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Vanorio-Vega I, Constantinou P, Bret V, Gentile S, Finne P, Sautenet B, Tuppin P, Couchoud C. Effect of comorbidities on healthcare expenditures for patients on kidney replacement therapy considering the treatment modality and duration in a French cohort. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024; 25:269-279. [PMID: 37004630 DOI: 10.1007/s10198-023-01585-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 03/16/2023] [Indexed: 06/19/2023]
Abstract
End-stage kidney disease (ESKD) is associated with a substantial economic burden. In France, the cost of care for such patients represents 2.5% of the total French healthcare expenditures but serves less than 1% of the population. These patients' healthcare expenditures are high because of the specialized and complex treatment needed as well as the presence of multiple comorbidities. This study aims to describe and assess the effect of comorbidities on healthcare expenditures (direct medical cost and non-medical costs including transportation and compensatory allowances) for patients with ESKD in France while considering the modality and duration of renal replacement therapy (RRT). This study included adults who started RRT for the first time between 2012 and 2014 in France and were followed for 5 years. Generalized linear models were built to predict mean monthly cost (MMC) by integrating first the time duration in the cohort, then patient characteristics and finally the duration of use of each treatment modalities. Comorbidities with the highest effect on MMC were inability to walk (+ 1435€), active cancer (+ 593€), HIV positivity (+ 507€) and diabetes (+ 396€). These effects vary according to age or treatment modalities. This study confirms the importance of considering patient characteristics, comorbidities and type of RRT when assessing healthcare expenditures for patients with ESKD.
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Affiliation(s)
- Isabella Vanorio-Vega
- Direction de la Stratégie des Études et des Statistiques, Caisse Nationale de L'assurance Maladie (CNAM), 75986, Paris, France.
- Agence de la Biomédecine, 1 Avenue du Stade de France, 93212, Saint-Denis, France.
| | - Panayotis Constantinou
- Direction de la Stratégie des Études et des Statistiques, Caisse Nationale de L'assurance Maladie (CNAM), 75986, Paris, France
| | - Victor Bret
- Direction de la Stratégie des Études et des Statistiques, Caisse Nationale de L'assurance Maladie (CNAM), 75986, Paris, France
| | - Stéphanie Gentile
- School of Medicine-La Timone Medical Campus, EA 3279: CEReSS-Health Service Research and Quality of Life Center, Aix Marseille University, Marseille, France
| | - Patrik Finne
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Bénédicte Sautenet
- MCU-PH Service Néphrologie-Hypertension Artérielle, Dialyses, Transplantation Rénale INSERM U1246 SPHERE, Nantes, France
| | - Philippe Tuppin
- Direction de la Stratégie des Études et des Statistiques, Caisse Nationale de L'assurance Maladie (CNAM), 75986, Paris, France
| | - Cécile Couchoud
- Agence de la Biomédecine, 1 Avenue du Stade de France, 93212, Saint-Denis, France
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Kazes I, Solignac J, Lassalle M, Mercadal L, Couchoud C. Twenty years of the French Renal Epidemiology and Information Network. Clin Kidney J 2024; 17:sfad240. [PMID: 38186909 PMCID: PMC10768769 DOI: 10.1093/ckj/sfad240] [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: 06/30/2023] [Indexed: 01/09/2024] Open
Abstract
Background The French Renal Epidemiology and Information Network (REIN) is 20 years old. It is not just a national data registry, but rather an epidemiological and informational network serving patients with chronic kidney disease, nephrology teams and health services. Methods The past 10-year trends of the incidence and prevalence of renal replacement therapy by dialysis or kidney transplantation and waitlist activity are presented. To detect potential significant changes in trends from 2012 and 2021, a Joinpoint regression model was used. Results The overall incidence of treated end-stage kidney disease (ESKD) was 169 per million population (pmp) in 2021. It was stable despite an increase in the incidence of diabetes. We found a decreasing trend in the proportion of patients starting dialysis in an emergency but an increase in those starting haemodialysis (HD) with a temporary catheter. Peritoneal dialysis decreased by 1.7% each year, whereas home HD, although involving only 1% of dialysis patients, increased by 10% each year. For patients not treated at home, the median time to drive from the patient's home to the dialysis unit was 17 min. The proportion of patients on the transplantation waitlist at the start of dialysis increased from 7% to 12%. Among the 111 263 new ESKD patients from 2012 to 2021, 8% received a first transplant at 1 year and 20% at 5 years. Among kidney transplant recipients, the mean time on the waitlist increased from 13.8 to 22.6 months. Living donor transplants increased in frequency, representing 15% of kidney transplants. Conclusions Data from the REIN registry allow for the evaluation of needs and provide a planning tool for French authorities. The progressive implementation of automatic data retrieval from dialysis informatics charts might alleviate the burden of data collection. Furthermore, the research activity the REIN engenders, resulting in renewed confidence by health authorities in the dynamism of French nephrology, allows for an optimistic outlook for the REIN.
