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Bamforth RJ, Trachtenberg A, Ho J, Wiebe C, Ferguson TW, Rigatto C, Forget E, Dodd N, Tangri N. Expanding Access to High KDPI Kidney Transplant for Recipients Aged 60 y and Older: Cost Utility and Survival. Transplant Direct 2024; 10:e1629. [PMID: 38757046 PMCID: PMC11098249 DOI: 10.1097/txd.0000000000001629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/05/2024] [Accepted: 02/21/2024] [Indexed: 05/18/2024] Open
Abstract
Background Modern organ allocation systems are tasked with equitably maximizing the utility of transplanted organs. Increasing the use of deceased donor organs at risk of discard may be a cost-effective strategy to improve overall transplant benefit. We determined the survival implications and cost utility of increasing the use of marginal kidneys in an older adult Canadian population of patients with end-stage kidney disease. Methods We constructed a cost-utility model with microsimulation from the perspective of the Canadian single-payer health system for incident transplant waitlisted patients aged 60 y and older. A kidney donor profile index score of ≥86 was considered a marginal kidney. Donor- and recipient-level characteristics encompassed in the kidney donor profile index and estimated posttransplant survival scores were used to derive survival posttransplant. Patients were followed up for 10 y from the date of waitlist initiation. Our analysis compared the routine use of marginal kidneys (marginal kidney scenario) with the current practice of limited use (status quo scenario). Results The 10-y mean cost and quality-adjusted life-years per patient in the marginal kidney scenario were estimated at $379 485.33 (SD: $156 872.49) and 4.77 (SD: 1.87). In the status quo scenario, the mean cost and quality-adjusted life-years per patient were $402 937.68 (SD: $168 508.85) and 4.37 (SD: 1.87); thus, the intervention was considered dominant. At 10 y, 62.8% and 57.0% of the respective cohorts in the marginal kidney and status quo scenarios remained alive. Conclusions Increasing the use of marginal kidneys in patients with end-stage kidney disease aged 60 y and older may offer cost savings, improved quality of life, and greater patient survival in comparison with usual care.
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Affiliation(s)
- Ryan J. Bamforth
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Aaron Trachtenberg
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Adult Kidney Program, Winnipeg, MB, Canada
| | - Julie Ho
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Adult Kidney Program, Winnipeg, MB, Canada
| | - Chris Wiebe
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Adult Kidney Program, Winnipeg, MB, Canada
| | - Thomas W. Ferguson
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Claudio Rigatto
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Evelyn Forget
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Nancy Dodd
- Transplant Manitoba Adult Kidney Program, Winnipeg, MB, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
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Shah N, Bennett PN, Cho Y, Leibowitz S, Abra G, Kanjanabuch T, Baharani J. Exploring Preconceptions as Barriers to Peritoneal Dialysis Eligibility: A Global Scenario-Based Survey of Kidney Care Physicians. Kidney Int Rep 2024; 9:941-950. [PMID: 38765569 PMCID: PMC11101779 DOI: 10.1016/j.ekir.2024.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/22/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Despite the growing number of patients requiring kidney replacement therapy (KRT), peritoneal dialysis (PD) is underutilized globally. A contributory factor may be clinician myths about its use. The aim of this study was to explore perceptions about PD initiation by clinicians according to various physical, social, and clinical characteristics of patients. Methods An online global survey (in English and Thai) was administered to ascertain nephrologists' and nephrology trainees' decisions on recommending PD as a treatment modality. Results A total of 645 participants (522 nephrologists and 123 trainees; 56% male) from 54 countries (66% from high-income countries [HICs], 22% from upper middle-income countries [UMICs], 12% from lower middle-income countries, and 1% from low-income countries [LICs]) completed the survey. Of the respondents, 81% identified as attending physicians or consultants, and 19% identified as trainees or other. PD was recommended for most scenarios, including repeated exposures to heavy lifting, swimming (especially in a private pool and ocean), among patients with cirrhosis or cognitive impairment with available support, and those living with a pet if a physical separation can be achieved during PD. Certain abdominal surgeries were more acceptable to proceed with PD (hysterectomy, 90%) compared to others (hemicolectomy, 45%). Similar variation was noted for different types of stomas (nephrostomies, 74%; suprapubic catheters, 53%; and ileostomies, 27%). Conclusion The probability of recommending PD in various scenarios was greater among clinicians from HICs, larger units, and consultants with more clinical experience. There is a disparity in recommending PD across various clinical scenarios driven by experience, unit-level characteristics, and region of practice. Globally, evidence-informed education is warranted to rectify misconceptions to enable greater PD uptake.
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Affiliation(s)
- Nikhil Shah
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Paul N. Bennett
- Renal Nursing (Clinical & Health Sciences), University of South Australia, Adelaide, Australia
| | | | | | - Graham Abra
- Satellite Healthcare and Department of Medicine, Division of Nephrology, Stanford University School of Medicine, California, USA
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine and Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Desbiens LC, Tennankore KK, Goupil R, Perl J, Trinh E, Chan CT, Nadeau-Fredette AC. Outcomes of Integrated Home Dialysis Care: Results From the Canadian Organ Replacement Register. Am J Kidney Dis 2024; 83:47-57.e1. [PMID: 37657633 DOI: 10.1053/j.ajkd.2023.05.011] [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: 02/22/2023] [Revised: 05/15/2023] [Accepted: 05/24/2023] [Indexed: 09/03/2023]
Abstract
RATIONALE & OBJECTIVE The integrated home dialysis model proposes the initiation of kidney replacement therapy (KRT) with peritoneal dialysis (PD) and a timely transition to home hemodialysis (HHD) after PD ends. We compared the outcomes of patients transitioning from PD to HHD with those initiating KRT with HHD. STUDY DESIGN Observational analysis of the Canadian Organ Replacement Register (CORR). SETTINGS & PARTICIPANTS All patients who initiated PD or HHD within the first 90 days of KRT between 2005 and 2018. EXPOSURE Patients transitioning from PD to HHD (PD+HHD group) versus patients initiating KRT with HHD (HHD group). OUTCOME (1) A composite of all-cause mortality and modality transfer (to in-center hemodialysis or PD for 90 days) and (2) all hospitalizations (considered as recurrent events). ANALYTICAL APPROACH A propensity score analysis for which PD+HHD patients were matched 1:1 to (1) incident HHD patients ("incident-match" analysis) or (2) HHD patients with a KRT vintage at least equivalent to the vintage of PD+HHD patients at the transition time ("vintage-matched" analysis). Cause-specific hazards models (composite outcome) and shared frailty models (hospitalization) were used to compare groups. RESULTS Among 63,327 individuals in the CORR, 163 PD+HHD patients (median of 1.9 years in PD) and 711 HHD patients were identified. In the incident-match analysis, compared to the HHD patients, the PD+HHD group had a similar risk of the composite outcome (HR, 0.88 [95% CI, 0.58-1.32]) and hospitalizations (HR, 1.04 [95% CI, 0.76-1.41]). In the vintage-match analysis, PD+HHD patients had a lower hazard for the composite outcome (HR, 0.61 [95% CI, 0.40-0.94]) but a similar hospitalization risk (HR, 0.85 [95% CI, 0.59-1.24]). LIMITATIONS Risk of survivor bias in the PD+HHD cohort and residual confounding. CONCLUSIONS Controlling for KRT vintage, the patients transitioning from PD to HHD had better clinical outcomes than the incident HHD patients. These data support the use of integrated home dialysis for patients initiating home-based KRT. PLAIN-LANGUAGE SUMMARY The integrated home dialysis model proposes the initiation of dialysis with peritoneal dialysis (PD) and subsequent transition to home hemodialysis (HHD) once PD is no longer feasible. It allows patients to benefit from initial lifestyle advantages of PD and to continue home-based treatments after its termination. However, some patients may prefer to initiate dialysis with HHD from the outset. In this study, we compared the long-term clinical outcomes of both approaches using a large Canadian dialysis register. We found that both options led to a similar risk of hospitalization. In contrast, the PD-to-HHD model led to improved survival when controlling for the duration of kidney failure.
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Affiliation(s)
- Louis-Charles Desbiens
- Department of Medicine, Université de Montréal, Quebec, Montreal; Hôpital Maisonneuve-Rosemont, Quebec, Montreal
| | | | - Rémi Goupil
- Department of Medicine, Université de Montréal, Quebec, Montreal; Hôpital du Sacré-Coeur de Montréal, Quebec, Montreal
| | - Jeffrey Perl
- St. Michael's Hospital, Toronto, Ontario, Canada
| | - Emilie Trinh
- McGill University Health Center, Quebec, Montreal
| | - Christopher T Chan
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Annie-Claire Nadeau-Fredette
- Department of Medicine, Université de Montréal, Quebec, Montreal; Hôpital Maisonneuve-Rosemont, Quebec, Montreal.
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Nguyen BN, Mital S, Bugden S, Nguyen HV. Cost-effectiveness of canagliflozin and dapagliflozin for treatment of patients with chronic kidney disease and type 2 diabetes. Diabetes Obes Metab 2023; 25:3030-3039. [PMID: 37409571 DOI: 10.1111/dom.15201] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/07/2023]
Abstract
AIM To examine the cost-effectiveness of adding canagliflozin or dapagliflozin to standard of care (SoC) versus SoC alone in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D). MATERIALS AND METHODS We used a Markov microsimulation model to assess the cost-effectiveness of canagliflozin plus SoC (canagliflozin + SoC), dapagliflozin plus SoC (dapagliflozin + SoC) and SoC alone. Analyses were conducted from a healthcare system perspective. Costs were measured in 2021 Canadian dollars (C$), and effectiveness was measured in quality-adjusted life-years (QALYs). RESULTS Over a patient's lifetime, canagliflozin + SoC and dapagliflozin + SoC yielded cost savings of C$33 460 and C$26 764 and generated 1.38 and 1.44 additional QALYs compared with SoC alone, respectively. While QALY gains with dapagliflozin + SoC were higher than those with canagliflozin + SoC, this strategy was also more costly with the incremental cost-effectiveness ratio exceeding the willingness to pay threshold of C$50 000 per QALY. Dapagliflozin + SoC, however, generated cost savings and QALY gains compared with canagliflozin + SoC over shorter time horizons of 5 or 10 years. CONCLUSIONS Dapagliflozin + SoC was not cost-effective versus canagliflozin + SoC in patients with CKD and T2D over the lifetime horizon. However, adding canagliflozin or dapagliflozin to SoC was less costly and more effective relative to SoC alone for treatment of CKD and T2D.
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Affiliation(s)
- Bao-Ngoc Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Shweta Mital
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shawn Bugden
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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Torreggiani M, Piccoli GB, Moio MR, Conte F, Magagnoli L, Ciceri P, Cozzolino M. Choice of the Dialysis Modality: Practical Considerations. J Clin Med 2023; 12:jcm12093328. [PMID: 37176768 PMCID: PMC10179541 DOI: 10.3390/jcm12093328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/02/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
Chronic kidney disease and the need for kidney replacement therapy have increased dramatically in recent decades. Forecasts for the coming years predict an even greater increase, especially in low- and middle-income countries, due to the rise in metabolic and cardiovascular diseases and the aging population. Access to kidney replacement treatments may not be available to all patients, making it especially strategic to set up therapy programs that can ensure the best possible treatment for the greatest number of patients. The choice of the "ideal" kidney replacement therapy often conflicts with medical availability and the patient's tolerance. This paper discusses the pros and cons of various kidney replacement therapy options and their real-world applicability limits.
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Affiliation(s)
- Massimo Torreggiani
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France
| | | | - Maria Rita Moio
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France
| | - Ferruccio Conte
- Renal Division, Department of Health Sciences, Uiniversity of Milan, San Paolo Hospital, 20142 Milan, Italy
| | - Lorenza Magagnoli
- Renal Division, Department of Health Sciences, Uiniversity of Milan, San Paolo Hospital, 20142 Milan, Italy
| | - Paola Ciceri
- Renal Division, Department of Health Sciences, Uiniversity of Milan, San Paolo Hospital, 20142 Milan, Italy
| | - Mario Cozzolino
- Renal Division, Department of Health Sciences, Uiniversity of Milan, San Paolo Hospital, 20142 Milan, Italy
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Kitzler TM, Chun J. Understanding the Current Landscape of Kidney Disease in Canada to Advance Precision Medicine Guided Personalized Care. Can J Kidney Health Dis 2023; 10:20543581231154185. [PMID: 36798634 PMCID: PMC9926383 DOI: 10.1177/20543581231154185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/19/2022] [Indexed: 02/15/2023] Open
Abstract
Purpose of Review To understand the impact of kidney disease in Canada and the priority areas of kidney research that can benefit from patient-oriented, precision medicine research using novel technologies. Sources of Information Information was collected through discussions between health care professionals, researchers, and patient partners. Literature was compiled using search engines (PubMed, PubMed central, Medline, and Google) and data from the Canadian Organ Replacement Register. Methods We reviewed the impact, prevalence, economic burden, causes of kidney disease, and priority research areas in Canada. After reviewing the priority areas for kidney research, potential avenues for future research that can integrate precision medicine initiatives for patient-oriented research were outlined. Key Findings Chronic kidney disease (CKD) remains among the top causes of morbidity and mortality in the world and exerts a large financial strain on the health care system. Despite the increasing number of people with CKD, funding for basic kidney research continues to trail behind other diseases. Current funding strategies favor existing clinical treatment and patient educational strategies. The identification of genetic factors for various forms of kidney disease in the adult and pediatric populations provides mechanistic insight into disease pathogenesis. Allocation of resources and funding toward existing high-yield personalized research initiatives have the potential to significantly affect patient-oriented research outcomes but will be difficult due to a constant decline of funding for kidney research. Limitations This is an overview primarily focused on Canadian-specific literature rather than a comprehensive systematic review of the literature. The scope of our findings and conclusions may not be applicable to health care systems in other countries.
