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Nemzoff C, Ahmed N, Olufiranye T, Igiraneza G, Kalisa I, Chadha S, Hakiba S, Rulisa A, Riro M, Chalkidou K, Ruiz F. Rapid cost-effectiveness analysis: hemodialysis versus peritoneal dialysis for patients with acute kidney injury in Rwanda. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2024; 22:35. [PMID: 38689271 PMCID: PMC11059575 DOI: 10.1186/s12962-024-00545-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/16/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND To ensure the long-term sustainability of its Community-Based Health Insurance scheme, the Government of Rwanda is working on using Health Technology Assessment (HTA) to prioritize its resources for health. The objectives of the study were to rapidly assess (1) the cost-effectiveness and (2) the budget impact of providing PD versus HD for patients with acute kidney injury (AKI) in the tertiary care setting in Rwanda. METHODS A rapid cost-effectiveness analysis for patients with AKI was conducted to support prioritization. An 'adaptive' HTA approach was undertaken by adjusting the international Decision Support Initiative reference case for time and data constraints. Available local and international data were used to analyze the cost-effectiveness and budget impact of peritoneal dialysis (PD) compared with hemodialysis (HD) in the tertiary hospital setting. RESULTS The analysis found that HD was slightly more effective and slightly more expensive in the payer perspective for most patients with AKI (aged 15-49). HD appeared to be cost-effective when only comparing these two dialysis strategies with an incremental cost-effectiveness ratio of 378,174 Rwandan francs (RWF) or 367 United States dollars (US$), at a threshold of 0.5 × gross domestic product per capita (RWF 444,074 or US$431). Sensitivity analysis found that reducing the cost of HD kits would make HD even more cost-effective. Uncertainty regarding PD costs remains. Budget impact analysis demonstrated that reducing the cost of the biggest cost driver, HD kits, could produce significantly more savings in five years than switching to PD. Thus, price negotiations could significantly improve the efficiency of HD provision. CONCLUSION Dialysis is costly and covered by insurance in many countries for the financial protection of patients. This analysis enabled policymakers to make evidence-based decisions to improve the efficiency of dialysis provision.
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Affiliation(s)
- Cassandra Nemzoff
- London School of Hygiene and Tropical Medicine, London, UK.
- Center for Global Development, International Decision Support Initiative, iDSI, London, UK.
| | - Nurilign Ahmed
- Center for Global Development, International Decision Support Initiative, iDSI, London, UK
| | - Tolulope Olufiranye
- Rwanda Social Security Board, Kigali, Rwanda
- Clinton Health Access Initiative, Kigali, Rwanda
| | | | - Ina Kalisa
- World Health Organization, Kigali, Rwanda
| | | | | | | | - Matiko Riro
- Clinton Health Access Initiative, Kigali, Rwanda
| | | | - Francis Ruiz
- London School of Hygiene and Tropical Medicine, London, UK
- Center for Global Development, International Decision Support Initiative, iDSI, London, UK
- Imperial College London, London, UK
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2
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Zhong G, Cai X, Wei R, Wei S, Cao X. Curcumenol improves renal function in 5/6 nephrectomy-induced chronic renal failure rats via the SIRT1/NF-κB pathway. Anat Rec (Hoboken) 2023; 306:3189-3198. [PMID: 36495299 DOI: 10.1002/ar.25137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 11/19/2022] [Accepted: 11/22/2022] [Indexed: 11/14/2023]
Abstract
The present work aimed to explore the protective effects of curcumenol and evaluate its pharmacological mechanisms in 5/6 nephrectomy-induced chronic renal failure (CRF). Rats with CRF were administrated curcumenol and the effects on renal functions were investigated. Renal function examinations were carried out, whereas serum levels of inflammatory mediators, including NF-κB, MCP-1 and IL-1β were analyzed by ELISA. The mRNA expression levels of SIRT1, p65 and IκBα were measured by qRT-PCR, and the SIRT1 protein levels were analyzed by western blot and immunohistochemistry. Our results indicated that curcumenol significantly improved the renal functions in the CRF rats. Compared to the sham group, serum levels of NF-κB, MCP-1, IL-1β, and the mRNA expression levels of p65 were significantly increased (p < 0.01), whereas the mRNA expression level of IκBα was significantly decreased (p < 0.01) and the SIRT1 levels were dramatically down-regulated (p < 0.05) in the CRF groups. Treatment with curcumenol remarkably inhibited inflammatory responses as reflected by the reduced levels of inflammatory mediators (p < 0.01) and SIRT1 up-regulation (p < 0.05). Our findings suggested that curcumenol could improve the renal function in 5/6 nephrectomy-induced CRF rats, and the mechanisms might involve suppressing the associated inflammation and modulating the SIRT1 and NF-κB signaling pathways.
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Affiliation(s)
- Guanghui Zhong
- Department of Nephrology, Ningbo Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Ningbo, China
| | - Xudong Cai
- Department of Nephrology, Ningbo Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Ningbo, China
| | - Renxiong Wei
- Department of Clinical Laboratory, Ningbo Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Ningbo, China
| | - Sheng Wei
- Department of Nephrology, Ningbo Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Ningbo, China
| | - Xiaodan Cao
- Department of Clinical Laboratory, Ningbo Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Ningbo, China
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3
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Busink E, Kendzia D, Kircelli F, Boeger S, Petrovic J, Smethurst H, Mitchell S, Apel C. A systematic review of the cost-effectiveness of renal replacement therapies, and consequences for decision-making in the end-stage renal disease treatment pathway. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:377-392. [PMID: 35716316 PMCID: PMC10060297 DOI: 10.1007/s10198-022-01478-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 05/10/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Comparative economic assessments of renal replacement therapies (RRT) are common and often used to inform national policy in the management of end-stage renal disease (ESRD). This study aimed to assess existing cost-effectiveness analyses of dialysis modalities and consider whether the methods applied and results obtained reflect the complexities of the real-world treatment pathway experienced by ESRD patients. METHODS A systematic literature review (SLR) was conducted to identify cost-effectiveness studies of dialysis modalities from 2005 onward by searching Embase, MEDLINE, EBM reviews, and EconLit. Economic evaluations were included if they compared distinct dialysis modalities (e.g. in-centre haemodialysis [ICHD], home haemodialysis [HHD] and peritoneal dialysis [PD]). RESULTS In total, 19 cost-effectiveness studies were identified. There was considerable heterogeneity in perspectives, time horizon, discounting, utility values, sources of clinical and economic data, and extent of clinical and economic elements included. The vast majority of studies included an incident dialysis patient population. All studies concluded that home dialysis treatment options were cost-effective interventions. CONCLUSIONS Despite similar findings across studies, there are a number of uncertainties about which dialysis modalities represent the most cost-effective options for patients at different points in the care pathway. Most studies included an incident patient cohort; however, in clinical practice, patients may switch between different treatment modalities over time according to their clinical need and personal circumstances. Promoting health policies through financial incentives in renal care should reflect the cost-effectiveness of a comprehensive approach that considers different RRTs along the patient pathway; however, no such evidence is currently available.
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Affiliation(s)
- Ellen Busink
- Health Economics, Market Access & Political Affairs, Fresenius Medical Care, Else-Kröner-Straße 3, 61352, Bad Homburg, Germany.
