodialysis and higher than conventional home hemodialysis in Australia and Canada in subsequent years. The higher costs of frequent compared to conventional home hemodialysis were because of higher consumable usage due to dialysis frequency. Thus, our findings reinforce the conclusions of previous studies showing that home-based conventional and more frequent hemodialysis may provide clinical benefit at reasonable costs.
Collapse
Affiliation(s)
- Paul Komenda
- Department of Medicine, Section of Nephrology, University of Manitoba, Manitoba Renal Program, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada.
| | | | | | | | | |
Collapse
|
35
|
Menzin J, Lines LM, Weiner DE, Neumann PJ, Nichols C, Rodriguez L, Agodoa I, Mayne T. A review of the costs and cost effectiveness of interventions in chronic kidney disease: implications for policy. PHARMACOECONOMICS 2011; 29:839-861. [PMID: 21671688 DOI: 10.2165/11588390-000000000-00000] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Given rising healthcare costs and a growing population of patients with chronic kidney disease (CKD), there is an urgent need to identify health interventions that provide good value for money. For this review, the English-language literature was searched for studies of interventions in CKD reporting an original incremental cost-utility (cost per QALY) or cost-effectiveness (cost per life-year) ratio. Published cost studies that did not report cost-effectiveness or cost-utility ratios were also reviewed. League tables were then created for both cost-utility and cost-effectiveness ratios to assess interventions in patients with stage 1-4 CKD, waitlist and transplant patients and those with end-stage renal disease (ESRD). In addition, the percentage of cost-saving or dominant interventions (those that save money and improve health) was compared across these three disease categories. A total of 84 studies were included, contributing 72 cost-utility ratios, 20 cost-effectiveness ratios and 42 other cost measures. Many of the interventions were dominant over the comparator, indicating better health outcomes and lower costs. For the three disease categories, the greatest number of dominant or cost-saving interventions was reported for stage 1-4 CKD patients, followed by waitlist and transplant recipients and those with ESRD (91%, 87% and 55% of studies reporting a dominant or cost-saving intervention, respectively). There is evidence of opportunities to lower costs in the treatment of patients with CKD, while either improving or maintaining the quality of care. In order to realize these cost savings, efforts will be required to promote and effectively implement changes in treatment practices.
Collapse
|
36
|
|
37
|
Abstract
Demand for renal replacement therapy (dialysis and transplantation) is projected to rise by approximately 5% every year until at least 2030. Therefore, particular attention should be paid to areas in which significant increases in demand are likely to lead to further pressure on services. There is evidence to support higher patient survival rates in home haemodialysis compared with those that receive hospital- or satellite-based haemodialysis (i.e. a smaller renal unit based in a community hospital closer to the patient's home). Furthermore, studies suggest that home haemodialysis is at least as effective as and less costly than hospital or satellite unit haemodialysis. Therefore, there is a greater requirement for expanding the provision of home haemodialysis, and to make this treatment option available to a wider range of patients.
Collapse
|
38
|
Hoppe A, von Puttkamer C, Linke U, Kahler C, Booss M, Braunauer-Kolberg R, Hofmann K, Joachimsky P, Hirte I, Schley S, Utsch B, Thumfart J, Briese S, Gellermann J, Zimmering M, Querfeld U, Müller D. A hospital-based intermittent nocturnal hemodialysis program for children and adolescents. J Pediatr 2011; 158:95-9, 99.e1. [PMID: 20691454 DOI: 10.1016/j.jpeds.2010.06.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2010] [Revised: 05/20/2010] [Accepted: 06/22/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To establish a hospital-based nocturnal hemodialysis (NHD) program for children and adolescents. STUDY DESIGN Sixteen patients (age, 0.5 to 17 years) were prospectively included. Uremia-associated measures as well as amount and dosage of medication were enumerated. Quality of life also was evaluated. Results were compared with data of the same patients on conventional hemodialysis and with matched control subjects (conventional HD). RESULTS NHD was well tolerated. Median Kt/V values increased. Predialytic mean arterial pressure, urea, phosphate, and parathyroid hormone levels decreased. There was an increase in protein catabolic rate. Dietary and fluid restrictions could be lifted. Amount and dosage of phosphate and potassium binders and antihypertensive medication could be reduced. Quality of life improved and days of absence from school decreased in all patients. CONCLUSIONS In addition to a better control of uremia-associated measures, NHD allows free dietary and fluid intake and improves patient well-being. Given the continuing shortage of donor organs for kidney transplantation and the high morbidity and mortality on conventional HD, intensified dialysis regimens are a much-needed therapeutic option.
