Although several studies have shown that simulated annual direct health care costs are substantially lower for patients undergoing more frequent hemodialysis (HD), there is limited information about the economics of daily HD and nocturnal HD.
The London Daily/Nocturnal Hemodialysis Study compared the economics of short daily HD (n = 10), long nocturnal HD (n = 12), and conventional thrice-weekly HD (n = 22) in patients over 18 months. A retrospective analysis of patients' conventional HD costs during the 12 months before study entry was conducted to measure the change in cost after switching to quotidian HD.
As the data show, annual costs (in Canadian dollars) for daily HD are substantially lower than for both nocturnal HD and conventional HD: approximately 67,300 Can dollars, 74,400 Can dollars, and 72,700 Can dollars per patient, respectively. Moreover, marginal changes in operating cost per patient year were - 9,800 Can dollars, -17,400 Can dollars, and +3,100 Can dollars for the daily HD, nocturnal HD, and conventional HD groups. Because of the increase in number of treatments, treatment supply costs per patient for the daily HD and nocturnal HD study groups were approximately twice those for conventional HD patients. However, average costs for consults, hospitalization days, emergency room visits, and laboratory tests for quotidian HD patients tended to decline after study entry. The major cost saving in home quotidian HD derived from the reduction in direct nursing time, excluding patient training. Total annualized cost per quality-adjusted life-year for the daily HD and nocturnal HD groups were 85,442 Can dollars and 120,903 Can dollars, which represented a marginal change of - 15,090 Can dollars and - 21,651 Can dollars, respectively, reflecting both improved quality of life and reduced costs for quotidian HD patients.
Substantial clinical benefits of home quotidian HD, combined with the economic advantage shown by this study, clearly justify its expansion.
To examine possible bias against peritoneal dialysis (PD) by nephrologists less familiar with it.
Secondary analysis of a previously reported survey.
All practicing Canadian nephrologists (n = 290, response rate 66.2%) and a subgroup of American nephrologists who were members of the National Kidney Foundation Council on Dialysis (n = 507, response rate 47.3%). Responses were then subdivided by type of dialysis practice: mainly or only hemodialysis (HD, n = 117), mainly or only PD (n = 16), or both HD and PD (n = 232).
Self-administered mailed questionnaire.
Opinions and attitudes of nephrologists concerning patient characteristics favoring one dialysis modality over the other, as well as the relative utilization of HD and PD currently and in a hypothetical ideal situation.
The main differences were present between physicians practicing mainly HD and physicians practicing mainly PD, with those practicing both giving answers usually intermediate to the others. The maximum weight suitable for PD was 10 kg less according to HD-oriented nephrologists compared with PD-oriented nephrologists (97.8 kg vs 108.5 kg). All nephrologists agreed that, ideally, 40% of prevalent end-stage renal disease patients should be on PD to optimize cost-effectiveness, whereas the proportion should be between 32% and 45% when one optimizes survival, wellness, and quality of life. In general, differences between groups were small.
Most nephrologists favored a proportion of PD higher than the current prevalence seen in either Canada or the U.S.A. If physicians' biases are contributing to the distribution of dialysis modalities, they are not likely to be major factors. Unknown but important factors, external to the physician, may shape modality distribution more than the opinions and attitudes of physicians. If a more balanced and cost-effective dialysis delivery system is desired, more understanding and manipulation of these non physician-related factors will be required.
To determine the opinions and attitudes of Canadian nephrologists about dialysis modality decisions and optimal dialysis system design.
Members of the Canadian Society of Nephrology.
A mailed survey questionnaire.
A 66% response rate was obtained. Decisions about modality are reported to be based most strongly on patient preference (4.4 on a scale from 1 to 5), followed by quality of life (4.06), morbidity (3.97), mortality (3.85), and rehabilitation (3.69), while neither facility (1.78) nor physician (1.62) reimbursement are important. When asked about the current relative utilization of each modality, nephrologists felt that hospital-based hemodialysis (HD) is slightly overutilized (2.53), continuous ambulatory peritoneal dialysis (CAPD) is about right (3.00), while cycler peritoneal dialysis (PD) (3.53), community-based full (3.83) and self-care HD (3.91), and home HD (4.02) are underutilized. A hypothetical question about optimal distribution to maximize survival revealed that a type of HD should constitute 62.8% of the mix, with more emphasis on cycler PD (14.9%), community-based full care HD (13.8%), self-care HD (14.5%), and home HD (9.0%) than is current practice. However, when the goal was to maximize cost effectiveness, HD fell slightly to 57.8%.
These survey results suggest that the current national average 66%/34% HD/PD ratio is reasonable. However, there appears to be a consensus that Canada could evolve to a more cost-effective, community-based dialysis system without compromising patient outcomes.
