Cost utility analysis of end stage renal disease treatment in Ministry of Health dialysis centres, Malaysia: Hemodialysis versus continuous ambulatory peritoneal dialysis

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Abstract

Objectives

In Malaysia, there is exponential growth of patients on dialysis. Dialysis treatment consumes a considerable portion of healthcare expenditure. Comparative assessment of their cost effectiveness can assist in providing a rational basis for preference of dialysis modalities.

Methods

A cost utility study of hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) was conducted from a Ministry of Health (MOH) perspective. A Markov model was also developed to investigate the cost effectiveness of increasing uptake of incident CAPD to 55% and 60% versus current practice of 40% CAPD in a five-year temporal horizon. A scenario with 30% CAPD was also measured. The costs and utilities were sourced from published data which were collected as part of this study. The transitional probabilities and survival estimates were obtained from the Malaysia Dialysis and Transplant Registry (MDTR). The outcome measures were cost per life year (LY), cost per quality adjusted LY (QALY) and incremental cost effectiveness ratio (ICER) for the Markov model. Sensitivity analyses were performed.

Results

LYs saved for HD was 4.15 years and 3.70 years for CAPD. QALYs saved for HD was 3.544 years and 3.348 for CAPD. Cost per LY saved was RM39,791 for HD and RM37,576 for CAPD. The cost per QALY gained was RM46,595 for HD and RM41,527 for CAPD. The Markov model showed commencement of CAPD in 50% of ESRD patients as initial dialysis modality was very cost-effective versus current practice of 40% within MOH. Reduction in CAPD use was associated with higher costs and a small devaluation in QALYs.

Conclusions

These findings suggest provision of both modalities is fiscally feasible; increasing CAPD as initial dialysis modality would be more cost-effective.

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Most cited references 35

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Chronic kidney disease as a global public health problem: approaches and initiatives - a position statement from Kidney Disease Improving Global Outcomes.

A S Levey, R. Atkins, J Coresh … (2007)

Chronic kidney disease (CKD) is increasingly recognized as a global public health problem. There is now convincing evidence that CKD can be detected using simple laboratory tests, and that treatment can prevent or delay complications of decreased kidney function, slow the progression of kidney disease, and reduce the risk of cardiovascular disease (CVD). Translating these advances to simple and applicable public health measures must be adopted as a goal worldwide. Understanding the relationship between CKD and other chronic diseases is important to developing a public health policy to improve outcomes. The 2004 Kidney Disease Improving Global Outcomes (KDIGO) Controversies Conference on 'Definition and Classification of Chronic Kidney Disease' represented an important endorsement of the Kidney Disease Outcome Quality Initiative definition and classification of CKD by the international community. The 2006 KDIGO Controversies Conference on CKD was convened to consider six major topics: (1) CKD classification, (2) CKD screening and surveillance, (3) public policy for CKD, (4) CVD and CVD risk factors as risk factors for development and progression of CKD, (5) association of CKD with chronic infections, and (6) association of CKD with cancer. This report contains the recommendations from the meeting. It has been reviewed by the conference participants and approved as position statement by the KDIGO Board of Directors. KDIGO will work in collaboration with international and national public health organizations to facilitate implementation of these recommendations.

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Propensity-matched mortality comparison of incident hemodialysis and peritoneal dialysis patients.

David T Gilbertson, Susan J. Snyder, Eric D Weinhandl … (2010)

Contemporary comparisons of mortality in matched hemodialysis and peritoneal dialysis patients are lacking. We aimed to compare survival of incident hemodialysis and peritoneal dialysis patients by intention-to-treat analysis in a matched-pair cohort and in subsets defined by age, cardiovascular disease, and diabetes. We matched 6337 patient pairs from a retrospective cohort of 98,875 adults who initiated dialysis in 2003 in the United States. In the primary intention-to-treat analysis of survival from day 0, cumulative survival was higher for peritoneal dialysis patients than for hemodialysis patients (hazard ratio 0.92; 95% CI 0.86 to 1.00, P = 0.04). Cumulative survival probabilities for peritoneal dialysis versus hemodialysis were 85.8% versus 80.7% (P < 0.01), 71.1% versus 68.0% (P < 0.01), 58.1% versus 56.7% (P = 0.25), and 48.4% versus 47.3% (P = 0.50) at 12, 24, 36, and 48 months, respectively. Peritoneal dialysis was associated with improved survival compared with hemodialysis among subgroups with age <65 years, no cardiovascular disease, and no diabetes. In a sensitivity analysis of survival from 90 days after initiation, we did not detect a difference in survival between modalities overall (hazard ratio 1.05; 95% CI 0.96 to 1.16), but hemodialysis was associated with improved survival among subgroups with cardiovascular disease and diabetes. In conclusion, despite hazard ratio heterogeneity across patient subgroups and nonconstant hazard ratios during the follow-up period, the overall intention-to-treat mortality risk after dialysis initiation was 8% lower for peritoneal dialysis than for matched hemodialysis patients. These data suggest that increased use of peritoneal dialysis may benefit incident ESRD patients.

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Peritoneal dialysis first: rationale.