Collapse
Affiliation(s)
- Anne Hoppe
- Charité, Department of Pediatric Nephrology, Berlin, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
|
40
|
MacRae JM, Rose CL, Jaber BL, Gill JS. Utilization and outcome of 'out-of-center hemodialysis' in the United States: a contemporary analysis. Nephron Clin Pract 2010; 116:c53-9. [PMID: 20502039 DOI: 10.1159/000314663] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Accepted: 12/18/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is increasing interest in the delivery of out-of-center hemodialysis (HD), particularly in the home setting, but little systematic information about its use and outcome in contemporary incident patients is available. PATIENTS AND METHODS Out-of-center HD was defined as HD delivered in a residential setting, mainly at home or in a long-term care facility (such as a nursing home) irrespective of the length and frequency of therapy. All-cause mortality was determined in an observational cohort study of 458,329 adult patients initiating dialysis in the United States with Medicare as a primary payer. RESULTS Between 1995 and 2004, out-of-center HD was the initial modality in 1,641 (0.4%) of eligible participants, although there was significant geographic variation. Patients initiating out-of-center HD were younger, more likely to be nonwhite, had fewer comorbidities, a higher median income, and were more likely to be employed than patients initiating in-center HD or peritoneal dialysis (PD). In multivariate analysis, out-of-center HD patients had a higher overall risk of death compared to in-center HD or PD patients (HR = 1.10, 95% CI 1.04, 1.17), although the relative risk of death was lower in younger and healthier patients (HR = 0.78; 95% CI 0.61, 1.00). CONCLUSION Out-of-center HD is not associated with a survival advantage among unselected patients initiating dialysis in the United States. These results call for better characterization of out-of-center HD in national registries, primarily to effectively compare the use, outcomes and potential benefits of home HD to standard therapies.
Collapse
Affiliation(s)
- Jennifer M MacRae
- Division of Nephrology, University of Calgary, Calgary, Alta., Canada.
| | | | | | | |
Collapse
|
41
|
Abstract
The typical dialysis patient faces both a poor quality of life and a significantly shortened survival. This is often blamed on "uremia." However, defining the clinical entity of uremia is surprisingly difficult. It represents the clinical sequelae of the effects of retention products, other effects of renal disease, and the effects of other comorbid conditions. The list of retention products that could act as uremic toxins is lengthy, but it would appear that urea itself does not contribute significantly to the uremic state. Larger molecular weight substances are likely the major contributors to the uremic milieu. Regardless of the causes, the uremic state persists in many patients who are reaching their dialysis adequacy targets as defined by urea clearance. This raises the possibility that more intensive hemodialysis could improve patient outcomes. Hemodialysis can be intensified by increasing dialysis efficiency without changing duration or frequency. Alternatively, hemodialysis duration, frequency, or both can be increased. All intensification methods increase small solute removal, but the removal of larger molecular weight retention products depends more upon treatment time. Modalities such as short daily hemodialysis, long intermittent hemodialysis, and quotidian nocturnal hemodialysis have been associated with a variety of clinical improvements, as well as improvements in quality of life and a lower standardized mortality ratio. However, the HEMO study approach of intensifying small solute clearance without significant modifications of the dialysis schedule does not appear to be effective. Future research will help to define the optimal treatment duration and frequency in hemodialysis patients.