| | - Dana Kendzia
- Health Economics, Market Access & Political Affairs, Fresenius Medical Care, Else-Kröner-Straße 3, 61352, Bad Homburg, Germany
| | - Fatih Kircelli
- Global Medical Information & Education, Fresenius Medical Care, Bad Homburg, Germany
| | - Sophie Boeger
- Health Economics, Market Access & Political Affairs, Fresenius Medical Care, Else-Kröner-Straße 3, 61352, Bad Homburg, Germany
| | - Jovana Petrovic
- Health Economics, Market Access & Political Affairs, Fresenius Medical Care, Else-Kröner-Straße 3, 61352, Bad Homburg, Germany
| | | | | | - Christian Apel
- Health Economics, Market Access & Political Affairs, Fresenius Medical Care, Else-Kröner-Straße 3, 61352, Bad Homburg, Germany
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4
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Yanful B, Kirubarajan A, Bhatia D, Mishra S, Allin S, Di Ruggiero E. Quality of care in the context of universal health coverage: a scoping review. Health Res Policy Syst 2023; 21:21. [PMID: 36959608 PMCID: PMC10035485 DOI: 10.1186/s12961-022-00957-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/28/2022] [Indexed: 03/25/2023] Open
Abstract
INTRODUCTION Universal health coverage (UHC) is an emerging priority of health systems worldwide and central to Sustainable Development Goal 3 (target 3.8). Critical to the achievement of UHC, is quality of care. However, current evidence suggests that quality of care is suboptimal, particularly in low- and middle-income countries. The primary objective of this scoping review was to summarize the existing conceptual and empirical literature on quality of care within the context of UHC and identify knowledge gaps. METHODS We conducted a scoping review using the Arksey and O'Malley framework and further elaborated by Levac et al. and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews reporting guidelines. We systematically searched MEDLINE, EMBASE, CINAHL-Plus, PAIS Index, ProQuest and PsycINFO for reviews published between 1 January 1995 and 27 September 2021. Reviews were eligible for inclusion if the article had a central focus on UHC and discussed quality of care. We did not apply any country-based restrictions. All screening, data extraction and analyses were completed by two reviewers. RESULTS Of the 4128 database results, we included 45 studies that met the eligibility criteria, spanning multiple geographic regions. We synthesized and analysed our findings according to Kruk et al.'s conceptual framework for high-quality systems, including foundations, processes of care and quality impacts. Discussions of governance in relation to quality of care were discussed in a high number of studies. Studies that explored the efficiency of health systems and services were also highly represented in the included reviews. In contrast, we found that limited information was reported on health outcomes in relation to quality of care within the context of UHC. In addition, there was a global lack of evidence on measures of quality of care related to UHC, particularly country-specific measures and measures related to equity. CONCLUSION There is growing evidence on the relationship between quality of care and UHC, especially related to the governance and efficiency of healthcare services and systems. However, several knowledge gaps remain, particularly related to monitoring and evaluation, including of equity. Further research, evaluation and monitoring frameworks are required to strengthen the existing evidence base to improve UHC.
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Affiliation(s)
- Bernice Yanful
- Division of Social and Behavioural Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| | - Abirami Kirubarajan
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Dominika Bhatia
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sujata Mishra
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sara Allin
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Erica Di Ruggiero
- Division of Social and Behavioural Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Centre for Global Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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5
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de Melo ACT, Lima AFC. Direct costs of rescue procedures to manage vascular access complications in conventional hemodialysis. Rev Esc Enferm USP 2021; 55:e20210156. [PMID: 34516605 DOI: 10.1590/1980-220x-reeusp-2021-0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/29/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To measure the average direct cost of procedures performed by health professionals, in a Dialysis Center, for the management of complications of vascular access for hemodialysis. METHOD Quantitative, exploratory-descriptive case study type research. The average direct cost was calculated by multiplying the time spent by health professionals by the unit cost of direct labor, adding this to the input costs (materials/ medicines/solutions). RESULTS The following average direct costs were obtained: US$0.72, US$2.00 and US$1.41 for "administration of easy-to-dilute, difficult-to-dilute, and undiluted antibiotics", respectively; $2.61 for "central venous catheter dressing with topical antibiotic"; $48.05 for "alteplase infusion"; US$183.68 for "insertion of central venous catheter for hemodialysis"; and $1.31 for "arteriovenous fistula puncture". CONCLUSION Material and drug costs significantly contributed to the composition of the average total direct cost of most procedures.
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Sharma M, Teerawattananon Y, Luz A, Li R, Rattanavipapong W, Dabak S. Institutionalizing Evidence-Informed Priority Setting for Universal Health Coverage: Lessons From Indonesia. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2021; 57:46958020924920. [PMID: 32513029 PMCID: PMC7285939 DOI: 10.1177/0046958020924920] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Planning and administering Universal Health Coverage (UHC) policies involve complex and critical decisions, especially in resource-scarce and densely populated settings such as Indonesia. Increasing investments alone do not ensure success and sustainability of UHC, and defining priorities is imperative. In 2013, Indonesia formally embarked on its journey of institutionalizing priority setting with technical assistance from the International Decision Support Initiative (iDSI), which is a global network of organizations in pursuit of evidence-based priority setting. This article provides a perspective for countries in pursuit of institutionalization of evidence-informed policy setting systems and sheds light on the factors conducive to the development of health technology assessment (HTA). It explores the main actors and the context of priority setting in Indonesia and articulates strategies and key outcomes and impact using the theory of change (ToC).
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Affiliation(s)
- Manushi Sharma
- Health Intervention and Technology Assessment Program, Ministry of Public Health, Thailand
| | - Yot Teerawattananon
- Health Intervention and Technology Assessment Program, Ministry of Public Health, Thailand.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Alia Luz
- Health Intervention and Technology Assessment Program, Ministry of Public Health, Thailand
| | - Ryan Li
- Imperial College London, United Kingdom
| | | | - Saudamini Dabak
- Health Intervention and Technology Assessment Program, Ministry of Public Health, Thailand
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7
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Wainstein M, Bello AK, Jha V, Harris DCH, Levin A, Gonzalez-Bedat MC, Rosa-Diez GJ, Ferreiro Fuentes A, Sola L, Pecoits-Filho R, Claure-Del Granado R, Madero M, Osman MA, Saad S, Zaidi D, Lunney M, Ye F, Katz IJ, Khan M, Shrapnel S, Tonelli M, Okpechi IG, Johnson DW. International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in Latin America. Kidney Int Suppl (2011) 2021; 11:e35-e46. [PMID: 33981469 DOI: 10.1016/j.kisu.2021.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/09/2020] [Accepted: 01/06/2021] [Indexed: 11/16/2022] Open
Abstract
Latin America is a region with a widely variable socioeconomic landscape, facing a surge in noncommunicable diseases, including chronic kidney disease and kidney failure, exposing significant limitations in the delivery of care. Despite region-wide efforts to explore and address these limitations, much uncertainty remains as to the capacity, accessibility, and quality of kidney failure care in Latin America. Through this second iteration of the International Society of Nephrology Global Kidney Health Atlas, we aimed to report on these indicators to provide a comprehensive map of kidney failure care in the region. Survey responses were received from 18 (64.2%) countries, representing 93.8% of the total population in Latin America. The median prevalence and incidence of treated kidney failure in Latin America were 715 and 157 per million population, respectively, the latter being higher than the global median (142 per million population), with Puerto Rico, Mexico, and El Salvador experiencing much of this growing burden. In most countries, public and private systems collectively funded most aspects of kidney replacement therapy (dialysis and transplantation) care, with patients incurring at least 1% to 25% of out-of-pocket costs. In most countries, >90% of dialysis patients able to access kidney replacement therapy received hemodialysis (n = 11; 5 high income and 6 upper-middle income), and only a small minority began with peritoneal dialysis (1%-10% in 67% of countries; n = 12). Few countries had chronic kidney disease registries or targeted detection programs. There is a large variability in the availability, accessibility, and quality of kidney failure care in Latin America, which appears to be subject to individual countries' funding structures, underreliance on cheap kidney replacement therapy, such as peritoneal dialysis, and limited chronic kidney disease surveillance and management initiatives.