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Affiliation(s)
- Isabelle Kazes
- Service de Néphrologie, Centre Hospitalo-Universitaire de Reims, Reims, France
| | - Justine Solignac
- Service de Néphrologie, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Mathilde Lassalle
- Registre REIN, Agence de la biomédecine, Saint Denis La Plaine, France
| | - Lucile Mercadal
- Service de Néphrologie, Hôpital de la Pitié Salpêtrière, APHP, Paris, France
| | - Cécile Couchoud
- Registre REIN, Agence de la biomédecine, Saint Denis La Plaine, France
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Abstract
On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of its link with health authorities, the following key messages were retained. One of the purposes of REIN is to contribute to a better understanding about patient management and its evolution, and thus to be called upon to develop health strategies aimed at improving the prevention and treatment of chronic renal failure. Indeed, the planning of the supply and the evaluation of the treatment are important issues for the public health decision-makers who must have the relevant indicators and tools to help them in their decision-making and follow-up processes. REIN is clearly identified as a source of information by institutional partners, as is shown by the various requests made by the Regional health agencies (ARS), the French National Authority for Health (HAS) and the General Directorate for Healthcare Services (DGOS), as well as other health authorities. It allows estimating the needs of the population within the framework of decree nos. 2002-1197 and 2002-1198 of September 2002 relating to the treatment of chronic renal failure by renal dialysis. The recent possibility of probabilistic matching of REIN data with the data from the National Healthcare Data System (SNDS) for a pseudonymised individual allows for more detailed studies on the different care pathways, as well as evaluating the impact of the different actions or experiments that are set up, with the help of detailed clinical information from the REIN and, among other things, the expenses reimbursed by the Health Insurance.
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Affiliation(s)
- Philippe Tuppin
- Caisse nationale d’Assurance maladie, Paris Cedex 20, France
| | - Clémence Béchade
- Coordination régionale REIN Basse-Normandie, Service de néphrologie, centre hospitalo-universitaire de Caen, Caen, France
| | - Cécile Couchoud
- Coordination nationale REIN, Agence de la biomédecine, Saint-Denis-La Plaine, France
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Prezelin-Reydit M, Lobbedez T, Lassalle M. [REIN: a tool for the benefit of renal transplantation]. Nephrol Ther 2023; 18:40-45. [PMID: 37638507 DOI: 10.1016/s1769-7255(22)00566-1] [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] [Indexed: 11/05/2022]
Abstract
On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of access to renal transplantation for ESKD patients, the following key messages were retained. The registry of the REIN includes data about kidney transplant and dialysis. It thus allows evaluating the access to kidney transplant in France based on the needs of the population with stage 5 CKD treated by renal replacement therapy. The data produced by the registry is complementary to the data in the report of the Agence de la biomédecine (Agency of Biomedicine) based on the activity of the transplant centres and the population of registered patients waiting for a transplant. The proportion of preemptive transplant (transplant without prior recourse to dialysis) as well as that of preemptive registration (before starting dialysis) have increased since 2012 but remain low. The proportion of preemptive transplant as the first replacement therapy remains low and stable over time at around 3 to 4%. The access to the waiting list and the transplant varies depending on the age and co-morbidities of the patients (diabetes, obesity) as well as on the region. The rates of registration on the kidney transplant waiting list at the time of initiation of dialysis and at 1 year from the start have been increasing since 2012, irrespective of the patients’ characteristics, though it remains low in elderly, diabetic and severely obese patients. This is partly the result related to the publication of the HAS (French National Authority for Health) recommendations in 2015 and the publications on the disparities in access to transplants established thanks to the REIN registry. The causes of non-registration at the time of initiation of dialysis have changed over time with some patients not registering for contraindication steadily decreasing since 2012. Thanks to several studies conducted using data from the registry, the variations in access to the list could be explained, partly, by the health condition of the dialysis population as well as by the socio-economic context and differences in practices according to dialysis networks. The median waiting time for a kidney transplant has been gradually increasing since 2012, with a delta of about 8 months between 2012 and 2020. However, the waiting time between the initiation of dialysis and the transplant has increased less significantly. The probability of receiving a first kidney transplant depends on the age, diabetic status and obesity of the patient, and has remained stable over time.