Collapse
|
42
|
VAN EPS CL, JEFFRIES JK, JOHNSON DW, CAMPBELL SB, ISBEL NM, MUDGE DW, HAWLEY CM. Quality of life and alternate nightly nocturnal home hemodialysis. Hemodial Int 2010; 14:29-38. [DOI: 10.1111/j.1542-4758.2009.00419.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
43
|
Agar JWM, Somerville CA, Dwyer KM, Simmonds RE, Boddington JM, Waldron CM. Nocturnal hemodialysis in australia. Hemodial Int 2009; 7:278-89. [PMID: 19379377 DOI: 10.1046/j.1492-7535.2003.00051.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Because home hemodialysis has long been a common Australian support modality, the advent of home-based nocturnal hemodialysis (NHD) in Canada stimulated the extension of our existing home- and satellite-based conventional hemodialysis (CHD) programs to NHD. As a result, the first government-funded, home-based, 6-nights-per-week NHD program in Australia began in July 2001. METHODS Sixteen patients have been trained for NHD; 13 dialyzed at home 8 to 9 hr per night for 6 nights per week, whereas 3 preferred to train for NHD at home using an 8- to 9-hr alternate-night regime. RESULTS The program experience to March 1, 2003, was 655 patient-weeks. Two patients had withdrawn for transplantation and 2 for social reasons, although 1 continues on alternate-night NHD. There hade been no deaths. Ten patients had dialyzed without partners. All patients ceased phosphate binders at entry. Thirteen of 16 discontinued all antihypertensive drugs. There were no fluid or dietary restrictions. Phosphate was added to the dialysate to prevent hypophosphatemia. Pre- and postdialysis urea and phosphate levels were broadly within the normal ranges. All patients reported restorative sleep; similarly partners reported stable sleep patterns and noted improved mood, cognitive function, and marital relationships in their NHD partners. Preliminary cost analyses show that whereas consumables had doubled, and epoetin and iron expenditures had risen by 28.9%, other pharmaceutical costs had fallen by 47%, and nursing wage costs were 48% of the notional cost had these patients remained on CHD. Three patients on NHD were retired, 7 worked full-time, 3 worked part-time, and 3 drew disability support, whereas previously on CHD, 3 were retired, 3 had worked full-time, 3 had worked part-time, and 7 had drawn disability support. CONCLUSION We believe that NHD is viable, safe, effective, and well accepted with significant lifestyle benefits and reemployment outcomes. Although initial setup costs are significant, NHD cost advantage over CHD progressively accrues as program numbers exceed 12 to 15 patients.
Collapse
Affiliation(s)
- John W M Agar
- Renal Unit, The Geelong Hospital, Barwon Health, Victoria, Australia.
| | | | | | | | | | | |
Collapse
|
44
|
Abstract
The prevalence of end-stage renal disease continues to increase globally, and most patients are treated with dialysis. Despite technological advances in dialysis care, the relatively high costs of providing dialysis have not decreased substantially over the past 4 decades. These 2 factors are a significant concern in this era of fiscal restraint and finite health care budgets. Economic evaluation of dialysis treatment consistently has shown that home-based hemodialysis and peritoneal dialysis are less costly than in-center hemodialysis. Although only a portion of patients may be eligible for this therapy, current use in Canada and the United States suggests that significantly more patients could be treated with these therapies, which would result in significant cost savings without compromising patient outcomes. There is some evidence to suggest that the modality of home nocturnal dialysis may offer improvements in clinical outcomes including quality of life, but further study of the cost effectiveness of this modality is required.
Collapse
|
45
|
Bayliss G, Danziger J. Nocturnal versus conventional haemodialysis: some current issues. Nephrol Dial Transplant 2009; 24:3612-7. [PMID: 19767631 DOI: 10.1093/ndt/gfp491] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
46
|
Gura V, Macy AS, Beizai M, Ezon C, Golper TA. Technical breakthroughs in the wearable artificial kidney (WAK). Clin J Am Soc Nephrol 2009; 4:1441-8. [PMID: 19696219 DOI: 10.2215/cjn.02790409] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The wearable artificial kidney (WAK) has been a holy grail in kidney failure for decades. Described herein are the breakthroughs that made possible the creation of the WAK V1.0 and its advanced versions V 1.1 and 1.2. DESIGN The battery-powered WAK pump has a double channel pulsatile counter phase flow. This study clarifies the role of pulsatile blood and dialysate flow, a high-flux membrane with a larger surface area, and the optimization of the dialysate pH. Flows and clearances from the WAK pump were compared with conventional pumps and with gravity steady flow. RESULTS Raising dialysate pH to 7.4 increased adsorption of ammonia. Clearances were higher with pulsatile flow as compared with steady flow. The light WAK pump, geometrically suitable for wearability, delivered the same clearances as larger and heavier pumps that cannot be battery operated. Beta(2) microglobulin (beta(2)M) was removed from human blood in vitro. Activated charcoal adsorbed most beta(2)M in the dialysate. The WAK V1.0 delivered an effective creatinine clearance of 18.5 +/- 3.2 ml/min and the WAK V1.1 27.0 +/- 4.0 ml/min in uremic pigs. CONCLUSIONS Half-cycle differences between blood and dialysate, alternating transmembrane pressures (TMP), higher amplitude pulsations, and a push-pull flow increased convective transport. This creates a yet undescribed type of hemodiafiltration. Further improvements were achieved with a larger surface area high-flux dialyzer and a higher dialysate pH. The data suggest that the WAK might be an efficient way of providing daily dialysis and optimizing end stage renal disease (ESRD) treatment.