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Affiliation(s)
- Marina Wainstein
- National Health and Medical Research Council Chronic Kidney Disease Centre of Research Excellence and Chronic Kidney Disease in Queensland, University of Queensland, Brisbane, Queensland, Australia.,Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Aminu K Bello
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales, New Delhi, India.,School of Public Health, Imperial College, London, UK.,Manipal Academy of Higher Education, Manipal, India
| | - David C H Harris
- Centre for Transplantation and Renal Research, The Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Maria C Gonzalez-Bedat
- Executive Board of the Latin American Dialysis and Transplantation Registry, Montevideo, Uruguay
| | - Guillermo J Rosa-Diez
- Division of Nephrology, Department of Medicine, University Institute Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.,Executive Board of the Latin American Dialysis and Transplantation Registry, Sociedad Latinoamericana de Nefrología e Hipertensión, Buenos Aires, Argentina
| | | | - Laura Sola
- Dialysis Unit, Centro Asistencial del Sindicato Médico del Uruguay Institución de Asistencia Médica Privada de Profesionales Sin Fines de Lucro, Montevideo, Uruguay
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Curitiba, Brazil.,Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Rolando Claure-Del Granado
- Division of Nephrology, Department of Medicine, Hospital Obrero #2-Caja Nacional de Salud, Universidad Mayor de San Simon School of Medicine, Cochabamba, Bolivia
| | - Magdalena Madero
- Division of Nephrology, Department of Medicine, National Heart Institute, Mexico City, Mexico
| | - Mohamed A Osman
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Syed Saad
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Deenaz Zaidi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Meaghan Lunney
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Feng Ye
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ivor J Katz
- Division of Medicine, Department of Renal Medicine, St George and Sutherland Hospitals, University of New South Wales, Sydney, New South Wales, Australia
| | - Maryam Khan
- Faculty of Science, University of Alberta, Edmonton, Alberta, Canada
| | - Sally Shrapnel
- School of Mathematics and Physics, University of Queensland, Brisbane, Queensland, Australia
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Pan-American Health Organization/World Health Organization's Collaborating Centre in Prevention and Control of Chronic Kidney Disease, University of Calgary, Calgary, Alberta, Canada
| | - Ikechi G Okpechi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - David W Johnson
- Department of Nephrology, Metro South and Ipswich Nephrology and Transplant Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Centre for Kidney Disease Research, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Translation Research Institute, Brisbane, Queensland, Australia
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8
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Paltiel O, Berhe E, Aberha AH, Tequare MH, Balabanova D. A public–private partnership for dialysis provision in Ethiopia: a model for high-cost care in low-resource settings. Health Policy Plan 2020; 35:1262-1267. [DOI: 10.1093/heapol/czaa085] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2020] [Indexed: 12/11/2022] Open
Abstract
Abstract
Our purpose was to explore whether private–public partnerships (PPPs) can serve as a model for access to high-cost care in low-resource settings by examining a unique PPP providing haemodialysis services in a remote setting, investigating challenges and enablers. The study setting is a 500-bed teaching hospital serving a catchment population of 8 million in Northern Ethiopia. Based on local data collection, observation and in-depth interviews, we identified the impetus for the PPP, described the partnership agreement, reported outcomes after 6 years of activity and examined challenges that have arisen since the programme’s inception, including funding sustainability. The PPP was established in 2013 based on a decision by local leadership that treatment of patients with acute kidney injury (AKI) is a necessity rather than a luxury. A private partner was sought who could ensure service delivery as well as a reliable supply of consumables. The hospital contributions included infrastructure, personnel and sharing of maintenance costs. The partnership has facilitated uninterrupted haemodialysis service to 101 patients with AKI and 202 with chronic kidney disease. The former (>50% cured) were mainly supported by charitable donations procured by the hospital’s leadership, while the latter were self-funded. The local university and community contributed to the charity. Utilization has increased yearly. Funding and logistical issues remain. In conclusion, this PPP enabled access to previously unavailable lifesaving care in Northern Ethiopia and could serve as a model for potential scale-up for haemodialysis provision in particular, and more broadly, high-cost care in low-resource settings. An ethical commitment to provide the service, combined with ongoing administrative and community involvement has contributed to its sustained success. Lack of affordability for most patients requiring chronic haemodialysis and reliance on charitable donations for treatment of patients with AKI pose challenges to long-term sustainability.
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Affiliation(s)
- Ora Paltiel
- Braun School of Public Health and Community Medicine, Hadassah-Hebrew University, Jerusalem, Israel
| | - Ephrem Berhe
- Department of Internal Medicine, Nephrology Unit, College of Health Science, Ayder Comprehensive Specialized Hospital, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Amanuel Haile Aberha
- College of Health Science, Ayder Comprehensive Specialized Hospital, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Mengistu Hagazi Tequare
- College of Health Sciences, School of Public Health, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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9
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Harris DCH, Davies SJ, Finkelstein FO, Jha V, Donner JA, Abraham G, Bello AK, Caskey FJ, Garcia GG, Harden P, Hemmelgarn B, Johnson DW, Levin NW, Luyckx VA, Martin DE, McCulloch MI, Moosa MR, O'Connell PJ, Okpechi IG, Pecoits Filho R, Shah KD, Sola L, Swanepoel C, Tonelli M, Twahir A, van Biesen W, Varghese C, Yang CW, Zuniga C. Increasing access to integrated ESKD care as part of universal health coverage. Kidney Int 2020; 95:S1-S33. [PMID: 30904051 DOI: 10.1016/j.kint.2018.12.005] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 12/28/2018] [Indexed: 12/17/2022]
Abstract
The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle-income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide.
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Affiliation(s)
- David C H Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia.
| | - Simon J Davies
- Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | | | - Vivekanand Jha
- George Institute for Global Health India, New Delhi, India; University of Oxford, Oxford, UK
| | - Jo-Ann Donner
- International Society of Nephrology, Brussels, Belgium
| | - Georgi Abraham
- Nephrology Division, Madras Medical Mission Hospital, Pondicherry Institute of Medical Sciences, Chennai, India
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Fergus J Caskey
- UK Renal Registry, Learning and Research, Southmead Hospital, Bristol, UK; Population Health Sciences, University of Bristol, Bristol, UK; The Richard Bright Renal Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Guillermo Garcia Garcia
- Servicio de Nefrologia, Hospital Civil de Guadalajara Fray Antonio Alcalde, University of Guadalajara Health Sciences Center, Hospital 278, Guadalajara, JAL, Mexico
| | - Paul Harden
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Brenda Hemmelgarn
- Departments of Community Health Sciences and Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David W Johnson
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Australia; Metro South and Ipswich Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Australia
| | - Nathan W Levin
- Mount Sinai Icahn School of Medicine, New York, New York, USA
| | - Valerie A Luyckx
- Institute of Biomedical Ethics, University of Zurich, Zurich, Switzerland; Lecturer, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Mignon I McCulloch
- Paediatric Intensive and Critical Unit, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Mohammed Rafique Moosa
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Philip J O'Connell
- Renal Unit, University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Ikechi G Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa; Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Roberto Pecoits Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Curitiba, Brazil; Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | | | - Laura Sola
- Dialysis Unit, CASMU-IAMPP, Montevideo, Uruguay
| | - Charles Swanepoel
- Division of Nephrology and Hypertension, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ahmed Twahir
- Parklands Kidney Centre, Nairobi, Kenya; Department of Medicine, The Aga Khan University Hospital, Nairobi, Kenya
| | - Wim van Biesen
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
| | | | - Chih-Wei Yang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Carlos Zuniga
- School of Medicine, Catholic University of Santisima Concepción, Concepcion, Chile
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10
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Sola L, Levin NW, Johnson DW, Pecoits-Filho R, Aljubori HM, Chen Y, Claus S, Collins A, Cullis B, Feehally J, Harden PN, Hassan MH, Ibhais F, Kalantar-Zadeh K, Levin A, Saleh A, Schneditz D, Tchokhonelidze I, Turan Kazancioglu R, Twahir A, Walker R, Were AJ, Yu X, Finkelstein FO. Development of a framework for minimum and optimal safety and quality standards for hemodialysis and peritoneal dialysis. Kidney Int Suppl (2011) 2020; 10:e55-e62. [PMID: 32149009 PMCID: PMC7031684 DOI: 10.1016/j.kisu.2019.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/14/2019] [Accepted: 11/26/2019] [Indexed: 12/11/2022] Open
Abstract
Substantial heterogeneity in practice patterns around the world has resulted in wide variations in the quality and type of dialysis care delivered. This is particularly so in countries without universal standards of care and governmental (or other organizational) oversight. Most high-income countries have developed such oversight based on documentation of adherence to standardized, evidence-based guidelines. Many low- and lower-middle-income countries have no or only limited organized oversight systems to ensure that care is safe and effective. The implementation and oversight of basic standards of care requires sufficient infrastructure and appropriate workforce and financial resources to support the basic levels of care and safety practices. It is important to understand how these standards then can be reasonably adapted and applied in low- and lower-middle-income countries.