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Affiliation(s)
| | - Thierry Lobbedez
- Service de néphrologie, Centre hospitalo-universitaire de Caen, Caen, France
| | - Mathilde Lassalle
- Coordination nationale REIN, Agence de la biomédecine, Saint-Denis-La Plaine, France
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Abstract
On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of trajectory of ESKD patients, the following key messages were retained. Apart from a few rare, absolute or relative contraindications, till date, there is no medical consensus on the indications of one treatment modality as compared to another, and therefore, no recommendations allowing defining criteria for guiding patients, based on their characteristics, to a technique/treatment modality. In addition, the patients’ choices and their changing needs over time must be taken into account. Thus, due to the limitations of each of these modalities, a good number of patients with stage 5 renal failure treated with kidney replacement therapy will move between these different modalities. For many years, the REIN registry has endeavoured to represent the patient flows between the different treatment modalities. In order to better understand and then optimise the trajectories followed by patients who have reached stage 5 of their chronic renal failure, it was necessary to develop tools to model these complex trajectories where the treatment modalities are considered as complementary.
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Affiliation(s)
| | - Olivier Moranne
- Coordination régionale REIN Languedoc-Roussillon, Hôpital universitaire de Nîmes, Carémeau, Nîmes, France
- UMR INSERM-UM, Institut Desbrest d’épidémiologie et santé publique (IDESP), Campus Santé, Montpellier, France
| | - Cécile Couchoud
- Coordination nationale REIN, Agence de la biomédecine, Saint-Denis-La Plaine, France
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Moranne O, Hamroun A, Couchoud C. What does the French REIN registry tell us about Stage 4-5 CKD care in older adults? FRONTIERS IN NEPHROLOGY 2023; 2:1026874. [PMID: 37675001 PMCID: PMC10479600 DOI: 10.3389/fneph.2022.1026874] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/02/2022] [Indexed: 09/08/2023]
Abstract
The aim of this paper is to illustrate all the clinical epidemiology searches made within the French network REIN to improve CKD stage 4-5 care in older adults. We summarize various studies describing clinical practice, care organization, prognosis and health economics evaluation in order to develop personalized care plans and decision-making tools. In France, for 20 years now, various databases have been mobilized including the national REIN registry which includes all patients receiving dialysis or transplantation. REIN data are indirectly linked to the French administrative healthcare database. They are also pooled with data from the PSPA cohort, a multicenter prospective cohort study of patients aged 75 or over with advanced CKD, monitored for 5 years, and the CKD-REIN clinical-based prospective cohort which included 3033 patients with CKD stage 3-4 from 2013 to 2016. During our various research work, we identified heterogeneous trajectories specific to this growing older population, raising ethical, organizational and economic issues. Renal registries will help clinicians, health providers and policy-makers if suitable decision- making tools are developed and validated.