Collapse
Affiliation(s)
- Victor Gura
- Cedars-Sinai Medical Center, Los Angeles, California 90212, USA.
| | | | | | | | | |
Collapse
|
47
|
Survival and hospitalization among patients using nocturnal and short daily compared to conventional hemodialysis: a USRDS study. Kidney Int 2009; 76:984-90. [PMID: 19692997 DOI: 10.1038/ki.2009.291] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We estimated the survival and hospitalization among frequent hemodialysis users in comparison to those patients undergoing thrice-weekly conventional hemodialysis. All patients had similar characteristics and medical histories. In this cohort study of frequent hemodialysis users and propensity score-matched controls, the collaborating clinicians identified 94 patients who used nocturnal hermodialysis (NHD) and 43 patients who used short-duration daily hemodialysis (SDHD) for a minimum of 60 days. Ten propensity score-matched control patients for each NHD and SDHD patient were identified from the United States Renal Data System database. Primary outcomes were risk for all-cause mortality and risk for the composite outcome of mortality or major morbid event (acute myocardial infarction or stroke) estimated using Cox proportional hazards models. Risks for all-cause, cardiovascular-related, infection-related, and vascular access-related hospital admissions were also studied. Nocturnal hemodialysis was associated with significant reductions in mortality risk and risk for mortality or major morbid event when compared to conventional hemodialysis. There was a reduced but non-significant risk of death for patients using SDHD compared to controls. All-cause and specific hospitalizations did not differ significantly between NHD and SDHD patients and their matched control cohorts. Our study suggests that NHD may improve patient survival.
Collapse
|
48
|
Valenstein M, Eisenberg D, McCarthy JF, Austin KL, Ganoczy D, Kim HM, Zivin K, Piette JD, Olfson M, Blow FC. Service implications of providing intensive monitoring during high-risk periods for suicide among VA patients with depression. PSYCHIATRIC SERVICES (WASHINGTON, D.C.) 2009. [PMID: 19339317 DOI: 10.1176/appi.ps.60.4.439] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Department of Veterans Affairs (VA) patients in depression treatment have high suicide rates after psychiatric hospitalization, antidepressant starts, and dosage changes. Policy makers have recommended closer monitoring during these periods to reduce suicide. This study assessed the frequency of high-risk periods in clinical settings, the levels of monitoring provided during these periods, and the estimated costs of providing monitoring consistent with the most stringent Food and Drug Administration recommendation for treatment periods after antidepressant change (seven visits in the first 12 weeks). METHODS Monitoring visits were identified in the 12-week period after antidepressant starts and dosage changes and after discharge from psychiatric hospitalization for 100,000 randomly selected VA patients in depression treatment between April 1, 1999, and September 30, 2004. Incremental costs of providing intensive monitoring were estimated by using VA Health Economics Resource Center average cost data. RESULTS Patients averaged less than one high-risk period each year. They completed an average of 2.4 monitoring visits during the 12-week period after antidepressant treatment events and 4.9 visits after psychiatric hospitalization. Providing intensive monitoring would cost an additional $408-$537 for each high-risk period after antidepressant treatment events and $313-$341 for each high-risk period after psychiatric hospitalization. During fiscal year 2004 providing intensive monitoring during all high-risk periods would have cost an additional $183-$270 million. Providing intensive monitoring only after psychiatric hospitalizations would have cost an additional $15-$17 million. CONCLUSIONS Providing intensive monitoring for VA patients in depression treatment during all high-risk periods for suicide would require substantial services reorganization and incremental expenditures. Modest expenditures would support intensive monitoring during the highest-risk period that follows psychiatric hospitalization.
Collapse
Affiliation(s)
- Marcia Valenstein
- Health Services Research and Development, Department of Veterans Affairs Medical Center, 2215 Fuller Rd., Box 130170, Ann Arbor, MI 48113-0170, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Oreopoulos DG, Thodis E, Passadakis P, Vargemezis V. Home dialysis as a first option: a new paradigm. Int Urol Nephrol 2009; 41:595-605. [DOI: 10.1007/s11255-009-9575-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 04/15/2009] [Indexed: 11/24/2022]
|
50
|
Ly D, Alex FZ, Christopher H. Cost Effectiveness Analysis of a Hypertension Management Program in Patients With Type 2 Diabetes. J Clin Hypertens (Greenwich) 2009; 11:116-24. [DOI: 10.1111/j.1751-7176.2009.00082.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|