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Affiliation(s)
- Thomas M. Kitzler
- Division of Medical Genetics, Department of Specialized Medicine, McGill University Health Centre, Montreal, QC, Canada,Department of Human Genetics, McGill University, Montreal, QC, Canada,Child Health and Human Development Program, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Justin Chun
- Department of Medicine, Cumming School of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, AB, Canada,Justin Chun, Division of Nephrology, Department of Medicine, University of Calgary, Health Research Innovation Centre, 4A12, 3280 Hospital Drive Northwest, Calgary, AB T2N 4Z6, Canada.
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Probiotic Bifidobacteria Mitigate the Deleterious Effects of para-Cresol in a Drosophila melanogaster Toxicity Model. mSphere 2022; 7:e0044622. [PMID: 36321825 PMCID: PMC9769938 DOI: 10.1128/msphere.00446-22] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Renal impairment associated with chronic kidney disease (CKD) causes the buildup of uremic toxins that are deleterious to patient health. Current therapies that manage toxin accumulation in CKD offer an incomplete therapeutic effect against toxins such as para-cresol (p-cresol) and p-cresyl sulfate. Probiotic therapies can exploit the wealth of microbial diversity to reduce toxin accumulation. Using in vitro culture techniques, strains of lactobacilli and bifidobacteria from a 24-strain synbiotic were investigated for their ability to remove p-cresol. Four strains of bifidobacteria internalized p-cresol from the extracellular environment. The oral supplementation of these toxin-clearing probiotics was more protective than control strains in a Drosophila melanogaster toxicity model. Bifidobacterial supplementation was also associated with higher abundance of lactobacilli in the gut microbiota of p-cresol-exposed flies. The present findings suggest that these strains might reduce p-cresol in the gut in addition to increasing the prevalence of other beneficial bacteria, such as lactobacilli, and should be tested clinically to normalize the dysbiotic gut microbiota observed in CKD patients. IMPORTANCE Chronic kidney disease (CKD) affects approximately 10% of the global population and has limited treatment options. The accumulation of gut microbiota-derived uremic toxins, such as para-cresol (p-cresol) and p-cresyl sulfate, is associated with the onset of comorbidities (i.e., atherosclerosis and cognitive disorders) in CKD. Unfortunately, dialysis, the gold standard therapy is unable to remove these toxins from the bloodstream due to their highly protein-bound nature. Some strains of Bifidobacterium have metabolic properties that may be useful in managing uremic toxicity. Using a Drosophila model, the present work highlights why dosing with certain probiotic strains may be clinically useful in CKD management.
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Kaplan JM, Niu J, Ho V, Winkelmayer WC, Erickson KF. A Comparison of US Medicare Expenditures for Hemodialysis and Peritoneal Dialysis. J Am Soc Nephrol 2022; 33:2059-2070. [PMID: 35981764 PMCID: PMC9678042 DOI: 10.1681/asn.2022020221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/02/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Observations that peritoneal dialysis (PD) may be an effective, lower-cost alternative to hemodialysis for the treatment of ESKD have led to policies encouraging PD and subsequent increases in its use in the United States. METHODS In a retrospective cohort analysis of Medicare beneficiaries who started dialysis between 2008 and 2015, we ascertained average annual expenditures (for up to 3 years after initiation of dialysis) for patients ≥67 years receiving in-center hemodialysis or PD. We also determined whether differences in Medicare expenditures across dialysis modalities persisted as more patients were placed on PD. We used propensity scores to match 8305 patients initiating PD with 8305 similar patients initiating hemodialysis. RESULTS Overall average expenditures were US$108,656 (2017) for hemodialysis and US$91,716 for PD (proportionate difference, 1.11; 95% confidence interval [CI], 1.09 to 1.13). This difference did not change over time (P for time interaction term=0.14). Hemodialysis had higher estimated intravenous (iv) dialysis drug costs (1.69; 95% CI, 1.64 to 1.73), rehabilitation expenditures (1.35; 95% CI, 1.26 to 1.45), and other nondialysis expenditures (1.34; 95% CI, 1.30 to 1.37). Over time, initial differences in total dialysis expenditures disappeared and differences in iv dialysis drug utilization narrowed as nondialysis expenditures diverged. Estimated iv drug costs declined by US$2900 per patient-year in hemodialysis between 2008 and 2014 versus US$900 per patient-year in PD. CONCLUSIONS From the perspective of the Medicare program, savings associated with PD in patients ≥67 years have remained unchanged, despite rapid growth in the use of this dialysis modality. Total dialysis expenditures for the two modalities converged over time, whereas nondialysis expenditures diverged.
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Affiliation(s)
| | - Jingbo Niu
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Vivian Ho
- Baker Institute for Public Policy, Rice University, Houston, Texas
| | | | - Kevin F Erickson
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
- Baker Institute for Public Policy, Rice University, Houston, Texas
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Koto P, Tennankore K, Vinson A, Krmpotic K, Weiss MJ, Theriault C, Beed S. An ex-ante cost-utility analysis of the deemed consent legislation compared to expressed consent for kidney transplantations in Nova Scotia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:55. [PMID: 36199099 PMCID: PMC9535887 DOI: 10.1186/s12962-022-00390-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background This study was an ex-ante cost-utility analysis of deemed consent legislation for deceased organ donation in Nova Scotia, a province in Canada. The legislation became effective in January 2021. The study's objective was to assess the conditions necessary for the legislation change’s cost-effectiveness compared to expressed consent, focusing on kidney transplantation (KT). Method We performed a cost-utility analysis using a Markov model with a lifetime horizon. The study was from a Canadian payer perspective. The target population was patients with end-stage kidney disease (ESKD) in Atlantic Canada waitlisted for KT. The intervention was the deemed consent and accompanying health system transformations. Expressed consent (before the change) was the comparator. We simulated the minimum required increase in deceased donor KT per year for the cost-effectiveness of the deemed consent. We also evaluated how changes in dialysis and maintenance immunosuppressant drug costs and living donor KT per year impacted cost-effectiveness in sensitivity analyses. Results The expected lifetime cost of an ESKD patient ranged from $177,663 to $553,897. In the deemed consent environment, the expected lifetime cost per patient depended on the percentage increases in the proportion of ESKD patients on the waitlist getting a KT in a year. The incremental cost-utility ratio (ICUR) increased with deceased donor KT per year. Cost-effectiveness of deemed consent compared to expressed consent required a minimum of a 1% increase in deceased donor KT per year. A 1% increase was associated with an ICUR of $32,629 per QALY (95% CI: − $64,279, $232,488) with a 81% probability of being cost-effective if the willingness-to-pay (WTP) was $61,466. Increases in dialysis and post-KT maintenance immunosuppressant drug costs above a threshold impacted value for money. The threshold for immunosuppressant drug costs also depended on the percent increases in deceased donor KT probability and the WTP threshold. Conclusions The deemed consent legislation in NS for deceased organ donation and the accompanying health system transformations are cost-effective to the extent that they are anticipated to contribute to more deceased donor KTs than before, and even a small increase in the proportion of waitlist patients receiving a deceased donor KT than before the change represents value for money. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-022-00390-z.
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Affiliation(s)
- Prosper Koto
- Research Methods Unit, Nova Scotia Health, 5790 University Avenue, Halifax, NS, B3H 1V7, Canada.
| | - Karthik Tennankore
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS, Canada
| | - Amanda Vinson
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS, Canada
| | - Kristina Krmpotic
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada
| | - Matthew J Weiss
- Centre Mère-Enfant Soleil du CHU de Québec, Transplant Québec, Québec, QC, Canada
| | - Chris Theriault
- Research Methods Unit, Nova Scotia Health, 5790 University Avenue, Halifax, NS, B3H 1V7, Canada
| | - Stephen Beed
- Department of Critical Care, Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
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Taha A, Iman Y, Hingwala J, Askin N, Mysore P, Rigatto C, Bohm C, Komenda P, Tangri N, Collister D. Patient Navigators for CKD and Kidney Failure: A Systematic Review. Kidney Med 2022; 4:100540. [PMID: 36185707 PMCID: PMC9516458 DOI: 10.1016/j.xkme.2022.100540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Rationale & Objective To what degree and how patient navigators improve clinical outcomes for patients with chronic kidney disease (CKD) and kidney failure is uncertain. We performed a systematic review to summarize patient navigator program design, evidence, and implementation in kidney disease. Study Design A search strategy was developed for randomized controlled trials and observational studies that evaluated the impact of navigators on outcomes in the setting of CKD and kidney failure. Articles were identified from various databases. Two reviewers independently screened the articles and identified those meeting the inclusion criteria. Setting & Participants Patients with CKD or kidney failure (in-center hemodialysis, peritoneal dialysis, home hemodialysis, or kidney transplantation). Selection Criteria for Studies Studies that compared patient navigators with a control, without limits on size, duration, setting, or language. Studies focusing solely on patient education were excluded. Data Extraction Data were abstracted from full texts and risk of bias was assessed. Analytical Approach No meta-analysis was performed. Results Of 3,371 citations, 17 articles met the inclusion criteria including 14 original studies. Navigators came from various healthcare backgrounds including nursing (n=6), social worker (n=2), medical interpreter (n=1), research (n=1), and also included kidney transplant recipients (n=2) and non-medical individuals (n=2). Navigators focused mostly on education (n=9) and support (n = 6). Navigators were used for patients with CKD (n=5), peritoneal dialysis (n=2), in-center hemodialysis (n=4), kidney transplantation (n=2), but not home hemodialysis. Navigators improved transplant workup and listing, peritoneal dialysis utilization, and patient knowledge. Limitations Many studies did not show benefits across other outcomes, were at a high risk of bias, and none reported cost-effectiveness or patient-reported experience measures. Conclusions Navigators improve some health outcomes for CKD but there was heterogeneity in their structure and function. High-quality randomized controlled trials are needed to evaluate navigator program efficacy and cost-effectiveness.
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Main Barriers to the Introduction of a Home Haemodialysis Programme in Poland: A Review of the Challenges for Implementation and Criteria for a Successful Programme. J Clin Med 2022; 11:jcm11144166. [PMID: 35887931 PMCID: PMC9321469 DOI: 10.3390/jcm11144166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: Home dialysis in Poland is restricted to the peritoneal dialysis (PD) modality, with the majority of dialysis patients treated using in-centre haemodialysis (ICHD). Home haemodialysis (HHD) is an additional home therapy to PD and provides an attractive alternative to ICHD that combines dialysis with social distancing; eliminates transportation needs; and offers clinical, economic, and quality of life benefits. However, HHD is not currently provided in Poland. This review was performed to provide an overview of the main barriers to the introduction of a HHD programme in Poland. Main findings: The main high-level barrier to introducing HHD in Poland is the absence of specific health legislation required for clinician prescribing of HHD. Other barriers to overcome include clear definition of reimbursement, patient training and education (including infrastructure and experienced personnel), organisation of logistics, and management of complications. Partnering with a large care network for HHD represents an alternative option to payers for the provision of a new HHD service. This may reduce some of the barriers which need to be overcome when compared with the creation of a new HHD service and its supporting network due to the pre-existing infrastructure, processes, and staff of a large care network. Conclusions: Provision of HHD is not solely about the provision of home treatment, but also the organisation and definition of a range of support services that are required to deliver the service. HHD should be viewed as an additional, complementary option to existing dialysis modalities which enables choice of modality best suited to a patient’s needs.
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Redeker S, Massey EK, van Merweland RG, Weimar W, Ismail S, Busschbach J. Induced Demand in Kidney Replacement Therapy. Health Policy 2022; 126:1062-1068. [DOI: 10.1016/j.healthpol.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 07/23/2022] [Accepted: 07/28/2022] [Indexed: 11/25/2022]
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Chabouh S, Hammami S, El Amraoui A, Bouchriha H, Guedri Y, Achour A, Fessi H. Estimating the cost of home dialysis in Tunisia: Application of the Activity-based costing methodology. LA TUNISIE MEDICALE 2022; 100:428-437. [PMID: 36206061 PMCID: PMC9585616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION In Tunisia, in-centre haemodialysis (ICHD) is the most common type of dialysis. Despite the increasing demand, the number of haemodialysis machines per 100,000 inhabitants is still low. Home Haemodialysis (HHD) is a candidate solution to this problem. Despite its confirmed benefits over ICHD, HHD has not taken place in Tunisia. AIM To describe the processes of home dialysis modalities, especially HHD, evaluate their costs, analyse them, in the context of medical practice in public health structures in Tunisia. METHOD The Activity-Based Costing technique was applied: the processes of home dialysis modalities were modelled, the main activity and resource cost drivers identified, and cost equations developed. Based on data from the nephrology department of Sahloul hospital, the cost per session and annual costs for each home dialysis modality were calculated and analyzed. RESULTS Home Peritoneal Dialysis, already implemented in Tunisia; presented the lowest annual cost per patient 25344 TND versus 29232 TND for Conventional HHD and 54144 TND for Short-Daily HHD. The cost per session of the Short-Daily HHD (188,8 TND) was comparable to ICHD (180 TND). Consumables presented the most expensive resource for these modalities. Finally, the cost structure of HHD was comparable in Tunisia and France as well as in previous costing studies. CONCLUSION The cost of one session of HHD is estimated to 188,8 TND. The Tunisian ministry of health could adopt a flexible policy to start HHD program by implementing Conventional HHD first.