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Affiliation(s)
- Laura Sola
- Dialysis Unit, Centro Asistencial del Sindicato Médico del Uruguay Institución de Asistencia Médica Privada de Profesionales Sin Fines de lucro, Montevideo, Uruguay
| | - Nathan W. Levin
- Mount Sinai Icahn School of Medicine, New York, New York, USA
| | - David W. Johnson
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Metro South and Ipswich Nephrology and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Curitiba, Brazil
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Harith M. Aljubori
- Nephrology Department, Alqassimi Hospital, Sharjah, United Arab Emirates
| | - Yuqing Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Key Lab of Renal Disease, Ministry of Health of China, Beijing, China
- Key Lab of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Stefaan Claus
- Nephrology Division, Ghent University Hospital, Ghent, Belgium
| | - Allan Collins
- NxStage Medical, Inc., Lawrence, Massachusetts, USA
- Department of Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Brett Cullis
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa
| | | | - Paul N. Harden
- Oxford Kidney Unit, Oxford University Hospitals National Health Service Foundation Trust, Oxford, UK
| | - Mohamed H. Hassan
- Division of Nephrology, Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Fuad Ibhais
- Yatta Governmental Hospital, Yatta, Palestine
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Abdulkarim Saleh
- Department of Nephrology Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Daneil Schneditz
- Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Irma Tchokhonelidze
- Nephrology Development Clinical Center, Tbilisi State Medical University, Tbilisi, Georgia
| | | | - Ahmed Twahir
- Parklands Kidney Centre, Nairobi, Kenya
- Department of Medicine, The Aga Khan University Hospital, Nairobi, Kenya
| | - Robert Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Anthony J.O. Were
- Renal Unit, Kenyatta National Hospital, Nairobi, Kenya
- School of Medicine, Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya
- East African Kidney Institute, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Xueqing Yu
- Division of Nephrology, Guangdong Provincial People’s School of Medicine, South China University of Technology, Guangzhou, China
- Key Laboratory of Nephrology, Ministry of Health, Guangzhou, Guangdong, China
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11
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Pecoits-Filho R, Okpechi IG, Donner JA, Harris DC, Aljubori HM, Bello AK, Bellorin-Font E, Caskey FJ, Collins A, Cueto-Manzano AM, Feehally J, Goh BL, Jager KJ, Nangaku M, Rahman M, Sahay M, Saleh A, Sola L, Turan Kazancioglu R, Walker RC, Walker R, Yao Q, Yu X, Zhao MH, Johnson DW. Capturing and monitoring global differences in untreated and treated end-stage kidney disease, kidney replacement therapy modality, and outcomes. Kidney Int Suppl (2011) 2020; 10:e3-e9. [PMID: 32149004 PMCID: PMC7031690 DOI: 10.1016/j.kisu.2019.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/11/2019] [Accepted: 11/07/2019] [Indexed: 12/17/2022] Open
Abstract
A large gap between the number of people with end-stage kidney disease (ESKD) who received kidney replacement therapy (KRT) and those who needed it has been recently identified, and it is estimated that approximately one-half to three-quarters of all people with ESKD in the world may have died prematurely because they could not receive KRT. This estimate is aligned with a previous report that estimated that >3 million people in the world died each year because they could not access KRT. This review discusses the reasons for the differences in treated and untreated ESKD and KRT modalities and outcomes and presents strategies to close the global KRT gap by establishing robust health information systems to guide resource allocation to areas of need, inform KRT service planning, enable policy development, and monitor KRT health outcomes.
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Affiliation(s)
- Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Curitiba, Brazil
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Ikechi G. Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Jo-Ann Donner
- International Society of Nephrology, Brussels, Belgium
| | - David C.H. Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Harith M. Aljubori
- Nephrology Department, Alqassimi Hospital, Sharjah, United Arab Emirates
| | - Aminu K. Bello
- Division of Nephrology and Immunity, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ezequiel Bellorin-Font
- Division of Nephology and Hypertension, Department of Medicine, Saint Louis University, Saint Louis, Missouri, USA
| | - Fergus J. Caskey
- UK Renal Registry, Learning and Research, Southmead Hospital, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol, UK
- The Richard Bright Renal Unit, Southmead Hospital, North Bristol National Health Service Trust, Bristol, UK
| | - Allan Collins
- NxStage Medical, Inc., Lawrence, Massachusetts, USA
- Department of Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Alfonso M. Cueto-Manzano
- Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | | | - Bak Leong Goh
- Department of Nephrology and Clinical Research Centre, Hospital Serdang, Jalan Puchong, Kajang, Selangor, Malaysia
| | - Kitty J. Jager
- European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands
| | - Masaomi Nangaku
- Division of Nephrology, The University of Tokyo School of Medicine, Hongo, Japan
| | - Muhibur Rahman
- Department of Nephrology, Sir Salimullah Medical College and Mitford Hospital, Dhaka, Bangladesh
| | - Manisha Sahay
- Department of Nephrology, Osmania Medical College and General Hospital, Hyderabad, Telangana, India
| | - Abdulkarim Saleh
- Department of Nephrology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Laura Sola
- Dialysis Unit, Centro Asistencial del Sindicato Médico del Uruguay Institución de Asistencia Médica Privada de Profesionales Sin Fines de lucro, Montevideo, Uruguay
| | - Rumeyza Turan Kazancioglu
- Division of Nephrology, Bezmialem Vakif University, Istanbul, Turkey
- Walker, School of Nursing, Eastern Institute of Technology, Napier, New Zealand
| | - Rachael C. Walker
- Division of Nephrology, Bezmialem Vakif University, Istanbul, Turkey
- Walker, School of Nursing, Eastern Institute of Technology, Napier, New Zealand
- Renal Department, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Robert Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Qiang Yao
- Medical Affairs, Baxter Healthcare, Guangzhou, China
| | - Xueqing Yu
- Division of Nephrology, Guangdong Provincial People’s School of Medicine, South China University of Technology, Guangzhou, China
- Key Laboratory of Nephrology, Ministry of Health, Guangzhou, Guangdong, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - David W. Johnson
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Metro South and Ipswich Nephrology and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
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12
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Hole B, Hemmelgarn B, Brown E, Brown M, McCulloch MI, Zuniga C, Andreoli SP, Blake PG, Couchoud C, Cueto-Manzano AM, Dreyer G, Garcia Garcia G, Jager KJ, McKnight M, Morton RL, Murtagh FEM, Naicker S, Obrador GT, Perl J, Rahman M, Shah KD, Van Biesen W, Walker RC, Yeates K, Zemchenkov A, Zhao MH, Davies SJ, Caskey FJ. Supportive care for end-stage kidney disease: an integral part of kidney services across a range of income settings around the world. Kidney Int Suppl (2011) 2020; 10:e86-e94. [PMID: 32149013 DOI: 10.1016/j.kisu.2019.11.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/11/2019] [Accepted: 11/07/2019] [Indexed: 12/11/2022] Open
Abstract
A key component of treatment for all people with advanced kidney disease is supportive care, which aims to improve quality of life and can be provided alongside therapies intended to prolong life, such as dialysis. This article addresses the key considerations of supportive care as part of integrated end-stage kidney disease care, with particular attention paid to programs in low- and middle-income countries. Supportive care should be an integrated component of care for patients with advanced chronic kidney disease, patients receiving kidney replacement therapy (KRT), and patients receiving non-KRT conservative care. Five themes are identified: improving information on prognosis and support, developing context-specific evidence, establishing appropriate metrics for monitoring care, clearly communicating the role of supportive care, and integrating supportive care into existing health care infrastructures. This report explores some general aspects of these 5 domains, before exploring their consequences in 4 health care situations/settings: in people approaching end-stage kidney disease in high-income countries and in low- and middle-income countries, and in people discontinuing KRT in high-income countries and in low- and middle-income countries.