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Affiliation(s)
- Olivier Moranne
- Service Néphrologie-Dialyse-Aphérèse, Hôpital Universitaire de Nîmes, Hôpital Carémeau, Nîmes, France
- UMR Inserm-UM, Institut Desbrest d'Epidemiologie et Santé publique (IDESP), Montpellier, France
| | - Aghilès Hamroun
- Service de Santé Publique, Service de Néphrologie-Dialyse-Transplantation rénale-Aphérèse, Hôpital Universitaire de Lille, Hôpital Huriez, Lille, France
| | - Cécile Couchoud
- French REIN registry, Agence de la biomédecine, La Plaine Saint-Denis, France
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Adoli L, Raffray M, Châtelet V, Vigneau C, Lobbedez T, Gao F, Bayer F, Campéon A, Vabret E, Laude L, Jais JP, Daugas E, Couchoud C, Bayat S. Women's Access to Kidney Transplantation in France: A Mixed Methods Research Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13524. [PMID: 36294104 PMCID: PMC9603645 DOI: 10.3390/ijerph192013524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
Kidney transplantation is the best renal replacement therapy (medically and economically) for eligible patients with end-stage kidney disease. Studies in some French regions and in other countries suggest a lower access to the kidney transplant waiting listing and also to kidney transplantation, once waitlisted, for women. Using a mixed methods approach, this study aims to precisely understand these potential sex disparities and their causes. The quantitative study will explore the geographic disparities, compare the determinants of access to the waiting list and to kidney transplantation, and compare the reasons and duration of inactive status on the waiting list in women and men at different scales (national, regional, departmental, and census-block). The qualitative study will allow describing and comparing women's and men's views about their disease and transplantation, as well as nephrologists' practices relative to the French national guidelines on waiting list registration. This type of study is important in the current societal context in which the reduction of sex/gender-based inequalities is a major social expectation.
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Affiliation(s)
- Latame Adoli
- Université de Rennes, EHESP, CNRS, INSERM, Arènes–UMR 6051, RSMS–U1309, 35000 Rennes, France
| | - Maxime Raffray
- Université de Rennes, EHESP, CNRS, INSERM, Arènes–UMR 6051, RSMS–U1309, 35000 Rennes, France
| | - Valérie Châtelet
- U1086 INSERM, Anticipe, Centre de Lutte Contre le Cancer François Baclesse, Centre Universitaire des Maladies Rénales, 14000 Caen, France
| | - Cécile Vigneau
- IRSET (Institut de Recherche en Santé, Environnement et Travail), Université de Rennes, Chu Rennes, INSERM, EHESP, UMR_s 1085, 35000 Rennes, France
| | - Thierry Lobbedez
- U1086 INSERM, Anticipe, Centre de Lutte Contre le Cancer François Baclesse, Centre Universitaire des Maladies Rénales, 14000 Caen, France
| | - Fei Gao
- Université de Rennes, EHESP, CNRS, INSERM, Arènes–UMR 6051, RSMS–U1309, 35000 Rennes, France
| | - Florian Bayer
- Renal Epidemiology and Information Network (Rein) Registry, Biomedecine Agency, Saint-Denis-la-Plaine, 93212 Paris, France
| | - Arnaud Campéon
- Arènes–UMR 6051, ISSAV, EHESP, CNRS, 35000 Rennes, France
| | - Elsa Vabret
- Service de Néphrologie, Chu Rennes, 35000 Rennes, France
| | - Laëtitia Laude
- Université de Rennes, EHESP, CNRS, INSERM, Arènes–UMR 6051, RSMS–U1309, 35000 Rennes, France
| | - Jean-Philippe Jais
- Unité de Biostatistique, Hôpital Necker-Enfants Malades, AP-HP, Institut Imagine, Université Paris-Cité, 75015 Paris, France
| | - Eric Daugas
- INSERM U1149, Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Service de Néphrologie, Hôpital Bichat, 75018 Paris, France
| | - Cécile Couchoud
- Renal Epidemiology and Information Network (Rein) Registry, Biomedecine Agency, Saint-Denis-la-Plaine, 93212 Paris, France
| | - Sahar Bayat
- Université de Rennes, EHESP, CNRS, INSERM, Arènes–UMR 6051, RSMS–U1309, 35000 Rennes, France
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Descriptions des hospitalisations au cours de l’année 2019 des patients dialysés en France. Nephrol Ther 2022; 18:534-540. [DOI: 10.1016/j.nephro.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 11/21/2022]
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Canaud B, Kooman JP, Selby NM, Taal M, Maierhofer A, Kopperschmidt P, Francis S, Collins A, Kotanko P. Hidden risks associated with conventional short intermittent hemodialysis: A call for action to mitigate cardiovascular risk and morbidity. World J Nephrol 2022; 11:39-57. [PMID: 35433339 PMCID: PMC8968472 DOI: 10.5527/wjn.v11.i2.39] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 10/30/2021] [Accepted: 03/23/2022] [Indexed: 02/06/2023] Open