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Affiliation(s)
- Safa Chabouh
- 1. Ecole nationale d’Ingénieurs de Tunis / Université de Tunis El Manar
| | - Sondes Hammami
- 2. Ecole nationale d’Ingénieurs de Carthage / Université de Carthage
| | - Adnen El Amraoui
- 3. Faculté des sciences appliquées Béthune / Université d’Artois
| | - Hanen Bouchriha
- 1. Ecole nationale d’Ingénieurs de Tunis / Université de Tunis El Manar
| | - Yosra Guedri
- 4. Service néphrologie de l’Hôpital Sahloul Sousse / Faculté de Médecine de Sousse
| | - Abdellatif Achour
- 4. Service néphrologie de l’Hôpital Sahloul Sousse / Faculté de Médecine de Sousse
| | - Hafedh Fessi
- 5. Service néphrologie de l’Hôpital Tenon Paris / Hôpital Tenon Paris
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Koto P, Tennankore K, Vinson A, Krmpotic K, Weiss MJ, Theriault C, Beed S. What are the short-term annual cost savings associated with kidney transplantation? COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:20. [PMID: 35505433 PMCID: PMC9063122 DOI: 10.1186/s12962-022-00355-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Kidney transplantation (KT) is often reported in the literature as associated with cost savings. However, existing studies differ in their choice of comparator, follow-up period, and the study perspective. Also, there may be unobservable heterogeneity in health care costs in the patient population which may divide the population into groups with differences in cost distributions. This study estimates the cost savings associated with KT from a payer perspective and identifies and characterizes both high and low patient cost groups. METHOD The current study was a population-based retrospective before-and-after study. The timespan involved at most three years before and after KT. The sample included end-stage kidney disease patients in Nova Scotia, a province in Canada, who had a single KT between January 1, 2011, and December 31, 2018. Each patient served as their control. The primary outcome measure was total annual health care costs. We estimated cost savings using unadjusted and adjusted models, stratifying the analyses by donor type. We quantified the uncertainty around the estimates using non-parametric and parametric bootstrapping. We also used finite mixture models to identify data-driven cost groups based on patients' pre-transplantation annual inpatient costs. RESULTS The mean annual cost savings per patient associated with KT was $19,589 (95% CI: $14,013, $23,397). KT was associated with a 24-29% decrease in mean annual health care costs per patient compared with the annual costs before KT. We identified and characterized patients in three cost groups made of 2.9% in low-cost (LC), 51.8% in medium-cost (MC) and 45.3% in high-cost (HC). Cost group membership did not change after KT. Comparing costs in each group before and after KT, we found that KT was associated with 17% mean annual cost reductions for the LC group, 24% for the MC group and 26% for the HC group. The HC group included patients more likely to have a higher comorbidity burden (Charlson comorbidity index ≥ 3). CONCLUSIONS KT was associated with reductions in annual health care costs in the short term, even after accounting for costs incurred during KT.
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Affiliation(s)
- Prosper Koto
- Research Methods Unit, Nova Scotia Health, 5790 University Avenue, Halifax, NS, B3H 1V7, Canada.
| | - Karthik Tennankore
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS, Canada
| | - Amanda Vinson
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS, Canada
| | - Kristina Krmpotic
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada
| | - Matthew J Weiss
- Centre Mère-Enfant Soleil du CHU de Québec, Transplant Québec, Québec, QC, Canada
| | - Chris Theriault
- Research Methods Unit, Nova Scotia Health, Halifax, NS, Canada
| | - Stephen Beed
- Department of Critical Care, Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
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15
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Wick J, Campbell DJT, McAlister FA, Manns BJ, Tonelli M, Beall RF, Hemmelgarn BR, Stewart A, Ronksley PE. Identifying subgroups of adult high-cost health care users: a retrospective analysis. CMAJ Open 2022; 10:E390-E399. [PMID: 35440486 PMCID: PMC9022936 DOI: 10.9778/cmajo.20210265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Few studies have categorized high-cost patients (defined by accumulated health care spending above a predetermined percentile) into distinctive groups for which potentially actionable interventions may improve outcomes and reduce costs. We sought to identify homogeneous groups within the persistently high-cost population to develop a taxonomy of subgroups that may be targetable with specific interventions. METHODS We conducted a retrospective analysis in which we identified adults (≥ 18 yr) who lived in Alberta between April 2014 and March 2019. We defined "persistently high-cost users" as those in the top 1% of health care spending across 4 data sources (the Discharge Abstract Database for inpatient encounters; Practitioner Claims for outpatient primary care and specialist encounters; the Ambulatory Care Classification System for emergency department encounters; and the Pharmaceutical Information Network for medication use) in at least 2 consecutive fiscal years. We used latent class analysis and expert clinical opinion in tandem to separate the persistently high-cost population into subgroups that may be targeted by specific interventions based on their distinctive clinical profiles and the drivers of their health system use and costs. RESULTS Of the 3 919 388 adults who lived in Alberta for at least 2 consecutive fiscal years during the study period, 21 115 (0.5%) were persistently high-cost users. We identified 9 subgroups in this population: people with cardiovascular disease (n = 4537; 21.5%); people receiving rehabilitation after surgery or recovering from complications of surgery (n = 3380; 16.0%); people with severe mental health conditions (n = 3060; 14.5%); people with advanced chronic kidney disease (n = 2689; 12.7%); people receiving biologic therapies for autoimmune conditions (n = 2538; 12.0%); people with dementia and awaiting community placement (n = 2520; 11.9%); people with chronic obstructive pulmonary disease or other respiratory conditions (n = 984; 4.7%); people receiving treatment for cancer (n = 832; 3.9%); and people with unstable housing situations or substance use disorders (n = 575; 2.7%). INTERPRETATION Using latent class analysis supplemented with expert clinical review, we identified 9 policy-relevant subgroups among persistently high-cost health care users. This taxonomy may be used to inform policy, including identifying interventions that are most likely to improve care and reduce cost for each subgroup.
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Affiliation(s)
- James Wick
- Department of Medicine (Wick, Campbell, Manns, Tonelli), Cumming School of Medicine; Department of Community Health Sciences (Campbell, Manns, Tonelli, Beall, Stewart, Ronksley), Cumming School of Medicine; Division of General Internal Medicine, Department of Medicine (McAlister); Department of Medicine, Faculty of Medicine & Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - David J T Campbell
- Department of Medicine (Wick, Campbell, Manns, Tonelli), Cumming School of Medicine; Department of Community Health Sciences (Campbell, Manns, Tonelli, Beall, Stewart, Ronksley), Cumming School of Medicine; Division of General Internal Medicine, Department of Medicine (McAlister); Department of Medicine, Faculty of Medicine & Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Finlay A McAlister
- Department of Medicine (Wick, Campbell, Manns, Tonelli), Cumming School of Medicine; Department of Community Health Sciences (Campbell, Manns, Tonelli, Beall, Stewart, Ronksley), Cumming School of Medicine; Division of General Internal Medicine, Department of Medicine (McAlister); Department of Medicine, Faculty of Medicine & Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Braden J Manns
- Department of Medicine (Wick, Campbell, Manns, Tonelli), Cumming School of Medicine; Department of Community Health Sciences (Campbell, Manns, Tonelli, Beall, Stewart, Ronksley), Cumming School of Medicine; Division of General Internal Medicine, Department of Medicine (McAlister); Department of Medicine, Faculty of Medicine & Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Marcello Tonelli
- Department of Medicine (Wick, Campbell, Manns, Tonelli), Cumming School of Medicine; Department of Community Health Sciences (Campbell, Manns, Tonelli, Beall, Stewart, Ronksley), Cumming School of Medicine; Division of General Internal Medicine, Department of Medicine (McAlister); Department of Medicine, Faculty of Medicine & Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Reed F Beall
- Department of Medicine (Wick, Campbell, Manns, Tonelli), Cumming School of Medicine; Department of Community Health Sciences (Campbell, Manns, Tonelli, Beall, Stewart, Ronksley), Cumming School of Medicine; Division of General Internal Medicine, Department of Medicine (McAlister); Department of Medicine, Faculty of Medicine & Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Brenda R Hemmelgarn
- Department of Medicine (Wick, Campbell, Manns, Tonelli), Cumming School of Medicine; Department of Community Health Sciences (Campbell, Manns, Tonelli, Beall, Stewart, Ronksley), Cumming School of Medicine; Division of General Internal Medicine, Department of Medicine (McAlister); Department of Medicine, Faculty of Medicine & Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Andrew Stewart
- Department of Medicine (Wick, Campbell, Manns, Tonelli), Cumming School of Medicine; Department of Community Health Sciences (Campbell, Manns, Tonelli, Beall, Stewart, Ronksley), Cumming School of Medicine; Division of General Internal Medicine, Department of Medicine (McAlister); Department of Medicine, Faculty of Medicine & Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Paul E Ronksley
- Department of Medicine (Wick, Campbell, Manns, Tonelli), Cumming School of Medicine; Department of Community Health Sciences (Campbell, Manns, Tonelli, Beall, Stewart, Ronksley), Cumming School of Medicine; Division of General Internal Medicine, Department of Medicine (McAlister); Department of Medicine, Faculty of Medicine & Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta.
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16
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Shamloo M, Mollard R, Wang H, Kingra K, Tangri N, MacKay D. A randomized double-blind cross-over trial to study the effects of resistant starch prebiotic in chronic kidney disease (ReSPECKD). Trials 2022; 23:72. [PMID: 35073986 PMCID: PMC8785497 DOI: 10.1186/s13063-022-06009-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/06/2022] [Indexed: 12/25/2022] Open
Abstract
Background Chronic kidney disease (CKD) is associated with a reduced quality of life and an increased risk of kidney failure, cardiovascular events, and all-cause mortality. Accumulation of nitrogen-based uremic toxins leads to worsening of symptoms in individuals with CKD. Many uremic toxins, such as indoxyl and p-cresol sulphate, are produced exclusively by the gut microbiome through the proteolytic digestion of aromatic amino acids. Strategies to reduce the production of these toxins by the gut microbiome in individuals with CKD may lessen symptom burden and delay the onset of dialysis. One such strategy is to change the overall metabolism of the gut microbiome so that less uremic toxins are produced. This can be accomplished by manipulating the energy source available to the microbiome. Fermentable carbohydrates which reach the gut microbiome, like resistant starch (RS), have been shown to inhibit or reduce bacterial amino acid metabolism. This study aims to investigate the effects of resistant potato starch (RPS) as a prebiotic in individuals with CKD before the onset of dialysis. Methods This is a double-blind, randomized two-period crossover trial. Thirty-six eligible participants will consent to follow a 26-week study regimen. Participants will receive 2 sachets per day containing either 15 g of RPS (MSPrebiotic, resistant potato starch treatment) or 15 g cornstarch (Amioca TF, digestible starch control). Changes in blood uremic toxins will be investigated as the primary outcome. Secondary outcomes include the effect of RPS consumption on symptoms, quality of life and abundance, and diversity and functionality of the gut microbiome. Discussion This randomized trial will provide further insight into whether the consumption of RPS as a prebiotic will reduce uremic toxins and symptoms in individuals who have CKD. Trial registration ClinicalTrials.govNCT04961164. Registered on 14 July 2021
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Affiliation(s)
- Maryam Shamloo
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada.,Department of Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Rebecca Mollard
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Haizhou Wang
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Kulwant Kingra
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada.,Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Dylan MacKay
- Department of Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada. .,Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
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17
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Roberts G, Holmes J, Williams G, Chess J, Hartfiel N, Charles JM, McLauglin L, Noyes J, Edwards RT. Current costs of dialysis modalities: A comprehensive analysis within the United Kingdom. ARCH ESP UROL 2022; 42:578-584. [DOI: 10.1177/08968608211061126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Previous evidence suggests home-based dialysis to be more cost-effective than unit-based or hospital-based dialysis. However, previous analyses to quantify the costs of different dialysis modalities have used varied perspectives, different methods, and required assumptions due to lack of available data. The National Institute for Health and Care Excellence reports uncertainty about the differences in costs between home-based and unit-based dialysis. This uncertainty limits the ability of policy makers to make recommendations based on cost effectiveness, which also impacts on the ability of budget holders to model the impact of any service redesign and to understand which therapies deliver better value. The aim of our study was to use a combination of top-down and bottom-up costing methods to determine the direct medical costs of different dialysis modalities in one UK nation (Wales) from the perspective of the National Health Service (NHS). Methods: Detailed hybrid top-down and bottom-up micro-costing methods were applied to estimate the direct medical costs of dialysis modalities across Wales. Micro-costing data was obtained from commissioners of the service and from interviews with renal consultants, nurses, accountants, managers and allied health professionals. Top-down costing information was obtained from the Welsh Renal Clinical Network (who commission renal services across Wales) and the Welsh Ambulance Service Trust. Results: The annual direct cost per patient for home-based modalities was £16,395 for continuous ambulatory peritoneal dialysis (CAPD), £20,295 for automated peritoneal dialysis (APD) and £23,403 for home-based haemodialysis (HHD). The annual cost per patient for unit-based modalities depended on whether or not patients required ambulance transport. Excluding transport, the cost of dialysis was £19,990 for satellite units run in partnership with independent sector providers and £23,737 for hospital units managed and staffed by the NHS. When ambulance transport was included, the respective costs were £28,931 and £32,678, respectively. Conclusion: Our study is the most comprehensive analysis of the costs of dialysis undertaken thus far in the United Kingdom and clearly demonstrate that CAPD is less costly than other dialysis modalities. When ambulance transport costs are included, other home therapies (APD and HHD) are also less costly than unit-based dialysis. This detailed analysis of the components that contribute to dialysis costs will help inform future cost-effectiveness studies, inform healthcare policy and drive service redesign.