Shorter travel times and distance to dialysis clinics have been associated with improved patient outcomes and a higher health-related quality of life (HRQOL). The objective of this study was to compare HRQOL between prevalent in-center and satellite dialysis patients, as well as compare travel-related factors that contribute to HRQOL between in-center and satellite-based patients. DESIGN, SETTING, PARTICIPANTS, & MEASURES: The London Health Sciences Centre is a tertiary care center with in-center and regional satellite hemodialysis units. Patients who consented and completed a questionnaire (n = 202) were enrolled into a cross-sectional, cohort observational study. Patients were administered the Medical Outcomes Short-Form 36 (SF-36) and the Kidney Disease Health Related Quality of Life (KDHRQOL) tool and were asked questions relating to travel to dialysis clinics.
Patients who underwent dialysis in the satellites had similar demographics, comorbidities, and laboratory parameters. Patients who underwent dialysis in satellite units reported a significantly superior score on the dialysis stress domain of the KDHRQOL questionnaire. There was no significant difference between in-center and satellite patients on the basis of the SF-36. Satellite patients also reported a significantly decreased cost of transportation, a significantly increased proportion who drive themselves to clinics, and significantly decreased travel time.
Patients who underwent dialysis in satellite units demonstrated similar characteristics, comorbidities, surrogate outcomes, and most aspects of HRQOL. Travel time, cost, and receiving treatment in one's own community are important factors that may contribute to a trend toward higher reported HRQOL by patients in satellite dialysis units.
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Costs for treating patients with end-stage renal disease (ESRD) have grown noticeably. However, most of the cost estimates to date have taken the perspective of the payers. Hence, direct costs of treating ESRD are not accurately known.
Files of all adult patients with ESRD who entered dialysis therapy between January 1, 1991, and December 31, 1996, were studied retrospectively, and all use of health care resources and services was recorded. Follow-up continued until December 31, 1996.
Two hundred fourteen patients fulfilled the study criteria, 138 patients started with in-center hemodialysis (HD) therapy, and 76 patients started with continuous ambulatory peritoneal dialysis (CAPD) therapy. Patients were followed up until death (72 patients) or treatment modality changed for more than 1 month. Fifty-five patients received a cadaveric transplant, and after transplantation (TX), they were examined as a separate group of TX patients. Direct health care costs for the first 6 months in the HD, CAPD, and TX groups were 32,566 US dollars, 25,504 dollars, and 38,265 dollars, and for the next 6 months, 26,272 dollars, 24,218 dollars, and 7,420 dollars, respectively. During subsequent years, annual costs were 54,140 US dollars and 54,490 dollars in the HD group, 45,262 dollars and 49,299 dollars in the CAPD group, and 11,446 dollars and 9,989 dollars in the TX group. Regression analyses showed 4 variables significantly associated with greater daily costs in dialysis patients: age, ischemic heart disease, nonprimary renal disease, and HD treatment.
Compared with HD, CAPD may be associated with lower costs, yet the absolute difference is not striking. After the TX procedure is performed once, annual costs decline remarkably, and cadaveric TX is less costly than both dialysis modalities.
End-stage renal disease (ESRD) requires costly life-sustaining therapy, either dialysis or kidney transplantation. The purpose of this study was to analyse and compare the cost-effectiveness of kidney transplantation and dialysis in Iceland.
Costs and effectiveness were assessed using the clinical records of the Division of Nephrology patient registration and billing systems and at Landspitali University Hospital, information from the Icelandic Health Insurance on payments for kidney transplantation at Rigshospitalet in Copenhagen, and published studies on survival and quality of life among patients with ESRD. All costs are presented at the 2006 price level and discounting was done according to the lowest interest rate of the Icelandic Housing Finance Fund in that year.
The cost associated with live donor kidney transplantation was greater in Denmark than at LUH, ISK 6.758.101 and ISK 5.442.763, respectively. The cost per quality-adjusted life year gained by live donor kidney transplantation was approximately ISK 2.5 million compared to ISK 10.7 million for dialysis.
The cost of live donor kidney transplantation is within the range generally considered acceptable for life-sustaining therapies. The transplant surgery is less expensive in Iceland than in Denmark. Increasing the number of kidney transplants is cost-effective in light of the lower cost per life-year gained by kidney transplantation compared to dialysis.
This study analyzes opportunity costs for the treatment of end-stage renal disease. Kidney transplantation remains the most cost-effective treatment for uremia and is one of the most cost-effective technologies in health care. Improved survival of grafts and increased numbers of transplants have the potential to reduce costs for dialysis programs. To support organ donation activities, the public and concerned health professionals should be informed about the opportunity cost of "unnecessary" dialysis. These resources could be reallocated from dialysis to other programs. Among patients in dialysis, a more common use of chronic ambulatory peritoneal dialysis instead of institution-based hemodialysis would greatly increase cost-utility and further reduce the program costs of renal replacement therapy.