Abstract
The development of maintenance hemodialysis (HD) for end stage kidney disease patients is a success story that continues to save many lives. Nevertheless, intermittent renal replacement therapy is also a source of recurrent stress for patients. Conventional thrice weekly short HD is an imperfect treatment that only partially corrects uremic abnormalities, increases cardiovascular risk, and exacerbates disease burden. Altering cycles of fluid loading associated with cardiac stretching (interdialytic phase) and then fluid unloading (intradialytic phase) likely contribute to cardiac and vascular damage. This unphysiologic treatment profile combined with cyclic disturbances including osmotic and electrolytic shifts may contribute to morbidity in dialysis patients and augment the health burden of treatment. As such, HD patients are exposed to multiple stressors including cardiocirculatory, inflammatory, biologic, hypoxemic, and nutritional. This cascade of events can be termed the dialysis stress storm and sickness syndrome. Mitigating cardiovascular risk and morbidity associated with conventional intermittent HD appears to be a priority for improving patient experience and reducing disease burden. In this in-depth review, we summarize the hidden effects of intermittent HD therapy, and call for action to improve delivered HD and develop treatment schedules that are better tolerated and associated with fewer adverse effects.
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Affiliation(s)
- Bernard Canaud
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
- Department of Nephrology, Montpellier University, Montpellier 34000, France
| | - Jeroen P Kooman
- Department of Internal Medicine, Maastricht University, Maastricht 6229 HX, Netherlands
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Maarten Taal
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Andreas Maierhofer
- Global Research Development, Fresenius Medical Care, Schweinfurt 97424, Germany
| | | | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
| | - Peter Kotanko
- Renal Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10065, United States
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Torreggiani M, Fois A, Chatrenet A, Nielsen L, Gendrot L, Longhitano E, Lecointre L, Garcia C, Breuer C, Mazé B, Hami A, Seret G, Saulniers P, Ronco P, Lavainne F, Piccoli GB. Incremental and Personalized Hemodialysis Start: A New Standard of Care. Kidney Int Rep 2022; 7:1049-1061. [PMID: 35571001 PMCID: PMC9091804 DOI: 10.1016/j.ekir.2022.02.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/07/2022] [Indexed: 12/21/2022] Open
Abstract
Introduction Incremental hemodialysis (iHD) may attenuate “dialysis shock” and reduce costs, preserving quality of life. It is considered difficult to reconcile with HD wards’ routine; fear of underdialysis and increasing mortality are additional concerns. The aim of this study was to evaluate mortality, morbidity, and costs in a large HD ward where iHD is the standard of HD start. Methods This observational study included all incident HD patients in 2017 to 2021, stratified according to HD start: iHD (1–2 sessions/wk), decremental HD (dHD, 3 sessions/wk at start, later reduced), or standard (3 sessions/wk). Results were compared with data recorded in the same unit before the incremental program (2015–2017) and with a propensity score-matched cohort from the French Renal Epidemiology and Information Network (REIN) registry. Results A total of 158 patients started HD in 2017 to 2021, 57.6% on iHD, 8.9% dHD, and 33.5% standard HD schedule. Patients on the standard schedule had lower initial estimated glomerular filtration rate (eGFR) (5 vs. 7 ml/min per 1.72 m2, P = 0.003). We found no survival differences according to period of start (same center) and propensity score matching (REIN). Patients intensively followed in the pre-HD period were more likely to start on iHD-dHD. Persistence on iHD-dHD was about 50% at 1 year and 35% at 2 years. Hospitalization rates and time to first hospitalization or death did not differ between the schedules. The iHD-dHD policy allowed a 16% cost saving, even accounting for supplemental biochemical tests. Conclusion Our study reveals that iHD can be a new standard of care, as it is safe and feasible in up to two-thirds of patients on incident HD.