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Affiliation(s)
| | | | | | - James Chess
- Department of Nephrology, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Ned Hartfiel
- Centre for Health Economics and Medicines Evaluation, School of Health Sciences, Bangor University, Bangor, UK
| | - Joanna M Charles
- Centre for Health Economics and Medicines Evaluation, School of Health Sciences, Bangor University, Bangor, UK
| | - Leah McLauglin
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Jane Noyes
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Rhiannon Tudor Edwards
- Centre for Health Economics and Medicines Evaluation, School of Health Sciences, Bangor University, Bangor, UK
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18
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Ferguson TW, Harper GD, Milad JE, Komenda PVJ. Cost of the quanta SC+ hemodialysis system for self-care in the United Kingdom. Hemodial Int 2022; 26:287-294. [PMID: 35001500 PMCID: PMC9544577 DOI: 10.1111/hdi.12994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 10/07/2021] [Accepted: 12/07/2021] [Indexed: 11/30/2022]
Abstract
Introduction New personal hemodialysis systems, such as the quanta SC+, are being developed; these systems are smaller and simpler to use while providing the clearances of conventional systems. Increasing the uptake of lower‐intensity assistance and full self‐care dialysis may provide economic benefits to the public health payer. In the United Kingdom, most hemodialysis patients currently receive facility‐based dialysis costing more than £36,350 per year including patient transport. As such, we aimed to describe the annual costs of using the SC+ hemodialysis system in the United Kingdom for 3×‐weekly and 3.5×‐weekly dialysis regimens, for self‐care hemodialysis provided both in‐center and at home. Methods We applied a cost minimization approach. Costs for human resources, equipment, and consumables were sourced from the dialysis machine developer (Quanta Dialysis Technologies) based upon discussions with dialysis providers. Facility overhead expenses and transport costs were taken from a review of the literature. Findings Annual costs associated with the use of the SC+ hemodialysis system were estimated to be £26,642 for hemodialysis provided 3× weekly as home self‐care; £30,235 for hemodialysis provided 3× weekly as self‐care in‐center; £29,866 for hemodialysis provided 3.5× weekly as home self‐care; and £36,185 for hemodialysis provided 3.5× weekly as self‐care in‐center. Discussion We found that the SC+ hemodialysis system offers improved cost‐effectiveness for both 3×‐weekly and 3.5×‐weekly self‐care dialysis performed at home or as self‐care in‐center versus fully assisted dialysis provided 3× weekly with conventional machines in facilities.
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Affiliation(s)
- Thomas W Ferguson
- Department of Nephrology, Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | | | - John E Milad
- Quanta Dialysis Technologies Limited, Alcester, UK
| | - Paul V J Komenda
- Department of Nephrology, Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada.,Quanta Dialysis Technologies Limited, Alcester, UK
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Zazoulina J, Khehra K, Gill J. Motivators and Barriers to Living Donor Kidney Transplant as Perceived by Past and Potential Donors. Can J Kidney Health Dis 2022; 9:20543581221137179. [PMID: 36419528 PMCID: PMC9677302 DOI: 10.1177/20543581221137179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/29/2022] [Indexed: 11/21/2022] Open
Abstract
Background: For patients with end-stage kidney disease, living donor kidney transplant is
the treatment of choice due to improved patient outcomes, longer graft
survival, and reduced expenses compared with other forms of renal
replacement therapy. However, organ shortage remains a challenge, and living
donation rates have stagnated in recent years, particularly among men. Objective: To understand the motivators and barriers for past and potential living
kidney transplant donors and inform policy and practice changes that support
donors in the future. Methods: Past and potential living donors in British Columbia, Canada in the preceding
2 years were surveyed. Motivators and barriers were examined in 5
categories: family pressures and domestic responsibilities, finances, the
recovery process, complications, and the transplant evaluation process.
Participants ranked statements in each category on a Likert-type scale. Results: A total of 138 responses were collected. In both women and men, policies that
address family and domestic responsibilities and finances were most strongly
identified as motivators to donate. A large proportion of women and men
reported that guaranteed job security (47% women and 38% of men), paid time
off (51% of women and 42% of men), reimbursement of lost wages (49% of women
and 38% of men), and protections to guarantee no impact on future
insurability (62% of women and 52% of men) were significant motivators to
donate. Timely and efficient medical evaluation was considered to be an
important motivator for donation, with 52% of men and 43% of women reporting
support for a “fast-track” option for evaluation to allow for a more rapid
evaluation process. Median barrier and motivator scores were similar between
women and men. Conclusion: Policies to decrease financial burden, ensure job security, improve childcare
support, and offer a fast-track medical evaluation may motivate potential
living kidney donors, irrespective of gender.
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Affiliation(s)
| | - Keesha Khehra
- The University of British Columbia, Vancouver, Canada
| | - Jagbir Gill
- The University of British Columbia, Vancouver, Canada
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20
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Prasad B, Osman M, Jafari M, Gordon L, Tangri N, Ferguson TW, Jin S, Kappel J, Kozakewycz D. Kidney Failure Risk Equation and Cost of Care in Patients with Chronic Kidney Disease. Clin J Am Soc Nephrol 2022; 17:17-26. [PMID: 34969699 PMCID: PMC8763151 DOI: 10.2215/cjn.06770521] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/14/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Patients with CKD exhibit heterogeneity in their rates of progression to kidney failure. The kidney failure risk equation (KFRE) has been shown to accurately estimate progression to kidney failure in adults with CKD. Our objective was to determine health care utilization patterns of patients on the basis of their risk of progression. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective cohort study of adults with CKD and eGFR of 15-59 ml/min per 1.73 m2 enrolled in multidisciplinary CKD clinics in the province of Saskatchewan, Canada. Data were collected from January 1, 2004 to December 31, 2012 and followed for 5 years (December 31, 2017). We stratified patients by eGFR and risk of progression and compared the number and cost of hospital admissions, physician visits, and prescription drugs. RESULTS In total, 1003 adults were included in the study. Within the eGFR of 15-29 ml/min per 1.73 m2 group, the costs of hospital admissions, physician visits, and drug dispensations over the 5-year study period comparing high-risk patients with low-risk patients were (Canadian dollars) $89,265 versus $48,374 (P=0.008), $23,423 versus $11,231 (P<0.001), and $21,853 versus $16,757 (P=0.01), respectively. Within the eGFR of 30-59 ml/min per 1.73 m2 group, the costs of hospital admissions, physician visits, and prescription drugs were $55,944 versus $36,740 (P=0.10), $13,414 versus $10,370 (P=0.08), and $20,394 versus $14,902 (P=0.02) in high-risk patients in comparison with low-risk patients, respectively, for progression to kidney failure. CONCLUSIONS In patients with CKD and eGFR of 15-59 ml/min per 1.73 m2 followed in multidisciplinary clinics, the costs of hospital admissions, physician visits, and drugs were higher for patients at higher risk of progression to kidney failure by the KFRE compared with patients in the low-risk category. The high-risk group of patients with CKD and eGFR of 15-29 ml/min per 1.73 m2 had stronger association with hospitalizations costs, physician visits, and drug utilizations.
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Affiliation(s)
- Bhanu Prasad
- Section of Nephrology, Department of Medicine, Regina General Hospital, Regina, Saskatchewan, Canada
| | - Meric Osman
- Economics Department, Saskatchewan Medical Association, Saskatoon, Saskatchewan, Canada
| | - Maryam Jafari
- Dr. T. Bhanu Prasad Medical Professional Corporation, Regina, Saskatchewan, Canada
| | - Lexis Gordon
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Navdeep Tangri
- Section of Nephrology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Thomas W. Ferguson
- Section of Nephrology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shan Jin
- Health Quality Council, Saskatoon, Saskatchewan, Canada
| | - Joanne Kappel
- Section of Nephrology, Department of Medicine, St. Paul’s Hospital, Saskatoon, Saskatchewan, Canada
| | - Diane Kozakewycz
- Section of Nephrology, Kidney Health Centre, Saskatchewan, Canada
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21
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Bamforth RJ, Beaudry A, Ferguson TW, Rigatto C, Tangri N, Bohm C, Komenda P. Costs of Assisted Home Dialysis: A Single-Payer Canadian Model From Manitoba. Kidney Med 2021; 3:942-950.e1. [PMID: 34939003 PMCID: PMC8664694 DOI: 10.1016/j.xkme.2021.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale & Objective The prevalence of kidney failure is increasing globally. Most of these patients will require life-sustaining dialysis at a substantial cost to the health care system. Assisted peritoneal dialysis (PD) and assisted home hemodialysis (HD) are potential alternatives to in-center HD and have demonstrated equivalent outcomes with respect to mortality and morbidity. We aim to describe the costs associated with assisted continuous cycling PD (CCPD) and assisted home HD. Study Design Cost minimization model. Setting & Population Adult incident maintenance dialysis patients in Manitoba, Canada. Intervention Full- and partial-assist home HD and CCPD. Full-assist modalities were defined as nurse-assisted dialysis setup and takedown performed by a health care aide, whereas partial-assist modalities only included nurse-assisted setup. Additionally, full-assist home HD was evaluated under a complete care scenario with the inclusion of a health care aide remaining with the patient throughout the duration of treatment. Outcomes Annual per-patient maintenance and training costs related to assisted and self-care home HD and CCPD, presented in 2019 Canadian dollars. Model, Perspective, & Time Frame This model took the perspective of the Canadian public health payer using a 1-year time frame. Results Annual total per-patient maintenance (and training) costs by modality were the following: full-assist CCPD, $75.717 (initial training costs, $301); partial-assist CCPD, $67,765 ($4,385); full-assist home HD, $47,862 ($301); partial-assist home HD, $44,650 ($14,813); and full-assist home HD (complete care), $64,659 ($301). Limitations This model did not account for costs taken from the societal perspective or costs related to PD failure and modality switching. Additionally, this analysis reflects only costs experienced by a single center. Conclusions Assisted home-based dialysis modalities are viable treatment options for patients from a cost perspective. Future studies to consider graduation rates to full self-care from assisted dialysis and the cost implications of respite care are needed.
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Affiliation(s)
- Ryan J Bamforth
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Alain Beaudry
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Thomas W Ferguson
- Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada.,Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Claudio Rigatto
- Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada.,Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada.,Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Clara Bohm
- Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada.,Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada.,Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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22
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Noyes J, Roberts G, Williams G, Chess J, Mc Laughlin L. Understanding the low take-up of home-based dialysis through a shared decision-making lens: a qualitative study. BMJ Open 2021; 11:e053937. [PMID: 34845074 PMCID: PMC8634024 DOI: 10.1136/bmjopen-2021-053937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To explore how people with chronic kidney disease who are pre-dialysis, family members and healthcare professionals together navigate common shared decision-making processes and to assess how this impacts future treatment choice. DESIGN Coproductive qualitative study, underpinned by the Making Good Decisions in Collaboration shared decision-model. Semistructured interviews with a purposive sample from February 2019 - January 2020. Interview data were analysed using framework analysis. Coproduction of logic models/roadmaps and recommendations. SETTING Five Welsh kidney services. PARTICIPANTS 95 participants (37 patients, 19 family members and 39 professionals); 44 people supported coproduction (18 patients, 8 family members and 18 professionals). FINDINGS Shared decision-making was too generic and clinically focused and had little impact on people getting onto home dialysis. Preferences of where, when and how to implement shared decision-making varied widely. Apathy experienced by patients, caused by lack of symptoms, denial, social circumstances and health systems issues made future treatment discussions difficult. Families had unmet and unrecognised needs, which significantly influenced patient decisions. Protocols containing treatment hierarchies and standards were understood by professionals but not translated for patients and families. Variation in dialysis treatment was discussed to match individual lifestyles. Patients and professionals were, however, defaulting to the perceived simplest option. It was easy for patients to opt for hospital-based treatments by listing important but easily modifiable factors. CONCLUSIONS Shared decision-making processes need to be individually tailored with more attention on patients who could choose a home therapy but select a different option. There are critical points in the decision-making process where changes could benefit patients. Patients need to be better educated and their preconceived ideas and misconceptions gently challenged. Healthcare professionals need to update their knowledge in order to provide the best advice and guidance. There needs to be more awareness of the costs and benefits of the various treatment options when making decisions.
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Affiliation(s)
- Jane Noyes
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Gareth Roberts
- Department of Nephrology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | - James Chess
- Renal Unit, Swansea Bay University Health Board, Port Talbot, UK
| | - Leah Mc Laughlin
- School of Medical and Health Sciences, Bangor University, Bangor, UK
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23
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Gorham G, Howard K, Cunningham J, Barzi F, Lawton P, Cass A. Do remote dialysis services really cost more? An economic analysis of hospital and dialysis modality costs associated with dialysis services in urban, rural and remote settings. BMC Health Serv Res 2021; 21:582. [PMID: 34140001 PMCID: PMC8212525 DOI: 10.1186/s12913-021-06612-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/07/2021] [Indexed: 11/16/2022] Open
Abstract
Background Rates of end-stage kidney disease in Australia are highest in the Northern Territory (NT), with the burden of disease heaviest in remote areas. However, the high cost of delivering dialysis services in remote areas has resulted in centralisation, requiring many people to relocate for treatment. Patients argue that treatment closer to home improves health outcomes and reduces downstream healthcare use. Existing dialysis cost studies have not compared total health care costs associated with treatment in different locations. Objective To estimate and compare, from a payer perspective, the observed health service costs (all cause hospital admissions, emergency department presentations and maintenance dialysis) associated with different dialysis models in urban, rural and remote locations. Methods Using cost weights attributed to diagnostic codes in the NT Department of Health’s hospital admission data set (2008–2014), we calculated the mean (SD) total annual health service costs by dialysis model for 995 dialysis patients. Generalized linear modeling with bootstrapping tested the marginal cost differences between different explanatory variables to estimate ‘best casemix’/‘worst casemix’ cost scenarios. Results The mean annual patient hospital expenditure was highest for urban models at $97 928 (SD $21 261) and $43 440 (SD $5 048) and lowest for remote at $19 584 (SD $4 394). When combined with the observed maintenance dialysis costs, expenditure was the highest for urban models at $148 510 (SD $19 774). The incremental cost increase of dialysing in an urban area, compared with a rural area, for a relocated person from a remote area, was $5 648 more and increased further for those from remote and very remote areas to $10 785 and $15 118 respectively. Conclusions This study demonstrates that dialysis treatment in urban areas for relocated people has health and cost implications that maybe greater than the cost of remote service delivery. The study emphasises the importance of considering all health service costs and cost consequences of service delivery models. Key points for decision makers Relocation for dialysis treatment has serious health and economic consequences. Relocated people have low dialysis attendance and high hospital costs in urban areas. While remote dialysis service models are more expensive than urban models, the comparative cost differences are significantly reduced when all health service costs are included. The delivery of equitable and accessible dialysis service models requires a holistic approach that incorporates the needs of the patient; hence dialysis cost studies must consider the full range of cost impacts beyond the dialysis treatments alone. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06612-z. Most people requiring ongoing treatment for end-stage kidney disease in the Northern Territory (NT) identify as Aboriginal with the majority residing in areas classified as remote or very remote. Unlike other jurisdictions in Australia, haemodialysis in a satellite unit is the most common form of treatment. However, there is a geographic mismatch between demand and service provision, with services centralised in urban areas. Patients and communities have long advocated for services at or closer to home, maintaining that the consequences of relocation and dislocation have far reaching health, psychosocial and economic ramifications. We analysed retrospective hospital data for 995 maintenance dialysis patients, stratified by the model of care they received in urban, rural and remote locations. Using cost weights attributed to diagnosis codes, we costed hospital admissions, emergency department presentations and maintenance dialysis attendances, to provide a mean total health service cost/patient/year for each model of care. We found that urban services were associated with low observed maintenance dialysis and high hospital costs, but the inverse was true for remote and very remote models. Remote models had high maintenance dialysis costs (due to expense of remote service delivery and good dialysis attendance) but low hospital usage and costs. When adjusted for other variables such as age, dialysis vintage and comorbidities, lower total hospital costs were associated with rural and remote service provision. In an environment of escalating demand and constrained budgets, this study underlines the need for policy decisions to consider the full cost consequences of different dialysis service models.
