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      Reimbursement and economic factors influencing dialysis modality choice around the world

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          Abstract

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

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          ESRD patients in 2004: global overview of patient numbers, treatment modalities and associated trends.

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            The differential impact of risk factors on mortality in hemodialysis and peritoneal dialysis.

            While the survival ramifications of dialysis modality selection are still debated, it seems reasonable to postulate that outcome comparisons are not the same for all patients at all times. Trends in available data indicate the relative risk of death with hemodialysis (HD) compared to peritoneal dialysis (PD) varies by time on dialysis and the presence of various risk factors. This study was undertaken to identify key patient characteristics for which the risk of death differs by dialysis modality. Analyses utilized incidence data from 398,940 United States Medicare patients initiating dialysis between 1995 and 2000. Proportional hazards regression identified the presence of diabetes, age, and the presence of comorbidity as factors that significantly interact with treatment modality. Stratifying by these factors, proportional and nonproportional hazards models were used to estimate relative risks of death [RR (HD:PD)]. Of the 398,940 patients studied, 11.6% used PD as initial therapy, 45% had diabetes mellitus (DM), 51% were 65 years or older, and 55% had at least one comorbidity. Among the 178,693 (45%) patients with no baseline comorbidity, adjusted mortality rates in nondiabetic (non-DM) patients were significantly higher on HD than on PD [age 18-44: RR (95% CI) = 1.24 (1.07, 1.44); age 45-64: RR = 1.13 (1.02, 1.25); age 65+: RR = 1.13 (1.05, 1.21)]. Among diabetic (DM) patients with no comorbidity, HD was associated with a higher risk of death among younger patients [age 18-44: RR = 1.22(1.05, 1.42)] and a lower risk of death among older patients [age 45-64: RR = 0.92 (0.85, 1.00); age 65+: RR = 0.86 (0.79, 0.93)]. Within the group of 220,247 (55%) patients with baseline comorbidity, adjusted mortality rates were not different between HD and PD among non-DM patients [age 18-44: RR = 1.19 (0.94, 1.50); age 45-64: RR = 1.01 (0.92, 1.11); age 65+: RR = 0.96 (0.91, 1.01)] and younger DM patients [age 18-44: RR = 1.10 (0.92, 1.32)], but were lower with HD among older DM patients with baseline comorbidity [age 45-64: RR = 0.82 (0.77, 0.87); age 65+: RR = 0.80 (0.76, 0.85)]. Valid mortality comparisons between HD and PD require patient stratification according to major risk factors known to interact with treatment modality. Survival differences between HD and PD are not constant, but vary substantially according to the underlying cause of ESRD, age, and level of baseline comorbidity. These results may help identify technical advances that will improve outcomes of patients on dialysis.
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              Maintenance dialysis population dynamics: current trends and long-term implications.

              Despite a general recognition that treatment of end-stage renal disease (ESRD) has become a large-scale undertaking, the size of the treated population and the associated costs are not well quantified. This report combines data available from a variety of sources and places the current (midyear 2001) estimated global maintenance dialysis population at just over 1.1 million patients. The size of this population has been expanding at a rate of 7% per year. Total therapy cost per patient per year in the United States is approximately 66,000 dollars. Assuming that this figure is a reasonable global average, the annual worldwide cost of maintenance ESRD therapy in the year 2001, excluding renal transplantation, will be between 70 and 75 billion US dollars. If current trends in ESRD prevalence continue, as seems probable, the ESRD population will exceed 2 million patients by the year 2010. The care of this group represents a major societal commitment: the aggregate cost of treating ESRD during the coming decade will exceed 1 trillion dollars, a thought-provoking sum by any economic metric.
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                Author and article information

                Journal
                Nephrol Dial Transplant
                ndt
                ndt
                Nephrology Dialysis Transplantation
                Oxford University Press
                0931-0509
                1460-2385
                July 2008
                30 January 2008
                30 January 2008
                : 23
                : 7
                : 2365-2373
                Affiliations
                [1 ]Baxter Healthcare Corporation, 1620 Waukegan Road, MPGR-A2E, McGaw Park, IL 60085, USA
                [2 ]Erasmus University Rotterdam , Postbus 1738, 3000 DR Rotterdam, The Netherlands
                [3 ]ICON Lifecycle Sciences Group, 525 West Monroe, Chicago, IL 60661, USA
                [4 ]Catholic University of Parana , Curitiba, Brazil, 2689 Iguassu Ave, Curitiba 80240 030, Brazil
                Author notes
                Correspondence and offprint requests to: Paul M. Just, Global Health Economics and Reimbursement, Renal Division, Baxter Healthcare Corporation, 1620 Waukegan Road, MPGR-A2E, McGaw Park, IL 60085, USA. Tel: +1-847-473-6127; Fax: +1-847-785-6959; E-mail: paul_just@ 123456baxter.com
                Article
                gfm939
                10.1093/ndt/gfm939
                2441769
                18234844
                9e431ed6-d1f0-4f99-bc50-b76563372c0a
                © The Author [2008].

                The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that: the original authorship is properly and fully attributed; the Journal and Oxford University Press are attributed as the original place of publication with the correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals.permissions@oxfordjournals.org

                History
                : 9 August 2007
                : 18 December 2007
                Categories
                Original Articles

                Nephrology
                peritoneal dialysis,reimbursement,cost,economics,haemodialysis
                Nephrology
                peritoneal dialysis, reimbursement, cost, economics, haemodialysis

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