Harbaksh Sangha, Ramesh Khanna, Kunal Chaudhary (2011)

The use of peritoneal dialysis (PD) has become wide spread since the introduction of continuous ambulatory PD more than 25 years ago. Over this time, many advances have been made and PD is an alternative to hemodialysis (HD), with excellent comparable survival, lower cost, and improved quality of life. The percentage of prevalent PD patients in the United States is approximately 7%, which is significantly lower compared with the 15% PD prevalence from the mid-1980s. Despite comparable survival of HD and PD and improved PD technique survival over the last few years, the percentage of patients performing PD in the United States has declined. The increased numbers of in-center HD units, physician comfort with the modality, perceived superiority of HD, and reimbursement incentives have all contributed to the underutilization of PD. In addition to a higher transplantation rate among patients treated with PD in the United States, an important reason for the low PD prevalence is the transfer to HD. There are various reasons for the transfer (e.g., episodes of peritonitis, membrane failure, patient fatigue, etc.). This review discusses the various factors that contribute to PD underutilization and the rationale and strategies to implement "PD first" and how to maintain it. The PD first concept implies that when feasible, PD should be offered as the first dialysis modality. This concept of PD first and HD second must not be seen as a competition between therapies, but rather that they are complementary, keeping in mind the long-term goals for the patient.

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Author and article information

Contributors

Naren Kumar Surendra:

ORCID: http://orcid.org/0000-0002-4365-9863

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Mohd Rizal Abdul Manaf: Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing

Lai Seong Hooi: Role: ConceptualizationRole: InvestigationRole: MethodologyRole: ValidationRole: VisualizationRole: Writing – review & editing

Sunita Bavanandan: Role: InvestigationRole: Project administrationRole: ValidationRole: Writing – review & editing

Fariz Safhan Mohamad Nor: Role: InvestigationRole: Project administrationRole: ValidationRole: Writing – review & editing

Shahnaz Shah Firdaus Khan: Role: InvestigationRole: Project administrationRole: ValidationRole: Writing – review & editing

Ong Loke Meng: Role: InvestigationRole: Project administrationRole: SupervisionRole: Writing – review & editing

Abdul Halim Abdul Gafor: Role: Funding acquisitionRole: SupervisionRole: Writing – review & editing

Wisit Cheungpasitporn: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 23 October 2019

Publication date Collection: 2019

Volume: 14

Issue: 10

Electronic Location Identifier: e0218422

Affiliations

[1 ] Department of Community Health, Faculty of Medicine, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

[2 ] Sultanah Aminah Hospital, Ministry of Health, Johor Bahru, Johor, Malaysia

[3 ] Kuala Lumpur Hospital, Ministry of Health, Kuala Lumpur, Malaysia

[4 ] Tengku Ampuan Afzan Hospital, Ministry of Health, Kuantan, Pahang, Malaysia

[5 ] Tengku Ampuan Rahimah Hospital, Ministry of Health, Klang, Selangor, Malaysia

[6 ] Pulau Pinang Hospital, Ministry of Health, Penang, Malaysia

[7 ] Nephrology Unit, Faculty of Medicine, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

University of Mississippi Medical Center, UNITED STATES

Author notes

Competing Interests: The authors have declared that no competing interests exist.

‡ These authors also contributed equally to this work.

* E-mail: mrizal@ 123456ppukm.ukm.edu.my

Author information

Naren Kumar Surendra http://orcid.org/0000-0002-4365-9863

Article

Publisher ID: PONE-D-19-15475

DOI: 10.1371/journal.pone.0218422

PMC ID: 6808325

PubMed ID: 31644577

SO-VID: 29ac2b6d-e317-4281-b779-017e283665c9

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 31 May 2019

Date accepted : 30 August 2019

Page count

Figures: 4, Tables: 6, Pages: 16

Funding

Funded by: funder-id http://dx.doi.org/10.13039/501100004515, Universiti Kebangsaan Malaysia;

Award ID: FF-2016-288

Award Recipient :

ORCID: http://orcid.org/0000-0002-4365-9863

Naren Kumar Surendra

Funded by: funder-id http://dx.doi.org/10.13039/100010995, Malaysian Society Nephrology;

Award Recipient :

ORCID: http://orcid.org/0000-0002-4365-9863

Naren Kumar Surendra

This research received fundamental research grant from Pusat Perubatan Universiti Kebangsaan Malaysia ( https://www.ppukm.ukm.my/) (Grant No: FF-2016-288) and an external research grant from the Malaysian Society of Nephrology ( https://www.msn.org.my/msn/). NKS received both grants. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Custom metadata

Data Availability The costs and utilities values in this study were imputed from the primary data which were collected as part of this study and the detailed methodology and results have been published. We have provided the dataset used in these analyses in the supporting documents section. Data on survival analysis are not publicly available because these data are provided by the National Renal Registry (NRR). We submitted official request to NRR in order to obtain that part of data mentioned above. Data release agreement was signed which highlighting the exclusive property of the dataset belongs to NRR. A processing fee was also charged. Other interested researchers can request data by submitting official request to the NRR secretariat at nrr@ 123456msn.org.my who will seek permission from the NRR steering committee, headed by Datuk Dr Ghazali ahmad https://www.msn.org.my/nrr/data_request.jsp. Researchers can replicate the study findings in their entirety by obtaining permission from NRR to use the survival dataset and following the protocol in the methods section. The dataset used in this study can be released to interested parties after a written approval is granted by NRR. Individual informed consent was not necessary since consent was waived as there was a public notice up on the walls of healthcare centres asking permission for the registry to collect data and patients have option to opt out. We also would like to confirm that authors did not have any special access privileges that others would not have.

Cost utility analysis of end stage renal disease treatment in Ministry of Health dialysis centres, Malaysia: Hemodialysis versus continuous ambulatory peritoneal dialysis

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Abstract

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Methods

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Conclusions

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Most cited references 35

Chronic kidney disease as a global public health problem: approaches and initiatives - a position statement from Kidney Disease Improving Global Outcomes.

Propensity-matched mortality comparison of incident hemodialysis and peritoneal dialysis patients.

Peritoneal dialysis first: rationale.

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