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Affiliation(s)
- Gillian Gorham
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, 0810, Darwin, Australia.
| | - Kirsten Howard
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Joan Cunningham
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, 0810, Darwin, Australia
| | - Federica Barzi
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, 0810, Darwin, Australia
| | - Paul Lawton
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, 0810, Darwin, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, 0810, Darwin, Australia
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24
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Paterson B, Fox DE, Lee CH, Riehl-Tonn V, Qirzaji E, Quinn R, Ward D, MacRae JM. Understanding Home Hemodialysis Patient Attrition: A Cohort Study. Can J Kidney Health Dis 2021; 8:20543581211022195. [PMID: 34178360 PMCID: PMC8207266 DOI: 10.1177/20543581211022195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/01/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Home hemodialysis (HHD) offers a flexible, patient-centered modality for patients with kidney failure. Growth in HHD is achieved by increasing the number of patients starting HHD and reducing attrition with strategies to prevent the modifiable reasons for loss. Objective: Our primary objective was to describe a Canadian HHD population in terms of technique failure and time to exit from HHD in order to understand reasons for exit. Our secondary objectives include the following: (1) determining reasons for training failure, (2) reasons for early exit from HHD, and (3) timing of program exit. Design: A retrospective cohort study of incident adult HHD patients between January 1, 2013—June 30, 2020. Setting: Alberta Kidney Care South, AKC-S HHD program. Participants: Patients who started training for HHD in AKC-S. Methods: A retrospective, cohort study of incident adult HHD patients with primary outcome time on home hemodialysis, secondary outcomes include reason for train failure, time to and reasons for technique failure. Cox-proportional hazard model to determine associations between patient characteristics and technique failure. The cumulative probability of technique failure over time was reported using a competing risks model. Results: A total of 167 patients entered HHD. Training failure occurred in 20 (12%), at 3.1 [2.0, 5.5] weeks; these patients were older (P < .001) and had 2 or more comorbidities (P < .001). Reasons for HHD exit after training included transplant (35; 21%), death (8; 4.8%), and technique failure (24; 14.4%). Overall, the median time to HHD exit, was 23 months [11, 41] and the median time of technique failure was 17 months [8.9, 36]. Reasons for technique failure included: psychosocial reasons (37%) at a median time 8.9 months [7.7, 13], safety (12.5%) at 19 months [19, 36], and medical (37.5%) at 26 months [11, 50]. Limitations: Small patient population with quality of data limited by the electronic-based medical record and non-standardized definitions of reasons for exit. Conclusions: Training failure is a particularly important source of patient loss. Reasons for exit differ according to duration on HHD. Early interventions aimed at reducing train failure and increasing psychosocial supports may help program growth.
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Affiliation(s)
- Bailey Paterson
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Danielle E Fox
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Chel Hee Lee
- Department of Mathematics and Statistics, University of Calgary, AB, Canada
| | - Victoria Riehl-Tonn
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Elena Qirzaji
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Rob Quinn
- Department of Community Health Sciences, University of Calgary, AB, Canada.,Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - David Ward
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Jennifer M MacRae
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Cardiac Sciences, University of Calgary, AB, Canada
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25
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Molnar AO, Harvey A, Walsh M, Jain AK, Bosch E, Brimble KS. The WISHED Randomized Controlled Trial: Impact of an Interactive Health Communication Application on Home Dialysis Use in People With Chronic Kidney Disease. Can J Kidney Health Dis 2021; 8:20543581211019631. [PMID: 34158965 PMCID: PMC8182179 DOI: 10.1177/20543581211019631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/24/2021] [Indexed: 12/03/2022] Open
Abstract
Background: While home dialysis therapies are more cost effective and may offer improved
health-related quality of life, uptake compared to in-center hemodialysis
remains low. Objective: To test whether a web-based interactive health communication application
(IHCA) compared to usual care would increase home dialysis use. Design: Randomized control trial Setting: Patients were recruited from 3 multidisciplinary kidney clinics across
Ontario, Canada (Hamilton, Kingston, London). Patients: We included adults with advanced chronic kidney disease (CKD) followed in
multidisciplinary kidney clinics. Patients who had not completed dialysis
modality education, who did not have access to a home computer or the
internet, who had significant hearing or vision impairment, who could not
read/write/speak English, who had a medical contraindication for home
dialysis, or who had selected conservative kidney care were excluded. Measurements: The primary outcome was any use of home dialysis (peritoneal dialysis or home
hemodialysis) within 90 days of dialysis initiation. Secondary outcomes were
social support, decision conflict and dialysis knowledge measured at
baseline, 6 months and 1 year. Methods: Eligible patients were randomized to either usual care or the IHCA in
addition to usual care in a 1:1 ratio. As part of usual care, all patients
received education about dialysis modalities and kidney transplantation
delivered by clinic nurses according to local practices. Randomization was
performed using a computer-generated sequence in randomly permuted block
sizes, stratified by site, and allocation occurred using sequentially
numbered sealed, opaque envelopes. Participants, care providers, and outcome
assessors were not blinded to the intervention. All analyses were performed
blinded using an intention to treat approach. We estimated the effect of the
ICHA on the odds of the primary outcome using unadjusted logistic regression
models. Linear mixed models for repeated measures over time were used to
analyze the impact of the IHCA on the secondary outcomes of interest. Results: We randomized 140 (usual care, n = 71; IHCA, n = 69) out of a planned 264
patients (mean [SD] age 61 [14.5] years, 65% men). Among patients randomized
to the IHCA group that completed 6-month and 1-year follow-up visits, 56.8%
and 71.4%, respectively, had not accessed the IHCA website within the past
month. There were 23 (32.4%) and 26 (37.7%) patients in the usual care and
IHCA groups who received a home dialysis therapy within 90 days of dialysis
initiation (odds ratio, OR = 1.3, 95% CI = [0.6-2.5], P =
.5). Among the 78 patients who initiated dialysis (n = 38 usual care, n = 40
IHCA), 60.5% and 65% in the usual care and IHCA groups received a home
therapy within 90 days of dialysis initiation (OR = 1.2, 95% CI = [0.5-3.0],
P = .7). Secondary outcomes did not differ by
intervention group over time. Limitations: The trial was underpowered due to poor recruitment and use of the IHCA was
low. Conclusions: We did not find evidence of a difference in home dialysis uptake with IHCA
use, but our analyses were notably underpowered. The incorporation of
greater patient engagement, qualitative research and design research, and
pilot implementation may help future evaluations of strategies to improve
home dialysis uptake. Trial Registration: ClinicalTrials.gov #NCT01403454, registration date: Jul 21,
2011
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | | | - Michael Walsh
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | - Arsh K Jain
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Eric Bosch
- Eric Bosch Consulting Inc, Hamilton, ON, Canada
| | - K Scott Brimble
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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26
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Chong C, Wick J, Klarenbach S, Manns B, Hemmelgarn B, Ronksley P. Cost of Potentially Preventable Hospitalizations Among Adults With Chronic Kidney Disease: A Population-Based Cohort Study. Can J Kidney Health Dis 2021; 8:20543581211018528. [PMID: 34158964 PMCID: PMC8182215 DOI: 10.1177/20543581211018528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/13/2021] [Indexed: 01/02/2023] Open
Abstract
Background: Prior studies report high hospitalization rates among patients with chronic
kidney disease (CKD) and approximately 10% to 20.9% of hospitalizations are
potentially preventable. Objective: To determine the rate, proportion, and cost of potentially preventable
hospitalizations and whether this varied by CKD category. Design: Retrospective cohort study using population-based data. Setting: Alberta, Canada. Patients: All adults with an outpatient serum creatinine measurement between January 1
and December 31, 2017 in the Alberta Kidney Disease Network data
repository. Measurements: CKD risk categories were based on measures of proteinuria (where available),
eGFR, and use of dialysis. Patients were linked to administrative data to
capture frequency and cost of hospital encounters and followed until death
or end of study (December 31, 2018). The outcomes of interest were the rate
and cost of potentially preventable hospitalizations, as identified using
the Canadian Institute for Health Information (CIHI)-defined ambulatory care
sensitive condition (ACSC) algorithm and a CKD-related ACSC algorithm. Methods: Unadjusted and adjusted rates per 1000-patient years, proportions, and cost
attributable to preventable hospitalizations were identified for the cohort
as a whole and for patients within each CKD risk category. Results: Of the 1,110,895 adults with eGFR and proteinuria measurements, 181,422 had
CKD. During a median follow-up of 1 year, there were 62,023 hospitalizations
among patients with CKD resulting in a total cost of $946 million CAD; 6907
(11.1%) of these hospitalizations were for CIHI-defined ACSCs while 4323
(7.0%) were for CKD-related ACSCs. Adjusted rates of hospitalization for
ACSCs increased with CKD risk category and were highest among patients
treated with dialysis. Among CKD patients, the total cost of potentially
preventable hospitalizations was $79 million and $58 million CAD for
CIHI-defined and CKD-related ACSCs (8.4% and 6.2% of total hospitalization
cost, respectively). Limitations: Based on the ACSC construct, we were unable to determine if these
hospitalizations were truly preventable. Conclusions: Potentially preventable hospitalizations have a substantial cost and burden
on the health care system among people with CKD. Effective strategies that
reduce preventable admissions among CKD patients may lead to significant
cost savings. Trial registration: Not applicable—observational study design
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Affiliation(s)
- Christy Chong
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
| | - James Wick
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Scott Klarenbach
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Braden Manns
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brenda Hemmelgarn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Paul Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
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27
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Li PKT, Chan GCK, Chen J, Chen HC, Cheng YL, Fan SLS, He JC, Hu W, Lim WH, Pei Y, Teo BW, Zhang P, Yu X, Liu ZH. Tackling Dialysis Burden around the World: A Global Challenge. KIDNEY DISEASES (BASEL, SWITZERLAND) 2021; 7:167-175. [PMID: 34179112 PMCID: PMC8215964 DOI: 10.1159/000515541] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/26/2021] [Indexed: 11/19/2022]
Abstract
CKD is a global problem that causes significant burden to the healthcare system and the economy in addition to its impact on morbidity and mortality of patients. Around the world, in both developing and developed economies, the nephrologists and governments face the challenges of the need to provide a quality and cost-effective kidney replacement therapy for CKD patients when their kidneys fail. In December 2019, the 3rd International Congress of Chinese Nephrologists was held in Nanjing, China, and in the meeting, a symposium and roundtable discussion on how to deal with this CKD burden was held with opinion leaders from countries and regions around the world, including Australia, Canada, China, Hong Kong, Singapore, Taiwan, the UK, and the USA. The participants concluded that an integrated approach with early detection of CKD, prompt treatment to slow down progression, promotion of home-based dialysis therapy like peritoneal dialysis and home HD, together with promotion of kidney transplantation, are possible effective ways to combat this ongoing worldwide challenge.
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Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Carol and Richard Yu Peritoneal Dialysis Research Centre, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Gordon Chun-Kau Chan
- Department of Medicine and Therapeutics, Carol and Richard Yu Peritoneal Dialysis Research Centre, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Jianghua Chen
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hung-Chun Chen
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yuk-Lun Cheng
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong, China
| | - Stanley L.-S. Fan
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, United Kingdom
| | - John Cijiang He
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Weixin Hu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Wai-Hon Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Washington, Australia
| | - York Pei
- Department of Medicine, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Boon Wee Teo
- Division of Nephrology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ping Zhang
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xueqing Yu
- Department of Nephrology, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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28
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Rastogi A, Lerma EV. Anemia management for home dialysis including the new US public policy initiative. Kidney Int Suppl (2011) 2021; 11:59-69. [PMID: 33777496 PMCID: PMC7983021 DOI: 10.1016/j.kisu.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 12/28/2022] Open
Abstract
Patients with end-stage kidney disease (ESKD) requiring kidney replacement therapy are often treated in conventional dialysis centers at substantial cost and patient inconvenience. The recent United States Executive Order on Advancing American Kidney Health, in addition to focusing on ESKD prevention and reforming the kidney transplantation system, focuses on providing financial incentives to promote a shift toward home dialysis. In accordance with this order, a goal was set to have 80% of incident dialysis patients receiving home dialysis or a kidney transplant by 2025. Compared with conventional in-center therapy, home dialysis modalities, including both home hemodialysis and peritoneal dialysis, appear to offer equivalent or improved mortality, clinical outcomes, hospitalization rates, and quality of life in patients with ESKD in addition to greater convenience, flexibility, and cost-effectiveness. Treatment of anemia, a common complication of chronic kidney disease, may be easier to manage at home with a new class of agents, hypoxia-inducible factor-prolyl hydroxylase inhibitors, which are orally administered in contrast to the current standard of care of i.v. iron and/or erythropoiesis-stimulating agents. This review evaluates the clinical, quality-of-life, economic, and social aspects of dialysis modalities in patients with ESKD, including during the coronavirus disease 2019 pandemic; explores new therapeutics for the management of anemia in chronic kidney disease; and highlights how the proposed changes in Advancing American Kidney Health provide an opportunity to improve kidney health in the United States.