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Affiliation(s)
- Barnaby Hole
- UK Renal Registry, Learning and Research, Southmead Hospital, Bristol, UK.,Population Health Sciences, University of Bristol, Bristol, UK
| | - Brenda Hemmelgarn
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Edwina Brown
- Imperial College Healthcare National Health Service Trust, London, UK
| | - Mark Brown
- Department of Renal Medicine, St. George Hospital, Sydney, New South Wales, Australia
| | - Mignon I McCulloch
- Paediatric Intensive and Critical Unit, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Carlos Zuniga
- School of Medicine, Catholic University of Santisima Concepción, Advanced Renal Care Unit - Las Higueras Hospital, Talcahuano, Chile
| | - Sharon P Andreoli
- Department of Pediatrics, Pediatric Nephrology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Peter G Blake
- Ontario Renal Network, Toronto, Ontario, Canada.,Division of Nephrology, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada
| | - Cécile Couchoud
- French Renal Epidemiology and Information Network (REIN) Registry, Biomedicine Agency, Paris, France
| | - Alfonso M Cueto-Manzano
- Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Gavin Dreyer
- Department of Nephrology, Barts Health National Health Service Trust, London, UK
| | - Guillermo Garcia Garcia
- Servicio de Nefrologia, Hospital Civil de Guadalajara Fray Antonio Alcalde, University of Guadalajara Health Sciences Center, Hospital 278, Guadalajara, Jalisco, Mexico
| | - Kitty J Jager
- The European Renal Association - European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands
| | - Marla McKnight
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Program in Global Noncommunicable Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachael L Morton
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Fliss E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Saraladevi Naicker
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gregorio T Obrador
- Universidad Panamericana Faculty of Health Sciences and School of Medicine, Mexico City, Mexico
| | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital and the Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Muhibur Rahman
- Department of Nephrology, Sir Salimullah Medical College and Mitford Hospital, Dhaka, Bangladesh
| | | | - Wim Van Biesen
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
| | - Rachael C Walker
- School of Nursing, Eastern Institute of Technology, Napier, New Zealand.,Renal Department, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Karen Yeates
- Division of Nephrology, Queen's University, Kingston, Ontario, Canada
| | - Alexander Zemchenkov
- Department of Internal Disease and Nephrology, North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia.,Department of Nephrology and Dialysis, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Key Lab of Renal Disease, Ministry of Health of China, Beijing, China.,Key Lab of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Simon J Davies
- Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | - Fergus J Caskey
- UK Renal Registry, Learning and Research, Southmead Hospital, Bristol, UK.,Population Health Sciences, University of Bristol, Bristol, UK.,The Richard Bright Renal Unit, Southmead Hospital, North Bristol National Health Service Trust, Bristol, UK
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13
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Jhamb M, Roumelioti ME. Socioeconomic Determinants of Quality of Life in Patients with Kidney Diseases. Clin J Am Soc Nephrol 2020; 15:162-164. [PMID: 37095653 PMCID: PMC7015099 DOI: 10.2215/cjn.14941219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, University of New Mexico, Albuquerque, New Mexico
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14
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Teerawattananon Y, Dabak SV, Khoe LC, Bayani DBS, Isaranuwatchai W. To include or not include: renal dialysis policy in the era of universal health coverage. BMJ 2020; 368:m82. [PMID: 31992542 PMCID: PMC7190365 DOI: 10.1136/bmj.m82] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Expensive treatments such as renal dialysis are a challenge for countries aiming for universal coverage. Yot Teerawattananon and colleagues set out a systematic approach to ensuring it is affordable
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Affiliation(s)
- Yot Teerawattananon
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Saudamini Vishwanath Dabak
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand
| | - Levina Chandra Khoe
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Diana Beatriz S Bayani
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Health Technology Assessment Unit, Department of Health, Manila, Republic of the Philippines
| | - Wanrudee Isaranuwatchai
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Centre for Excellence in Economic Analysis Research (CLEAR), Toronto, Ontario, Canada
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15
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Abstract
PURPOSE OF REVIEW To assess the use, access to and outcomes of hemodialysis and peritoneal dialysis in low-resource settings. RECENT FINDINGS Hemodialysis tends to predominate because of costs and logistics, however services tend to be located in larger cities, often paid for out of pocket. Outcomes of dialysis-requiring acute kidney injury and end-stage kidney disease may be similar with hemodialysis and peritoneal dialysis, and therefore choice of therapy is dominated by availability, accessibility and patient or physician choice. Some countries have implemented peritoneal dialysis-first policies to reduce costs and improve access, because peritoneal dialysis requires less infrastructure, can be scaled up more easily and can be cheaper when fluids are manufactured locally. SUMMARY Access to both hemodialysis and peritoneal dialysis remains highly inequitable in lower-resource settings. Although challenges associated with dialysis in low-resource settings are similar, and there are more adults who require dialysis in low-resource settings, addressing hemodialysis and peritoneal dialysis needs of children in low-resource settings requires attention as the global inequities are greatest in this area. Lower-income countries are increasingly seeking to improve access to dialysis through various strategies, but meeting the costs of the entire dialysis population continues to be a major challenge.
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16
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Piccoli GB, Cabiddu G, Breuer C, Jadeau C, Testa A, Brunori G. Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices? J Clin Med 2019; 8:jcm8020276. [PMID: 30823518 PMCID: PMC6406585 DOI: 10.3390/jcm8020276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/14/2019] [Accepted: 02/21/2019] [Indexed: 12/15/2022] Open
Abstract
Allowing patients to live for decades without the function of a vital organ is a medical miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care expenditure in countries where dialysis is available without restrictions. While transplantation is the preferred treatment in patients without contraindications, old age and comorbidity limit its indications, and low organ availability may result in long waiting times. As a consequence, 30–70% of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs of dialysis are differently defined, and its reimbursement follows different rules. There are three main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation, hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs). Each one has advantages and drawbacks, and impacts differently on the organization and delivery of care: payment per session may favour fragmentation and make a global appraisal difficult; a correct capitation system needs a careful correction for comorbidity, and may exacerbate competition between public and private settings, the latter aiming at selecting the least complex cases; a bundle system, in which the main elements linked to the dialysis sessions are considered together, may be a good compromise but risks penalising complex patients, and requires a rapid adaptation to treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for predialysis care are not established and its development may be unfavourable for the provider. A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high quality of dialysis care.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | | | - Conrad Breuer
- Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Christelle Jadeau
- Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France.
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17
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Kaur G, Prinja S, Ramachandran R, Malhotra P, Gupta KL, Jha V. Cost of hemodialysis in a public sector tertiary hospital of India. Clin Kidney J 2018; 11:726-733. [PMID: 30288270 PMCID: PMC6165756 DOI: 10.1093/ckj/sfx152] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 11/28/2017] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Nearly 220000 patients are diagnosed with end-stage renal disease (ESRD) every year, which calls for an additional demand of 34 million dialysis sessions in India. The government of India has announced a National Dialysis Programme to provide for free dialysis in public hospitals. In this article we estimate the overall cost of performing hemodialysis (HD) in a tertiary care hospital. Second, we assess the catastrophic impact of out-of-pocket expenditures (OOPEs) for HD on households and its determinants. METHODS The economic health system cost of HD was estimated using bottom-up costing methods. All resources, capital and recurrent, utilized for service delivery from April 2015 to March 2016 were identified, measured and valued. Capital costs were annualized after accounting for their useful life and discounting at 3% for future years. Sensitivity analyses were undertaken to determine the effect of variation in the input prices and other assumptions on the annual health system cost. OOPEs were assessed by interviewing 108 patients undergoing HD in the study hospital to account for costs from the patient's perspective. The prevalence of catastrophic health expenditures (CHEs) was computed per threshold of 40% of non-food expenditures. RESULTS The overall average cost incurred by the health system per HD session was INR 4148 (US$64). Adjusting for capacity utilization, the health system incurred INR 3025 (US$47) per HD at 100% bed occupancy. The mean OOPE per patient per session was INR 2838 (US$44; 95% confidence interval US$34-55). The major components of this OOPE were medicines and consumables (64.1%). The prevalence of a CHE per HD session was 11.1%. CONCLUSION Our study findings would be useful in the context of planning for dialysis services, setting provider payment rates for dialysis under various publicly sponsored health insurance schemes and undertaking future cost-effectiveness analysis to guide resource allocation decisions.
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Affiliation(s)
- Gunjeet Kaur
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Krishan Lal Gupta
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivekanand Jha
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
- George Institute for Global Health, New Delhi, India
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18
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Rope R, Nanayakkara N, Wazil A, Dickowita S, Abeyeskera R, Gunerathne L, Adoosoriya D, Karunasena N, Rathnayake C, Anand S, Saxena A. Expanding CAPD in Low-Resource Settings: A Distance Learning Approach. Perit Dial Int 2018; 38:343-348. [PMID: 29793981 PMCID: PMC6126978 DOI: 10.3747/pdi.2017.00251] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/28/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite growing need, treatment for end-stage renal disease is limited in low- and middle-income countries due to resource restraints. We describe the development of an educational curriculum and quality improvement program to support continuous ambulatory peritoneal dialysis (CAPD) performed primarily by non-nephrology providers in Sri Lanka. METHODS We developed a program of education, outcome tracking, and expert consultation to support providers in Kandy, Sri Lanka. Education included videos and in-person didactics covering core topics in CAPD. Event-tracking sheets recorded root causes and management of infections and hospitalizations. Conferences reviewed clinical cases and overall clinic management. We evaluated the patient census, peritonitis rates, and root causes and management of infections over 1 year. RESULTS The curriculum was published through the International Society of Nephrology online academy. High provider turnover limited curriculum assessments. The CAPD patient census rose from 63 to 116 during the year. The peritonitis rate declined significantly, from 0.8 episodes per patient-year in the first 6 months to 0.4 in the latter 6 months, though the most common root causes of peritonitis, related to contamination events and hygiene, persisted. The appropriate ascertainment of culture data and prescription of antibiotics also increased. CONCLUSIONS Our project supported the expansion of a CAPD program in a resource-limited setting, while also improving peritonitis outcomes. Ongoing challenges include ensuring a durable educational system for rotating providers, tracking outcomes beyond peritonitis, and formalizing management protocols. Our program can serve as an example of how established dialysis programs can support the burgeoning work of providers in resource-limited setting.