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Affiliation(s)
- Anjay Rastogi
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Edgar V. Lerma
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago/Advocate Christ Medical Center, Section of Nephrology, Oak Lawn, Illinois, USA
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29
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Kliuk-Ben Bassat O, Schwartz D, Zubkov A, Gal-Oz A, Gorevoy A, Romach I, Grupper A. WoundClot® Hemostatic Gauze Reduces Bleeding Time after Arterial Venous Fistula Decannulation. Blood Purif 2021; 50:952-958. [PMID: 33789264 DOI: 10.1159/000514934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/01/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Decannulation of the arteriovenous fistula (AVF) after each hemodialysis session requires a precise compression on the needle puncture site. The objective of our study was to evaluate the bleeding time (BT) needed to achieve hemostasis using WoundClot, an innovative hemostatic gauze, and to assess whether its long-term use can improve AVF preservation. METHODS This is a prospective single center study. Initially, the time to hemostasis after AVF decannulation was compared between WoundClot and cotton gauze in 24 prevalent hemodialysis patients. Thereafter, the patients continued to use WoundClot for 12 months and were compared to a control group consisting of 25 patients using regular cotton gauze. Follow-up data included parameters of dialysis adequacy, AVF interventions, and thrombotic events. RESULTS WoundClot use shortened significantly the time needed for hemostasis. Mean venous BT decreased by 3.99 (±4.6) min and mean arterial BT by 6.38 (±4.8) min when using WoundClot compared to cotton gauze (p < 0.001). At the end of the study, dialysis adequacy expressed by spKt/V was higher in the WoundClot group compared to control (1.73 vs. 1.53, respectively, p = 0.047). Although patients in WoundClot group had a higher baseline BT, arterial and venous pressures did not differ between the groups after a median follow up of 10.8 months. AVF thrombosis rate was similar between the groups. CONCLUSIONS WoundClot hemostatic gauze significantly reduced the time required for hemostasis after AVF decannulation and may be associated with better AVF preservation. We suggest using WoundClot for arterial BT longer than 15 min and for venous BT longer than 12.5 min.
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Affiliation(s)
- Orit Kliuk-Ben Bassat
- Department of Nephrology, Tel Aviv Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Doron Schwartz
- Department of Nephrology, Tel Aviv Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Zubkov
- Department of Nephrology, Tel Aviv Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Gal-Oz
- Department of Intensive Care, Tel Aviv Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Gorevoy
- Department of Nephrology, Tel Aviv Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iris Romach
- Department of Nephrology, Tel Aviv Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ayelet Grupper
- Department of Nephrology, Tel Aviv Medical Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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30
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Weinhandl ED. Economic Impact of Home Hemodialysis. Adv Chronic Kidney Dis 2021; 28:136-142. [PMID: 34717859 DOI: 10.1053/j.ackd.2021.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/12/2021] [Accepted: 06/21/2021] [Indexed: 11/11/2022]
Abstract
Home hemodialysis (HD) is growing in the United States, but the economics of the modality are largely unknown, especially considering the unique aspects of home HD in the United States . In this review, I focus on details of Medicare coverage, which directly applies to most patients on dialysis and influences the policies of private insurers. Key details in Medicare comprise the relationship between home dialysis training and initial Medicare eligibility, reimbursement for home HD training, coverage of additional HD treatments (ie., in excess of 3 treatments per week), and monthly capitated payments to nephrologists. The overarching narrative is that frequent home HD directly increases Medicare costs for outpatient dialysis, but these added costs can be mitigated by lower inpatient expenditures if increased HD treatment frequency lowers the risk of cardiovascular hospitalization and infection control is emphasized. I also review recent international literature; conventional home HD exhibits a superior cost profile, whereas frequent home HD is generally cost-effective over multiple treatment years (ie, if early technique failure is avoided). Out-of-pocket expenses for patients should be considered. The future economics of home HD in the United States will be determined by new equipment, new adaptations of the modality, and new payment models.
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Lavoie-Cardinal M, Nadeau-Fredette AC. Physical Infrastructure and Integrated Governance Structure for Home Hemodialysis. Adv Chronic Kidney Dis 2021; 28:149-156. [PMID: 34717861 DOI: 10.1053/j.ackd.2021.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 02/11/2021] [Accepted: 02/25/2021] [Indexed: 01/17/2023]
Abstract
In view of the growing enthusiasm for home dialysis use, new dialysis centers may build or expend their home hemodialysis program in the next few years. This review will discuss the main challenges faced by small and large home hemodialysis programs in terms of physical spaces, human resource, training considerations, and overall governance. We will elaborate on the inclusion of home hemodialysis in the kidney replacement therapy care continuum, with a specific interest for collaboration and transition between peritoneal dialysis and home hemodialysis programs.
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Klomjit N, Kattah AG, Cheungpasitporn W. The Cost-effectiveness of Peritoneal Dialysis Is Superior to Hemodialysis: Updated Evidence From a More Precise Model. Kidney Med 2021; 3:15-17. [PMID: 33605939 PMCID: PMC7873827 DOI: 10.1016/j.xkme.2020.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nattawat Klomjit
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Andrea G. Kattah
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
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Prasad B, Jafari M, Shah S, McNaught C, Diebel L. Barriers to Peritoneal Dialysis in Saskatchewan Canada: Results From a Province-Wide Survey. Can J Kidney Health Dis 2020; 7:2054358120975545. [PMID: 33403116 PMCID: PMC7747106 DOI: 10.1177/2054358120975545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/29/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Peritoneal dialysis (PD) is an underutilized, therapeutic option to in-center hemodialysis (HD), given its similar survival and clinical efficacy but provides lifestyle benefits and cost savings. Despite these advantages, PD prevalence rates remains below 20% in many Canadian jurisdictions. Objectives: The primary objective of this study was to identify and assess patient-perceived barriers to PD implementation in Saskatchewan. The secondary objectives were to examine variations in patient-perceived barriers to PD by dialysis units (main dialysis units vs satellite dialysis units) and specific challenges faced by First Nation patients residing on reserves. Design: A cross-sectional observational survey study. Setting: Two major centers (Regina and Saskatoon) and 5 associated satellite units attached to each center across the province of Saskatchewan. Patients: We approached all prevalent in-center HD patients across Saskatchewan, 366 (49%) agreed to participate in the study. Measurements: Self-reported barriers to PD were assessed using a 26-question survey which was created after engagement of our multidisciplinary team. Methods: We conducted a cross-sectional survey of 740 prevalent in-center HD patients within the province of Saskatchewan, Canada, from June 2018 to January 2019. Around 366 (49%) patients agreed to participate in the study. The questionnaire was designed to capture patients’ perceived barriers to PD. Descriptive statistics were used to present the data. Chi-square and Mann-Whitney U-test were used to compare the patients’ responses (main dialysis units vs satellite dialysis units, and First Nation reserves vs nonreserves). Results: Of the 366 patients who completed the survey, 284 met the eligibility criteria and were included in the analysis. Patient-reported satisfaction with current in-center HD care was the most common barrier to PD uptake (92%), followed by proximity to their HD unit (61%). A lack of understanding of the benefits/risks of PD, fear of family burden (54% each), and unwillingness to dialyze daily and to learn a new technique (51% each) were additional factors. Patients residing on reserves compared to nonreserve residents felt PD had a higher risk of infection compared to HD (54% vs 34%, P = .005), and felt PD led to suboptimal care (47% vs 31%, P = .021). Limitations: We used a nonstandardized locally derived questionnaire to quantify barriers, and this prevents inclusion of additional barriers than individual patients may consider important. Cross-sectional data can only be used as a snapshot. Only 366 patients agreed to participate, and the results cannot be generalized to 740 prevalent HD patients. We did not capture data on demographics (age, income, and literacy level), comorbidities, and dialysis vintage, which would have been helpful in interpretation of the results. We did not involve patients, carers, or patients of First Nations heritage, in the design of the survey and the study. Conclusions: The results of our survey indicate that the major patient-reported barrier to PD uptake in our province is clinical inertia in patients defaulted to in-center HD at the onset of dialysis. Lack of patient awareness and knowledge of PD as a viable treatment modality also figured prominently, as did fears/concerns surrounding the safety, efficacy, and perceived family burden with PD compared with in-center HD. Trial Registration: The study was not registered on a publicly accessible registry because it did not involve any health care intervention on human participants.
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Affiliation(s)
- Bhanu Prasad
- Section of Nephrology, Department of Medicine, Regina General Hospital, Saskatchewan Health Authority, Regina, Canada
| | - Maryam Jafari
- Dr. T. Bhanu Prasad Medical Prof Corp, Regina, SK, Canada
| | - Sachin Shah
- Section of Nephrology, Department of Medicine, St. Paul's Hospital, Saskatoon, SK, Canada
| | - Connie McNaught
- Hemodialysis, Regina General Hospital, Saskatchewan Health Authority, Regina, Canada
| | - Lucas Diebel
- College of Medicine, University of Saskatchewan, Regina, Canada
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Ferguson TW, Whitlock RH, Bamforth RJ, Beaudry A, Darcel J, Di Nella M, Rigatto C, Tangri N, Komenda P. Cost-Utility of Dialysis in Canada: Hemodialysis, Peritoneal Dialysis, and Nondialysis Treatment of Kidney Failure. Kidney Med 2020; 3:20-30.e1. [PMID: 33604537 PMCID: PMC7873742 DOI: 10.1016/j.xkme.2020.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Rationale & Objective The kidney failure population is growing, necessitating the expansion of dialysis programs. These programs are costly and require a substantial amount of health care resources. Tools that accurately forecast resource use can aid efficient allocation. The objective of this study is to describe the development of an economic simulation model that incorporates treatment history and detailed modality transitions for patients with kidney disease using real-world data to estimate associated costs, utility, and survival by initiating modality. Study Design Cost-utility model with microsimulation. Setting & Population Adult incident maintenance dialysis patients in Canada who initiated facility-based hemodialysis (HD) or home peritoneal dialysis (PD) between 2004 and 2013. Intervention HD and PD. Outcomes Costs (related to dialysis, transplantation, infections, and hospitalizations), survival, utility, and dialysis modality mix over time. Model, Perspective, & Timeframe The model took the perspective of the health care payer. Patients were followed up for 10 years from initiation of dialysis. Our cost-utility analysis compared the intervention with receiving no treatment. Results During a 10-year time horizon, the cost-utility ratio for all patients initiating dialysis was $103,779 per quality-adjusted life-year (QALY) in comparison to no treatment. Patients who initiated with facility-based HD were treated at a cost-utility ratio of $104,880/QALY and patients who initiated with home PD were treated at a cost-utility ratio of $83,762/QALY. During this time horizon, the total mean cost and QALYs per patient were estimated at $350,774 ± $204,704 and 3.38 ± 2.05) QALYs respectively. Limitations The results do not include costs from the societal perspective. Rare patient trajectories were unable to be assessed. Conclusions This model demonstrates that patients who initiated dialysis with PD were treated more cost-effectively than those who initiated with HD during a 10-year time horizon.
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Affiliation(s)
- Thomas W. Ferguson
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Reid H. Whitlock
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Ryan J. Bamforth
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Alain Beaudry
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Joseph Darcel
- Department of Medicine, University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Michelle Di Nella
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Claudio Rigatto
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
- Address for Correspondence: Paul Komenda, MD, MHA, Seven Oaks General Hospital, 2LB10-2300 McPhillips Street, Winnipeg, MB, Canada R2V 3M3.
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Tonelli M, Vanholder R, Himmelfarb J. Health Policy for Dialysis Care in Canada and the United States. Clin J Am Soc Nephrol 2020; 15:1669-1677. [PMID: 32586926 PMCID: PMC7646249 DOI: 10.2215/cjn.14961219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Contemporary dialysis treatment for chronic kidney failure is complex, is associated with poor clinical outcomes, and leads to high health costs, all of which pose substantial policy challenges. Despite similar policy goals and universal access for their kidney failure programs, the United States and Canada have taken very different approaches to dealing with these challenges. While US dialysis care is primarily government funded and delivered predominantly by private for-profit providers, Canadian dialysis care is also government funded but delivered almost exclusively in public facilities. Differences also exist for regulatory mechanisms and the policy incentives that may influence the behavior of providers and facilities. These differences in health policy are associated with significant variation in clinical outcomes: mortality among patients on dialysis is consistently lower in Canada than in the United States, although the gap has narrowed in recent years. The observed heterogeneity in policy and outcomes offers important potential opportunities for each health system to learn from the other. This article compares and contrasts transnational dialysis-related health policies, focusing on key levers including payment, finance, regulation, and organization. We also describe how policy levers can incentivize favorable practice patterns to support high-quality/high-value, person-centered care and to catalyze the emergence of transformative technologies for alternative kidney replacement strategies.
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Affiliation(s)
- Marcello Tonelli
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium, European Kidney Health Alliance
| | - Jonathan Himmelfarb
- Kidney Research Institute, School of Medicine, Seattle, Washington .,Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
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Abstract
Rationale & Objective Most patients with kidney failure receive hemodialysis 3 times per week in a facility. More frequent and longer duration dialysis prescriptions improve a number of key outcome measures. These prescriptions are best suited to self-care and home regimens. The Quanta SC+ hemodialysis system is a novel device with demonstrated ease of use for patients and health care practitioners through human factors testing. The primary objective of this study is to report the efficacy and safety of the SC+ system using conventional hemodialysis prescriptions. Study Design Nonrandomized observational study. Setting & Participants Prevalent hemodialysis patients in 4 sites in the United Kingdom were recruited to switch from their current device to the SC+ system with no other changes to their prescription. Interventions SC+ hemodialysis system. Outcomes Efficacy data were collected in terms of dialysis adequacy, urea reduction ratios, and net fluid removal accuracy. Results 60 patients were enrolled in the study, resulting in 1,333 evaluable treatments. The threshold single-pool Kt/V of 1.2 was exceeded in 96.6% of treatments in patients receiving 3-times-weekly regimens, whereas the threshold standard Kt/V of 2.1 was exceeded in 94% of treatments and 97.6% of treatments in patients without significant residual kidney function. Ultrafiltration accuracy was determined by measuring net fluid removal and validated to be within acceptable limits. The adverse event profile during treatment was typical of hemodialysis. There were no serious adverse events. Limitations Few patients on high-frequency treatment regimens were enrolled. Conclusions The SC+ system delivers safe and effective hemodialysis across a range of patients and dialysis prescriptions. It is one of the smallest systems available and has validated usability for patients to perform self-care safely with minimal training. This device may encourage patients to feel empowered to take on home hemodialysis, unlocking beneficial clinical and patient-reported outcomes associated with these modalities.
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Abstract
Peritoneal dialysis in the United States is underutilized when compared to the experience in other developed countries. The reasons for this are multifactorial and include government regulatory issues, the priority of dialysis facilities, and education and training of nephrology trainees and patients. The challenges to expanding PD in the United States are discussed and strategies to overcome the barriers are outlined.
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Wang A, Turnbull L, Williams J, Thomas S, Saunders S, Levin A, Djurdjev O, Copland M, Singh S, Hemmett J. Systematic Evaluation of a Provincial Initiative to Improve Transition to Home Dialysis Therapies. Can J Kidney Health Dis 2020; 7:2054358120949811. [PMID: 32922826 PMCID: PMC7457697 DOI: 10.1177/2054358120949811] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 07/05/2020] [Indexed: 11/15/2022] Open
Abstract
Background: The transition from choosing to initiating home dialysis therapies (HDTs) is not clearly standardized for patients and staff, causing increased anxiety and suboptimal self-management for chronic kidney disease (CKD) patients. At BC Renal, a “Transition to HDTs” guidebook (the Guide) was designed, outlining a step-wise approach to transitioning to HDTs for patients, to help address some of these concerns. Objective: We used the Logic Model evaluation framework to assess the value of the Guide to improve patient and staff experience with transitioning to HDTs. Design: This is a prospective cohort quality improvement study. Setting: This study took place at home dialysis programs in British Columbia, Canada, with 2 pilot sites and 2 control sites. Patients: Patients above age 18 who attended kidney care clinics and identified HDT as their renal replacement treatment of choice were included in this study. Measurements: Patient demographics were obtained from British Columbia Renal Patient Records and Outcomes Management Information System, with differences analyzed using Mann-Whitney U test and chi-square test where applicable. Patient surveys were based on Likert rating scales, analyzed using Cochran-Armitage trend test. All tests were 2-sided, with P < .05 considered significant. Methods: The study enrolled patients from December 2018 to April 2019 at 2 pilot and 2 control sites. Patients were followed up for 8 months. The intervention strategies included (1) training of front-line staff to use the Guide and (2) dissemination of the guide to patients. Evaluation tools measuring data at baseline and at the 8-month point included (1) qualitative and quantitative patient surveys, (2) qualitative staff surveys, (3) structured feedback session with renal care staff, and (4) transition rate and time between choosing and starting a HDT. Results: In total, 108 patients were enrolled: 43 patients at pilot sites and 65 in control sites. Twenty-three of 65 in control vs 18 of 43 in pilot transitioned to a HDT by 8-month follow-up. Transition time was 80 vs 89 days in pilot vs control group, but it was not statistically different (P = .37). The proportion of patients that transitioned to a HDT was 42% vs 35% in pilot vs control group (P = .497). Patients’ anxiety, illness knowledge, and activation of resources were not significantly different between patients who successfully transitioned at control and pilot sites. During interviews, patients confirmed that the Guide was effective and helped retain knowledge. The staff felt that the intervention did not increase their workload and that the Guide was a good communication tool, but was used inconsistently. Limitations: We had a small sample size and limited number of patients enrolled who chose home hemodialysis, with none in the control group. The results are therefore more applicable to peritoneal dialysis. Conclusions: The Logic Model was useful to evaluate our multi-intervention strategy. While there were no statistically significant differences in transition time, rate, and patient anxiety with or without the Guide, qualitative opinions from patients indicate that the Guide was a useful supplement. In addition, feedback from renal care staff suggested that the Guide served as a framework for communicating the transition process with patients, and was perceived as a useful tool. Future work is required to standardize the Guide’s utilization. Trial registration: As this is a quality improvement evaluation study, trial registration is not applicable.
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Affiliation(s)
- Alice Wang
- The University of British Columbia, Vancouver, Canada
| | | | | | | | | | - Adeera Levin
- The University of British Columbia, Vancouver, Canada
| | | | - Michael Copland
- Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Suneet Singh
- The University of British Columbia, Vancouver, Canada
| | - Juliya Hemmett
- The University of British Columbia, Vancouver, Canada.,Foothills Medical Centre, University of Calgary, AB, Canada
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Diebel L, Jafari M, Shah S, Day C, McNaught C, Prasad B. Barriers to Home Hemodialysis Across Saskatchewan, Canada: A Cross-Sectional Survey of In-Center Dialysis Patients. Can J Kidney Health Dis 2020; 7:2054358120948293. [PMID: 32843987 PMCID: PMC7418229 DOI: 10.1177/2054358120948293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/24/2020] [Indexed: 01/28/2023] Open
Abstract
Background Despite clinical and lifestyle advantages of home hemodialysis (HHD) compared with in-center hemodialysis (ICHD), it remains underutilized in our province. The aim of the study was to explore the patients' perception and to identify the barriers to use of HHD in Saskatchewan, Canada. Objectives The primary objective of the study was to evaluate and explore patient perceptions of HHD and to identify the obstacles for adoption of HHD in Saskatchewan. The secondary objective was to examine variations in the patients' perceptions and barriers to HHD by center (main dialysis units vs satellite dialysis units). Design This is a cross-sectional observational survey study. Setting Two major centers (Regina and Saskatoon) and 5 associated satellite units attached to each center across the province of Saskatchewan. Patients We approached all prevalent ICHD patients across Saskatchewan, 398 agreed to participate in the study. Measurements Self-reported barriers to HHD were assessed using a questionnaire. Methods A questionnaire was designed to determine the patients' perceived barriers to HHD. Descriptive statistics was used to present the data. Chi-square and Mann-Whitney U test were used to compare the patients' responses between main and satellite units. Results Satisfaction with current dialysis care (91%), increase in utility bills (65%), fear of catastrophic events at home (59%), medicalization of one's home (54%), and knowledge deficits toward treatment modalities (54%) were the main barriers to HHD uptake. Compared with patients dialyzing in our main units, satellite patients chose not to pursue HHD more frequently because they had greater satisfaction with their current dialysis unit care (97% vs 87%, P < .001), felt more comfortable dialyzing under the supervision of medical staff (95% vs 86%, P < .007), could not afford additional utility costs (92% vs 45%, P < .001), were unaware of the risks and benefits of HHD (83% vs 33%, P < .001), had concerns over time commitments for training to HHD (69% vs 32%, P < .001), and had concern for family burnout (60.8% vs 40.6%, P < .001). Limitations We used questionnaires to quantify known barriers, and this prevents inclusion of additional barriers that individual patients may consider important. Cross-sectional data can only be used as a snapshot. Only 398 patients agreed to participate, and the results cannot be generalized to 740 prevalent HD patients. We did not capture data on demographics (age, income, and literacy level), comorbidities, and dialysis vintage, which would have been helpful in interpretation of the results. Conclusions Satisfaction with in-center care, lack of awareness and education, specifically in the satellite population, concerns with family burnout, expenses associated with utilities, and training time will need to be addressed to increase the uptake of HHD. Trial Registration The study was not registered on a publicly accessible registry as it did not involve any health care intervention on human participants.
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Affiliation(s)
- Lucas Diebel
- College of Medicine, University of Saskatchewan, Regina, Canada
| | - Maryam Jafari
- Dr. T. Bhanu Prasad Medical Professional Corporation, Regina, SK, Canada
| | - Sachin Shah
- Section of Nephrology, Department of Medicine, St. Paul's Hospital, Saskatoon, SK, Canada
| | - Christine Day
- Peritoneal Dialysis, Regina General Hospital, Saskatchewan Health Authority, Regina, Canada
| | - Connie McNaught
- Hemodialysis, Regina General Hospital, Saskatchewan Health Authority, Regina, Canada
| | - Bhanu Prasad
- Section of Nephrology, Department of Medicine, Regina General Hospital, Saskatchewan Health Authority, Regina, Canada
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Abstract
The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis — particularly haemodialysis and most notably in high-income countries (HICs) — the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization. Dialysis is a life-saving therapy; however, costs of dialysis are high, access is inequitable and outcomes are inadequate. This Review describes the current landscape of dialysis therapy from an epidemiological, economic, ethical and patient-centred framework, and describes initiatives that are aimed at stimulating innovations in the field to one that supports high-quality, high-value care. The global dialysis population is growing rapidly, especially in low-income and middle-income countries; however, worldwide, a substantial number of people lack access to kidney replacement therapy, and millions of people die of kidney failure each year, often without supportive care. The costs of dialysis care are high and will likely continue to rise as a result of increased life expectancy and improved therapies for causes of kidney failure such as diabetes mellitus and cardiovascular disease. Patients on dialysis continue to bear a high burden of disease, shortened life expectancy and report a high symptom burden and a low health-related quality of life. Patient-focused research has identified fatigue, insomnia, cramps, depression, anxiety and frustration as key symptoms contributing to unsatisfactory outcomes for patients on dialysis. Initiatives to transform dialysis outcomes for patients require both top-down efforts (that is, efforts that promote incentives based on systems level policy, regulations, macroeconomic and organizational changes) and bottom-up efforts (that is, patient-led and patient-centred advocacy efforts as well as efforts led by individual teams of innovators). Patients, payors, regulators and health-care systems increasingly demand improved value in dialysis care, which can only come about through true patient-centred innovation that supports high-quality, high-value care.
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Abstract
BACKGROUND Uninsured patients with end-stage renal disease face barriers to peritoneal dialysis (PD), a type of home dialysis that is associated with improved quality of life and reduced Medicare costs. Although uninsured patients using PD at dialysis start receive retroactive Medicare coverage for required predialysis services, coverage only applies for the calendar month of dialysis start. Thus, initiating dialysis later in the month yields longer retroactive coverage. OBJECTIVES To examine whether differences in retroactive Medicare were associated with decreased long-term PD use. RESEARCH DESIGN We exploited the dialysis start date using a regression discontinuity design on a national cohort from the US Renal Data System. SUBJECTS 36,256 uninsured adults starting dialysis between January 1, 2006 and December 31, 2014. MEASURES PD use at dialysis days 1, 90, 180, and 360. RESULTS Starting dialysis on the first versus last day of the calendar month was associated with an absolute decrease in PD use of 2.7% [95% confidence interval (CI), 1.5%-3.9%], or a relative decrease of 20% (95% CI, 12%-27%) at dialysis day 360. The absolute decrease was 5.5% (95% CI, 3.5%-7.2%) after Medicare established provider incentives for PD in 2011 and 7.2% (95% CI, 2.5%-11.9%) after Medicaid expansion in 2014. Patients were unlikely to switch from hemodialysis to PD after the first month of dialysis (probability of 6.9% in month 1, 1.5% in month 2, and 0.9% in month 4). CONCLUSIONS Extending retroactive coverage for preparatory dialysis services could increase PD use and reduce overall Medicare spending in the uninsured.
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Elshahat S, Cockwell P, Maxwell AP, Griffin M, O’Brien T, O’Neill C. The impact of chronic kidney disease on developed countries from a health economics perspective: A systematic scoping review. PLoS One 2020; 15:e0230512. [PMID: 32208435 PMCID: PMC7092970 DOI: 10.1371/journal.pone.0230512] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 03/02/2020] [Indexed: 11/18/2022] Open
Abstract
Chronic kidney disease (CKD) affects over 10% of the global population and poses significant challenges for societies and health care systems worldwide. To illustrate these challenges and inform cost-effectiveness analyses, we undertook a comprehensive systematic scoping review that explored costs, health-related quality of life (HRQoL) and life expectancy (LE) amongst individuals with CKD. Costs were examined from a health system and societal perspective, and HRQoL was assessed from a societal and patient perspective. Papers published in English from 2015 onward found through a systematic search strategy formed the basis of the review. All costs were adjusted for inflation and expressed in US$ after correcting for purchasing power parity. From the health system perspective, progression from CKD stages 1-2 to CKD stages 3a-3b was associated with a 1.1-1.7 fold increase in per patient mean annual health care cost. The progression from CKD stage 3 to CKD stages 4-5 was associated with a 1.3-4.2 fold increase in costs, with the highest costs associated with end-stage renal disease at $20,110 to $100,593 per patient. Mean EuroQol-5D index scores ranged from 0.80 to 0.86 for CKD stages 1-3, and decreased to 0.73-0.79 for CKD stages 4-5. For treatment with renal replacement therapy, transplant recipients incurred lower costs and demonstrated higher HRQoL scores with longer LE compared to dialysis patients. The study has provided a comprehensive updated overview of the burden associated with different CKD stages and renal replacement therapy modalities across developed countries. These data will be useful for the assessment of new renal services/therapies in terms of cost-effectiveness.