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Affiliation(s)
- Robert Rope
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | | | | | | | | | | | | | | | - Shuchi Anand
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Anjali Saxena
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
- Division of Nephrology, Santa Clara Valley Medical Center, San Jose, CA, USA
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19
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Carrero JJ, Hecking M, Ulasi I, Sola L, Thomas B. Chronic Kidney Disease, Gender, and Access to Care: A Global Perspective. Semin Nephrol 2018; 37:296-308. [PMID: 28532558 DOI: 10.1016/j.semnephrol.2017.02.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Little is known regarding the ways in which chronic kidney disease (CKD) prevalence and progression differ between the sexes. Still less is known regarding how social disparities between men and women may affect access to care for CKD. In this review, we briefly describe biological sex differences, noting how these differences currently do not influence CKD management recommendations. We then describe what is known within the published literature regarding differences in CKD epidemiology between sexes; namely prevalence, progression, and access to treatment throughout the major world regions. We highlight that health care expenditure and social gender disparities ultimately may determine whether women have equitable access to care for CKD and end-stage kidney disease. Among many high- and low-income settings, women more often donate and are less likely to receive kidney transplants when compared with men. Research is needed urgently to elucidate the reasons behind these disparities, as well as to develop CKD treatment strategies tailored to women's unique health care needs.
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Affiliation(s)
- Juan-Jesus Carrero
- Division of Kidney Medicine, Karolinska Institute, Solna, Stockholm, Sweden.
| | - Manfred Hecking
- Medizinische Universität Wien, Universitätsklinik für Innere Medizin III, Klinische Abteilung für Nephrologie und Dialyse, Wein, Austria
| | - Ifeoma Ulasi
- Department of Medicine, College of Medicine, University of Nigeria, Nsukka, Nigeria
| | - Laura Sola
- División Epidemiologia, Ministerio de Salud, Departamento Medicina Preventiva y Social, Universidad de la República, Montevideo, Uruguay
| | - Bernadette Thomas
- Department of Global Health, University of Washington, Seattle, WA, USA
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20
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Abstract
PURPOSE OF REVIEW Chronic breathlessness is common in patients with advanced illness who require palliative care. Achieving good symptom control can be challenging. More people with advanced illness live in low and middle income than in high-income countries, but they are much less likely to receive palliative care. Most of the emerging evidence for the palliative management of chronic breathlessness is from high-income countries. This review explores the context of chronic breathlessness in low-income settings, how evidence for control of chronic breathlessness might relate to these settings and where further work should be focused. RECENT FINDINGS Systems for control of noncommunicable diseases (NCDs) in these low-income contexts are poorly developed and health services are often overwhelmed with high levels both of NCD and communicable disease. Multidisciplinary and holistic approaches to disease management are often lacking in these settings. Developing an integrated primary care approach to NCD management is increasingly recognized as a key strategy and this should include palliative care. Most evidence-based approaches to the control of chronic breathlessness could be adapted for use in these contexts SUMMARY: Hand held fans, breathing techniques, graded exercise and use of low-dose morphine can all be used in low-income settings particularly in the context of holistic care. Research is needed into the most effective ways of implementing such interventions and palliative care needs to be promoted as a fundamental aspect of NCD management.
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21
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Htay H, Alrukhaimi M, Ashuntantang GE, Bello AK, Bellorin-Font E, Benghanem Gharbi M, Braam B, Feehally J, Harris DC, Jha V, Jindal K, Kalantar-Zadeh K, Kazancioglu R, Kerr PG, Levin A, Lunney M, Okpechi IG, Olah ME, Olanrewaju TO, Osman MA, Parpia Y, Perl J, Qarni B, Rashid HU, Rateb A, Rondeau E, Salako BL, Sola L, Tchokhonelidze I, Tonelli M, Wiebe N, Wirzba I, Yang CW, Ye F, Zemchenkov A, Zhao MH, Johnson DW. Global access of patients with kidney disease to health technologies and medications: findings from the Global Kidney Health Atlas project. Kidney Int Suppl (2011) 2018; 8:64-73. [PMID: 30675440 DOI: 10.1016/j.kisu.2017.10.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Access to essential medications and health products is critical to effective management of kidney disease. Using data from the ISN Global Kidney Health Atlas multinational cross-sectional survey, global access of patients with kidney disease to essential medications and health products was examined. Overall, 125 countries participated, with 118 countries, composing 91.5% of the world's population, providing data on this domain. Most countries were unable to access eGFR and albuminuria in their primary care settings. Only one-third of low-income countries (LICs) were able to measure serum creatinine and none were able to access eGFR or quantify proteinuria. The ability to monitor diabetes mellitus through serum glucose and glycated hemoglobin measurements was suboptimal. Pathology services were rarely available in tertiary care in LICs (12%) and lower middle-income countries (45%). While acute and chronic hemodialysis services were available in almost all countries, acute and chronic peritoneal dialysis services were rarely available in LICs (18% and 29%, respectively). Kidney transplantation was available in 79% of countries overall and in 12% of LICs. While over one-half of all countries publicly funded RRT and kidney medications with or without copayment, this was less common in LICs and lower middle-income countries. In conclusion, this study demonstrated significant gaps in services for kidney care and funding that were most apparent in LICs and lower middle-income countries.
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Affiliation(s)
- Htay Htay
- Department of Nephrology, Metro South and Ipswich Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Australia.,Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Gloria E Ashuntantang
- Faculty of Medicine and Biomedical Sciences, Yaounde General Hospital, University of Yaounde I, Yaounde, Cameroon
| | - Aminu K Bello
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Ezequiel Bellorin-Font
- Division of Nephrology and Kidney Transplantation, Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela
| | - Mohammed Benghanem Gharbi
- Urinary Tract Diseases Department, Faculty of Medicine and Pharmacy of Casablanca, University Hassan II of Casablanca, Casablanca, Morocco
| | - Branko Braam
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - John Feehally
- Department of Infection, Inflammation and Immunity, University Hospitals of Leicester, University of Leicester, Leicester, UK
| | - David C Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Vivekanand Jha
- George Institute for Global Health India, New Delhi, India.,University of Oxford, Oxford, UK
| | - Kailash Jindal
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA
| | | | - Peter G Kerr
- Department of Nephrology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Meaghan Lunney
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ikechi G Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Michelle E Olah
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Mohamed A Osman
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Yasin Parpia
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital and the Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Bilal Qarni
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Harun Ur Rashid
- Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh
| | - Ahmed Rateb
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Eric Rondeau
- Intensive Care Nephrology and Transplantation Department, Hopital Tenon, Assistance Publique-Hopitaux de Paris, Paris, France.,Université Paris VI, Paris, France
| | | | - Laura Sola
- Division Epidemiologia, Direccion General de Salud-Ministerio Salud Publica, Montevideo, Uruguay
| | - Irma Tchokhonelidze
- Nephrology Development Clinical Center, Tbilisi State Medical University, Tbilisi, Georgia
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Natasha Wiebe
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Isaac Wirzba
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Chih-Wei Yang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Feng Ye
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Alexander Zemchenkov
- Department of Internal Disease and Nephrology, North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia.,Department of Nephrology and Dialysis, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Key Lab of Renal Disease, Ministry of Health of China, Beijing, China.,Key Lab of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - David W Johnson
- Department of Nephrology, Metro South and Ipswich Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Australia.,Centre for Kidney Disease Research, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia
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22
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Finkelstein EA, Ozdemir S, Malhotra C, Jafar TH, Choong HL, Suhardjono J. Identifying Factors That Influence Physicians' Recommendations for Dialysis and Conservative Management in Indonesia. Kidney Int Rep 2017; 2:212-218. [PMID: 29142957 PMCID: PMC5678627 DOI: 10.1016/j.ekir.2016.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 11/14/2016] [Accepted: 12/05/2016] [Indexed: 11/07/2022] Open
Abstract
Introduction For elderly end-stage renal disease (ESRD) patients with multiple comorbidities, dialysis may offer little survival benefit compared to conservative management (CM). Yet, many elderly ESRD patients undergo dialysis, partly due to physicians’ recommendations regarding treatment choice. This study aims to elucidate the factors that influence these recommendations. Methods We surveyed a convenience sample of physicians who attended the 9th Asian Forum of Chronic Kidney Disease Initiative conference. We used vignettes that vary by age and comorbidity status, and asked physicians to recommend dialysis or CM for a hypothetical patient with that profile and to predict survival with both treatment options. We also compared the physician’s recommendations to patients for what they would recommend for themselves if they were diagnosed with ESRD. Results On average, physicians believed that dialysis extends life relative to CM. Yet, a large subset believed that CM confers greater survival. Estimates range from 17.3% (for a 65-year-old with diabetes and CHF) to 50% for patients with advanced cancer. Results further reveal high discordance regarding treatment recommendations. For a 65-year-old patient with diabetes, 62% recommended dialysis and 38% did not. For advanced cancer, the split was 25% and 75%. Physicians were far more likely to recommend dialysis for themselves than for their patients. Discussion This study suggests that physicians would benefit from a greater understanding of survival benefits of dialysis and CM for elderly patients with different comorbidity profiles. This would allow patients to make more informed decisions.
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Affiliation(s)
| | | | | | - Tazeen H Jafar
- Duke-NUS Medical School Singapore, Singapore.,Singapore General Hospital, Singapore
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23
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Economic evaluation of policy options for dialysis in end-stage renal disease patients under the universal health coverage in Indonesia. PLoS One 2017; 12:e0177436. [PMID: 28545094 PMCID: PMC5436694 DOI: 10.1371/journal.pone.0177436] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 04/27/2017] [Indexed: 12/01/2022] Open
Abstract
Objectives This study aims to assess the value for money and budget impact of offering hemodialysis (HD) as a first-line treatment, or the HD-first policy, and the peritoneal dialysis (PD) first policy compared to a supportive care option in patients with end-stage renal disease (ESRD) in Indonesia. Methods A Markov model-based economic evaluation was performed using local and international data to quantify the potential costs and health-related outcomes in terms of life years (LYs) and quality-adjusted life years (QALYs). Three policy options were compared, i.e., the PD-first policy, HD-first policy, and supportive care. Results The PD-first policy for ESRD patients resulted in 5.93 life years, equal to the HD-first policy, with a slightly higher QALY gained (4.40 vs 4.34). The total lifetime cost for a patient under the PD-first policy is around 700 million IDR, which is lower than the cost under the HD-first policy, i.e. 735 million IDR per patient. Compared to supportive care, the incremental cost-effectiveness ratio of the PD-first policy is 193 million IDR per QALY, while the HD-first policy resulted in 207 million IDR per QALY. Budget impact analysis indicated that the required budget for the PD-first policy is 43 trillion IDR for 53% coverage and 75 trillion IDR for 100% coverage in five years, which is less than the HD-first policy, i.e. 88 trillion IDR and 166 trillion IDR. Conclusions The PD-first policy was found to be more cost-effective compared to the HD-first policy. Budget impact analysis provided evidence on the enormous financial burden for the country if the current practice, where HD dominates PD, continues for the next five years.
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24
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Bello AK, Levin A, Tonelli M, Okpechi IG, Feehally J, Harris D, Jindal K, Salako BL, Rateb A, Osman MA, Qarni B, Saad S, Lunney M, Wiebe N, Ye F, Johnson DW. Assessment of Global Kidney Health Care Status. JAMA 2017; 317:1864-1881. [PMID: 28430830 PMCID: PMC5470418 DOI: 10.1001/jama.2017.4046] [Citation(s) in RCA: 243] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Kidney disease is a substantial worldwide clinical and public health problem, but information about available care is limited. OBJECTIVE To collect information on the current state of readiness, capacity, and competence for the delivery of kidney care across countries and regions of the world. DESIGN, SETTING, AND PARTICIPANTS Questionnaire survey administered from May to September 2016 by the International Society of Nephrology (ISN) to 130 ISN-affiliated countries with sampling of key stakeholders (national nephrology society leadership, policy makers, and patient organization representatives) identified by the country and regional nephrology leadership through the ISN. MAIN OUTCOMES AND MEASURES Core areas of country capacity and response for kidney care. RESULTS Responses were received from 125 of 130 countries (96%), including 289 of 337 individuals (85.8%, with a median of 2 respondents [interquartile range, 1-3]), representing an estimated 93% (6.8 billion) of the world's population of 7.3 billion. There was wide variation in country readiness, capacity, and response in terms of service delivery, financing, workforce, information systems, and leadership and governance. Overall, 119 (95%), 95 (76%), and 94 (75%) countries had facilities for hemodialysis, peritoneal dialysis, and kidney transplantation, respectively. In contrast, 33 (94%), 16 (45%), and 12 (34%) countries in Africa had facilities for hemodialysis, peritoneal dialysis, and kidney transplantation, respectively. For chronic kidney disease (CKD) monitoring in primary care, serum creatinine with estimated glomerular filtration rate and proteinuria measurements were reported as always available in only 21 (18%) and 9 (8%) countries, respectively. Hemodialysis, peritoneal dialysis, and transplantation services were funded publicly and free at the point of care delivery in 50 (42%), 48 (51%), and 46 (49%) countries, respectively. The number of nephrologists was variable and was low (<10 per million population) in Africa, the Middle East, South Asia, and Oceania and South East Asia (OSEA) regions. Health information system (renal registry) availability was limited, particularly for acute kidney injury (8 countries [7%]) and nondialysis CKD (9 countries [8%]). International acute kidney injury and CKD guidelines were reportedly accessible in 52 (45%) and 62 (52%) countries, respectively. There was relatively low capacity for clinical studies in developing nations. CONCLUSIONS AND RELEVANCE This survey demonstrated significant interregional and intraregional variability in the current capacity for kidney care across the world, including important gaps in services and workforce. Assuming the responses accurately reflect the status of kidney care in the respondent countries, the findings may be useful to inform efforts to improve the quality of kidney care worldwide.
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Affiliation(s)
- Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada4Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ikechi G Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - John Feehally
- University Hospitals of Leicester, University of Leicester, Leicester, England
| | - David Harris
- Centre for Transplantation and Renal Research, University of Sydney at Westmead Hospital, Sydney, Australia
| | - Kailash Jindal
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Babatunde L Salako
- Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Ahmed Rateb
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Mohamed A Osman
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Bilal Qarni
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Syed Saad
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Meaghan Lunney
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada4Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Natasha Wiebe
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Feng Ye
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - David W Johnson
- Centre for Kidney Disease Research, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia10Translational Research Institute, Brisbane, Australia11Metro South and Ipswich Nephrology and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
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25
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iTRAQ-Based Proteomics of Chronic Renal Failure Rats after FuShengong Decoction Treatment Reveals Haptoglobin and Alpha-1-Antitrypsin as Potential Biomarkers. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2017; 2017:1480514. [PMID: 28536642 PMCID: PMC5425835 DOI: 10.1155/2017/1480514] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 03/29/2017] [Accepted: 04/10/2017] [Indexed: 02/06/2023]
Abstract
Background. Chronic renal failure (CRF) has become a global health problem and bears a huge economic burden. FuShengong Decoction (FSGD) as traditional Chinese medicine has multiple pharmacological effects. Objectives. To understand the underlying molecular mechanism and signaling pathway involved in the FSGD treatment of CRF and screen differentially expressed proteins in rats with CRF treated with FSGD. Methods. Thirty-three male Sprague-Dawley rats were randomly divided into control group, CRF group, and FSGD group. Differentially expressed proteins were screened by iTRAQ coupled with nanoLC-MS/MS, and these identified proteins were later analyzed by GO, KEGG, and STRING. Additionally, haptoglobin (HP) and alpha-1-antitrypsin (AAT) were finally verified by ELISA, Western blot, and real time PCR. Results. A total of 417 proteins were identified. Nineteen differentially expressed proteins were identified in the FSGD group compared with the model group, of which 3 proteins were upregulated and 16 proteins were downregulated. Cluster analysis indicated that inflammatory response was associated with these proteins and complement and coagulation cascade pathways were predominantly involved. The validation methods further confirmed that the levels of HP and AAT were significantly increased. Conclusions. HP and AAT may be the important biomarkers in the pathogenesis of CRF and FSGD therapy.