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Affiliation(s)
- Sarah Elshahat
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Paul Cockwell
- University Hospitals Birmingham, Birmingham, England, United Kingdom
| | - Alexander P. Maxwell
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | | | | | - Ciaran O’Neill
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
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Takasato M, Wymeersch FJ. Challenges to future regenerative applications using kidney organoids. CURRENT OPINION IN BIOMEDICAL ENGINEERING 2020. [DOI: 10.1016/j.cobme.2020.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Moradpour A, Hadian M, Tavakkoli M. Economic evaluation of End Stage Renal Disease treatments in Iran. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2020. [DOI: 10.1016/j.cegh.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Abra G, Schiller B. Public policy and programs – Missing links in growing home dialysis in the United States. Semin Dial 2020; 33:75-82. [DOI: 10.1111/sdi.12850] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Graham Abra
- Satellite Healthcare San Jose CA USA
- Division of Nephrology Department of Medicine Stanford University Palo Alto CA USA
| | - Brigitte Schiller
- Satellite Healthcare San Jose CA USA
- Division of Nephrology Department of Medicine Stanford University Palo Alto CA USA
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Imbeault B, Nadeau-Fredette AC. Optimization of Dialysis Modality Transitions for Improved Patient Care. Can J Kidney Health Dis 2019; 6:2054358119882664. [PMID: 31666977 PMCID: PMC6798163 DOI: 10.1177/2054358119882664] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 08/17/2019] [Indexed: 02/01/2023] Open
Abstract
Purpose of review: Initial and subsequent modality decisions are important, impacting both
clinical outcomes and quality of life. Transition from chronic kidney
disease to dialysis and between dialysis modalities are periods were
patients may be especially vulnerable. Reviewing our current knowledge
surrounding these critical periods and identifying areas for future research
may allow us to develop dialysis strategies beneficial to patients. Sources of information: We searched the electronic database PubMed and queried Google Scholar for
English peer-reviewed articles using appropriate keywords (non-exhaustive
list): dialysis transitions, peritoneal dialysis, home hemodialysis,
integrated care pathway, and health-related quality of life. Primary sources
were accessed whenever possible. Methods: In this narrative review, we aim to expose the controversies surrounding
home-dialysis first strategies and examine the evidence underpinning
home-dialysis first strategies as well as home-to-home and home-to-in-center
transitions. Key findings: Diverse factors must be taken into consideration when choosing initial and
subsequent dialysis modalities. Given the limitations of available data (and
lack of convincing benefit or detriment of one modality over the other),
patient-centered considerations may prime over suspected mortality benefits
of one modality or another. Limitations: Available data stem almost exclusively from retrospective and observational
studies, often using large national and international databases, susceptible
to bias. Furthermore, this is a narrative review which takes into account
the views and opinions of the authors, especially as it pertains to optimal
dialysis pathways. Implications: Emphasis must be placed on individual patient goals and preferences during
modality selection while planning ahead to achieve timely and appropriate
transitions limiting discomfort and anxiety for patients. Further research
is required to ascertain specific interventions which may be beneficial to
patients.
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Affiliation(s)
- Benoit Imbeault
- Division of Nephrology, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada.,Division of Nephrology, University Health Network, Toronto, ON, Canada
| | - Annie-Claire Nadeau-Fredette
- Division of Nephrology, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada.,Research Center, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada
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Hager D, Ferguson TW, Komenda P. Cost Controversies of a "Home Dialysis First" Policy. Can J Kidney Health Dis 2019; 6:2054358119871541. [PMID: 31516718 PMCID: PMC6719463 DOI: 10.1177/2054358119871541] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 06/16/2019] [Indexed: 11/15/2022] Open
Abstract
Purpose of review Kidney Failure is highly prevalent and uses a disproportionate amount of health care funding. In Canada (excluding Quebec), 37 647 people were living with kidney failure in 2016. The single-payer Canadian health care system spends approximately 1.2% of their annual budget on kidney failure. In 2016, 58.4% of patients with kidney failure in Canada (excluding Quebec) were on dialysis as opposed to living with a functioning kidney transplant. Home dialysis modalities including peritoneal dialysis (PD) and home hemodialysis (HD) were used by 18.9% and 4.7% of these patients, respectively. In-center HD and home dialysis (PD and home HD) are often considered equally efficacious and have similar impacts on quality of life. Despite cost minimization analyses suggesting that home dialysis offers cost savings over in-center HD, there has been a slow uptake of home dialysis in developed nations over time, suggesting that controversies and barriers to implementation currently exist. The primary objective of this health policy briefing article is to introduce and address some of the major controversies surrounding the cost effectiveness in supporting advocacy for a "Home Dialysis First" policy with a primary focus on single-payer systems in a developed nation such as Canada. Sources of information Canadian Agency for Drugs and Technologies in Health (CADTH), Canadian and US epidemiologic databases, national/international conference presentations, primary literature review, and discussion with experts within the field of home dialysis. Methods We have conducted a focused primary literature review alongside individuals with expertise in the field of home dialysis to discuss the cost controversies surrounding the implementation of a "Home Dialysis First" policy. Key findings First, the primary literature is limited to mostly observational studies which are highly variable in study design and content. Local economic assessments, however, have provided convincing data for home dialysis cost savings in Canada. Second, the cost of delivering dialysis differs significantly throughout the world, explained by differing costs of labor and supplies in developing nations. Third, the indirect patient costs of water, energy, and home modifications are often barriers to implementation and may be overcome by introducing cost reimbursement programs. Fourth, home dialysis requires upfront training costs. We explore the impact of premature switches from home dialysis to in-center HD or a functioning kidney transplant on overall cost savings. Fifth, we discuss the effect of physician financial incentives and program funding on the uptake of home dialysis. Finally, we introduce the controversial topic of comparing the societal value of freedom of modality choice against the societal cost savings of a "Home Dialysis First" policy. Limitations Narrative reviews, due to their inherently reduced methodological quality in comparison with systematic reviews, may expose our collected literature to selection bias. We have attempted to compose a diverse collection of available literature alongside consensus expertise to provide a fair and concise review of home dialysis cost controversies. Implications Implementation of a "Home Dialysis First" policy would be a disruptive change to kidney failure care in Canada. To make informed policy decisions, we should recognize the cost savings associated with home dialysis in developed nations, the significance of patient-borne costs as a barrier to implementation, the impact of training costs and early modality switching in home dialysis, the lack of evidence regarding physician financial incentives, and the importance of program funding. Ultimately, we must consider the societal value of freedom of patient modality choice in comparison with the potential cost savings of a "Home Dialysis First" policy.
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Affiliation(s)
- Drew Hager
- Internal Medicine Residency Program, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Paul Komenda
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada.,Section of Nephrology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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Wilk AS, Hirth RA, Messana JM. Paying for Frequent Dialysis. Am J Kidney Dis 2019; 74:248-255. [PMID: 30922595 PMCID: PMC7758184 DOI: 10.1053/j.ajkd.2019.01.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/29/2019] [Indexed: 11/11/2022]
Abstract
In late 2017, the 7 regional contractors responsible for paying dialysis claims in Medicare proposed new payment rules that would restrict payment for hemodialysis treatments in excess of 3 weekly to exceptional acute-care circumstances. Frequent hemodialysis is performed more frequently than the traditional thrice-weekly pattern, and many stakeholders-patients, providers, dialysis machine manufacturers, and others-have expressed concern that these payment rules will inhibit the growth of this treatment modality's use among US dialysis patients. In this Perspective, we explain the role of these contractors in the context of Medicare's in-center hemodialysis-centric dialysis payment system and assess how well this system accommodates the higher treatment frequencies of both peritoneal dialysis and frequent hemodialysis. Then, given the available evidence concerning the relative effectiveness of these modalities versus thrice-weekly in-center hemodialysis and trends in their use, we discuss options for modifying Medicare's payment system to support frequent dialysis.
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Affiliation(s)
- Adam S Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA.
| | - Richard A Hirth
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Joseph M Messana
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI
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Harasemiw O, Day C, Milad JE, Grainger J, Ferguson T, Komenda P. Human factors testing of the Quanta SC+ hemodialysis system: An innovative system for home and clinic use. Hemodial Int 2019; 23:306-313. [PMID: 30968548 PMCID: PMC6850132 DOI: 10.1111/hdi.12757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/27/2019] [Accepted: 03/15/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Uptake rates of home hemodialysis are the lowest among all modality types, despite providing patients with clinical and quality of life benefits at a lower cost to providers. Currently, there is a need to develop dialysis systems that are appealing to patients while also being suitable for use across the continuum of care. The SC+ hemodialysis system was developed by Quanta Dialysis Technologies Ltd. to provide patients with a dialysis system that is small, simple to use, and powerful enough to deliver acceptable dialysis adequacy. METHODS As part of the SC+ design validation, human factors testing was performed with 17 Healthcare Professionals (nephrology nurses and healthcare assistants) and 15 Home Users (patients and caregivers). To assess usability and safety, the human factors testing involved between 4.5 and 6 hours of training and, after a period of training decay, a subsequent test session in which participants independently performed tasks on SC+. FINDINGS Between the two user groups, there were only 29 errors observed out of 1216 opportunities for errors, despite minimal training. Errors that did occur were minor and attributed to an initial lack of familiarity with the device; none were safety related. DISCUSSION Among prevalent dialysis patients and healthcare professionals, the SC+ hemodialysis system was easy to use, even with minimal training and a learning decay period, and had a high level of use safety. By taking into account human factors to optimize the user experience, SC+ has the potential to address systemic and patient barriers, allowing for wider self-care and home hemodialysis adoption.
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Affiliation(s)
- Oksana Harasemiw
- Chronic Disease Innovation CentreSeven Oaks General HospitalWinnipegCanada
- Department of Internal MedicineUniversity of ManitobaWinnipegCanada
| | - Clara Day
- Department of Renal MedicineQueen Elizabeth HospitalBirminghamUK
| | | | | | - Thomas Ferguson
- Chronic Disease Innovation CentreSeven Oaks General HospitalWinnipegCanada
- Department of Internal MedicineUniversity of ManitobaWinnipegCanada
| | - Paul Komenda
- Chronic Disease Innovation CentreSeven Oaks General HospitalWinnipegCanada
- Department of Internal MedicineUniversity of ManitobaWinnipegCanada
- Quanta Dialysis Technologies Ltd.AlcesterUK
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Gorham G, Howard K, Zhao Y, Ahmed AMS, Lawton PD, Sajiv C, Majoni SW, Wood P, Conlon T, Signal S, Robinson SL, Brown S, Cass A. Cost of dialysis therapies in rural and remote Australia - a micro-costing analysis. BMC Nephrol 2019; 20:231. [PMID: 31238898 PMCID: PMC6593509 DOI: 10.1186/s12882-019-1421-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/12/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maintenance dialysis is a costly and resource intense activity. In Australia, inadequate health infrastructure and poor access to technically skilled staff can limit service provision in remote areas where many Aboriginal dialysis patients live. With most studies based on urban service provision, there is little evidence to guide service development. However permanent relocation to an urban area for treatment can have significant social and financial impacts that are poorly quantified. This study is part of a broader project to quantify the costs and benefits of dialysis service models in urban and remote locations in Australia's Northern Territory (NT). METHODS We undertook a micro-costing analysis of dialysis service delivery costs in urban, rural and remote areas in the NT from the payer perspective. Recurrent maintenance costs (salaries, consumables, facility management and transportation) as well as capital costs were included. Missing and centralised costs were standardised; results were inflated to 2017 values and reported in Australian dollars. RESULTS There was little difference between the average annual cost for urban and rural services with respective median costs of $85,919 versus $84,629. However remote service costs were higher ($120,172 - $124,492), driven by higher staff costs. The inclusion of capital costs did not add substantially to annual costs. Annual home haemodialysis costs ($42,927) were similar to other jurisdictions despite the significant differences in program delivery and payment of expenses not traditionally borne by governments. Annual peritoneal dialysis costs ($58,489) were both higher than home and in-centre haemodialysis by recent national dialysis cost studies. CONCLUSION The cost drivers for staffed services were staffing models and patient attendance rates. Staff salaries and transport costs were significantly higher in remote models of care. Opportunities to reduce expenditure exist by encouraging community supported services and employing local staff. Despite the delivery challenges of home haemodialysis including high patient attrition, the program still provides a cost benefit compared to urban staffed services. The next component of this study will examine patient health service utilisation and costs by model of care to provide a more comprehensive analysis of the overall cost of providing services in each location.
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Affiliation(s)
- G Gorham
- Renal Program, Wellbeing & Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia.
| | - K Howard
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Y Zhao
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia
| | | | - P D Lawton
- Renal Program, Wellbeing & Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - C Sajiv
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia.,Flinders University Northern Territory Medical Program, Darwin, Northern Territory, Australia
| | - S W Majoni
- Renal Program, Wellbeing & Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia.,Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia.,Flinders University Northern Territory Medical Program, Darwin, Northern Territory, Australia
| | - P Wood
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia
| | - T Conlon
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia
| | - S Signal
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia
| | - S L Robinson
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia
| | - S Brown
- Western Desert Nganampa Walytja Palyantjaku Tjutaku Northern Territory, Alice Springs, Australia
| | - A Cass
- Renal Program, Wellbeing & Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
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