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26
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Thomas B, Matsushita K, Abate KH, Al-Aly Z, Ärnlöv J, Asayama K, Atkins R, Badawi A, Ballew SH, Banerjee A, Barregård L, Barrett-Connor E, Basu S, Bello AK, Bensenor I, Bergstrom J, Bikbov B, Blosser C, Brenner H, Carrero JJ, Chadban S, Cirillo M, Cortinovis M, Courville K, Dandona L, Dandona R, Estep K, Fernandes J, Fischer F, Fox C, Gansevoort RT, Gona PN, Gutierrez OM, Hamidi S, Hanson SW, Himmelfarb J, Jassal SK, Jee SH, Jha V, Jimenez-Corona A, Jonas JB, Kengne AP, Khader Y, Khang YH, Kim YJ, Klein B, Klein R, Kokubo Y, Kolte D, Lee K, Levey AS, Li Y, Lotufo P, El Razek HMA, Mendoza W, Metoki H, Mok Y, Muraki I, Muntner PM, Noda H, Ohkubo T, Ortiz A, Perico N, Polkinghorne K, Al-Radaddi R, Remuzzi G, Roth G, Rothenbacher D, Satoh M, Saum KU, Sawhney M, Schöttker B, Shankar A, Shlipak M, Silva DAS, Toyoshima H, Ukwaja K, Umesawa M, Vollset SE, Warnock DG, Werdecker A, Yamagishi K, Yano Y, Yonemoto N, Zaki MES, Naghavi M, Forouzanfar MH, Murray CJL, Coresh J, Vos T. Global Cardiovascular and Renal Outcomes of Reduced GFR. J Am Soc Nephrol 2017; 28:2167-2179. [PMID: 28408440 DOI: 10.1681/asn.2016050562] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 01/15/2017] [Indexed: 01/27/2023] Open
Abstract
The burden of premature death and health loss from ESRD is well described. Less is known regarding the burden of cardiovascular disease attributable to reduced GFR. We estimated the prevalence of reduced GFR categories 3, 4, and 5 (not on RRT) for 188 countries at six time points from 1990 to 2013. Relative risks of cardiovascular outcomes by three categories of reduced GFR were calculated by pooled random effects meta-analysis. Results are presented as deaths for outcomes of cardiovascular disease and ESRD and as disability-adjusted life years for outcomes of cardiovascular disease, GFR categories 3, 4, and 5, and ESRD. In 2013, reduced GFR was associated with 4% of deaths worldwide, or 2.2 million deaths (95% uncertainty interval [95% UI], 2.0 to 2.4 million). More than half of these attributable deaths were cardiovascular deaths (1.2 million; 95% UI, 1.1 to 1.4 million), whereas 0.96 million (95% UI, 0.81 to 1.0 million) were ESRD-related deaths. Compared with metabolic risk factors, reduced GFR ranked below high systolic BP, high body mass index, and high fasting plasma glucose, and similarly with high total cholesterol as a risk factor for disability-adjusted life years in both developed and developing world regions. In conclusion, by 2013, cardiovascular deaths attributed to reduced GFR outnumbered ESRD deaths throughout the world. Studies are needed to evaluate the benefit of early detection of CKD and treatment to decrease these deaths.
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Affiliation(s)
- Bernadette Thomas
- Institute for Health Metrics and Evaluation, .,Internal Medicine, Nephrology, University of Washington, Seattle, Washington
| | - Kunihiro Matsushita
- Department of Epidemiology and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Ziyad Al-Aly
- Washington University in St. Louis, St. Louis, Missouri
| | - Johan Ärnlöv
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Huddinge, Sweden.,School of Health and Social Studies, Dalarna University, Falun, Sweden
| | - Kei Asayama
- Teikyo University School of Medicine, Tokyo, Japan
| | - Robert Atkins
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Alaa Badawi
- Public Health Agency of Canada, Toronto, Ontario, Canada.,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shoshana H Ballew
- Department of Epidemiology and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Amitava Banerjee
- Farr Institute of Health Informatics Research, University College London, London, England, United Kingdom
| | - Lars Barregård
- Department of Occupational and Environmental Health, University of Gothenburg, Gothenburg, Sweden
| | | | | | - Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Boris Bikbov
- Department of Nephrology Issues of Transplanted Kidney, Academician V.I. Shumakov Federal Research Center of Transplantology and Artificial Organs, Moscow, Russia
| | - Christopher Blosser
- Internal Medicine, Nephrology, University of Washington, Seattle, Washington
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Juan-Jesus Carrero
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Steve Chadban
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia.,Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Renal Medicine, Royal Prince Alfred Hospital, New South Wales, Australia
| | | | - Monica Cortinovis
- Istituto Di Ricovero E Cura A Carattere Scientifico, Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | - Karen Courville
- Istituto Di Ricovero E Cura A Carattere Scientifico, Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | - Lalit Dandona
- Institute for Health Metrics and Evaluation.,Public Health Foundation of India, New Delhi, India
| | - Rakhi Dandona
- Institute for Health Metrics and Evaluation.,Public Health Foundation of India, New Delhi, India
| | - Kara Estep
- Institute for Health Metrics and Evaluation
| | - João Fernandes
- Center for Biotechnology and Fine Chemistry, Associate Laboratory, Faculty of Biotechnology, Catholic University of Portugal, Porto, Portugal
| | | | - Caroline Fox
- National Heart, Lung, and Blood Institute, Framingham, MA
| | | | | | | | - Samer Hamidi
- Hamdan Bin Mohammed Smart University, Dubai, United Arab Emirates
| | | | - Jonathan Himmelfarb
- Internal Medicine, Nephrology, University of Washington, Seattle, Washington
| | - Simerjot K Jassal
- Veterans Affairs, University of California, San Diego, San Diego, California
| | - Sun Ha Jee
- Department of Epidemiology and Health Promotion, Institute for Health Promotion, Graduate School of Public Health, Yonsei University, Seoul, South Korea
| | - Vivekanand Jha
- George Institute for Global Health, New Delhi, India.,University of Oxford, Oxford, England, United Kingdom
| | - Aida Jimenez-Corona
- Department of Ocular Epidemiology and Visual Health, Institute of Ophthalmology Conde de Valencia, Mexico City, Mexico.,General Directorate of Epidemiology, Ministry of Health, Mexico City, Mexico
| | - Jost B Jonas
- Department of Ophthalmology, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Andre Pascal Kengne
- South African Medical Research Council, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yousef Khader
- Jordan University of Science and Technology, Irbid, Jordan
| | - Young-Ho Khang
- College of Medicine, Seoul National University, Seoul, South Korea
| | - Yun Jin Kim
- Southern University College, Skudai, Malaysia
| | | | - Ronald Klein
- Department of Ophthalmology and Visual Sciences and
| | - Yoshihiro Kokubo
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Dhaval Kolte
- Division of Cardiology, Brown University, Providence, Rhode Island
| | - Kristine Lee
- Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Yongmei Li
- General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | | | | | | | | | - Yejin Mok
- Department of Epidemiology and Health Promotion, Institute for Health Promotion, Graduate School of Public Health, Yonsei University, Seoul, South Korea
| | - Isao Muraki
- Osaka Medical Center for Cancer and Cardiovascular Diseases Prevention, Osaka, Japan
| | | | - Hiroyuki Noda
- Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | | | - Norberto Perico
- Istituto Di Ricovero E Cura A Carattere Scientifico, Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
| | - Kevan Polkinghorne
- Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Giuseppe Remuzzi
- Istituto Di Ricovero E Cura A Carattere Scientifico, Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy.,Azienda Socio-Sanitaria Territoriale, Papa Giovanni XXIII, Bergamo, Italy.,Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | | | | | | | - Kai-Uwe Saum
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | | | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Institute of Health Care and Social Sciences, Hochschule für Oekonomie & Management University, Essen, Germany
| | | | - Michael Shlipak
- General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | | | | | - Kingsley Ukwaja
- Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Nigeria
| | | | - Stein Emil Vollset
- Center for Disease Burden, Norwegian Institute of Public Health, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Institute for Health Metrics and Evaluation
| | - David G Warnock
- Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Andrea Werdecker
- Competence Center Mortality-Follow-Up of the German National Cohort, Federal Institute for Population Research, Wiesbaden, Germany
| | - Kazumasa Yamagishi
- Department of Public Health Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yuichiro Yano
- Department of Preventive Medicine, Northwestern University, Chicago, IL; and
| | - Naohiro Yonemoto
- **************Department of Biostatistics, School of Public Health, Kyoto University, Kyoto, Japan
| | | | | | | | | | - Josef Coresh
- Department of Epidemiology and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Theo Vos
- Institute for Health Metrics and Evaluation
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27
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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.
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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
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