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Fu EL, Evans M, Carrero JJ, Putter H, Clase CM, Caskey FJ, Szymczak M, Torino C, Chesnaye NC, Jager KJ, Wanner C, Dekker FW, van Diepen M. Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease: nationwide cohort study. BMJ 2021; 375:e066306. [PMID: 34844936 PMCID: PMC8628190 DOI: 10.1136/bmj-2021-066306] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To identify the optimal estimated glomerular filtration rate (eGFR) at which to initiate dialysis in people with advanced chronic kidney disease. DESIGN Nationwide observational cohort study. SETTING National Swedish Renal Registry of patients referred to nephrologists. PARTICIPANTS Patients had a baseline eGFR between 10 and 20 mL/min/1.73 m2 and were included between 1 January 2007 and 31 December 2016, with follow-up until 1 June 2017. MAIN OUTCOME MEASURES The strict design criteria of a clinical trial were mimicked by using the cloning, censoring, and weighting method to eliminate immortal time bias, lead time bias, and survivor bias. A dynamic marginal structural model was used to estimate adjusted hazard ratios and absolute risks for five year all cause mortality and major adverse cardiovascular events (composite of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) for 15 dialysis initiation strategies with eGFR values between 4 and 19 mL/min/1.73 m2 in increments of 1 mL/min/1.73 m2. An eGFR between 6 and 7 mL/min/1.73 m2 (eGFR6-7) was taken as the reference. RESULTS Among 10 290 incident patients with advanced chronic kidney disease (median age 73 years; 3739 (36%) women; median eGFR 16.8 mL/min/1.73 m2), 3822 started dialysis, 4160 died, and 2446 had a major adverse cardiovascular event. A parabolic relation was observed for mortality, with the lowest risk for eGFR15-16. Compared with dialysis initiation at eGFR6-7, initiation at eGFR15-16 was associated with a 5.1% (95% confidence interval 2.5% to 6.9%) lower absolute five year mortality risk and 2.9% (0.2% to 5.5%) lower risk of a major adverse cardiovascular event, corresponding to hazard ratios of 0.89 (95% confidence interval 0.87 to 0.92) and 0.94 (0.91 to 0.98), respectively. This 5.1% absolute risk difference corresponded to a mean postponement of death of 1.6 months over five years of follow-up. However, dialysis would need to be started four years earlier. When emulating the intended strategies of the Initiating Dialysis Early and Late (IDEAL) trial (eGFR10-14 v eGFR5-7) and the achieved eGFRs in IDEAL (eGFR7-10 v eGFR5-7), hazard ratios for all cause mortality were 0.96 (0.94 to 0.99) and 0.97 (0.94 to 1.00), respectively, which are congruent with the findings of the randomised IDEAL trial. CONCLUSIONS Very early initiation of dialysis was associated with a modest reduction in mortality and cardiovascular events. For most patients, such a reduction may not outweigh the burden of a substantially longer period spent on dialysis.
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Affiliation(s)
- Edouard L Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Marie Evans
- Department of Clinical Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Fergus J Caskey
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Claudia Torino
- IFC-CNR, Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Nicholas C Chesnaye
- ERA-EDTA Registry, Department of Medical Informatics, Academic University Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic University Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
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12
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Liao K, Lin KC, Chiou SJ. Self-efficacy remains a vital factor in reducing the risk of dialysis in type 2 diabetes care. Medicine (Baltimore) 2021; 100:e26644. [PMID: 34260563 PMCID: PMC8284740 DOI: 10.1097/md.0000000000026644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/25/2021] [Indexed: 01/04/2023] Open
Abstract
Studies have provided promising outcomes of the pay-for-performance (P4P) program or with good continuity of care levels in diabetes control.We investigate the different exposures in continuity of care (COC) with their providers and those who participate in the P4P program and its effects on the risk of diabetes diabetic nephropathy in the future.We obtained COC and P4P information from the annual database, to which we applied a hierarchical linear modeling (HLM) in 3 levels adjusted to account for other covariates as well as the effects of hospital clustering and accumulating time.Newly diagnosed type 2 diabetes in 2003At the individual level, those with a higher Diabetes Complications Severity Index (DCSI) score have a higher likelihood of diabetic nephropathy than those with a lower DCSI (OR, 1.46), whereas contrasting results were obtained for the Charlson Comorbidity Index (CCI) (odds ratio[OR], 0.88). Patients who visited family physicians, endocrinologists, and gastroenterologists showed a lower likelihood of diabetic nephropathy (OR, 0.664, 0.683, and 0.641, respectively), whereas those who continued to visit neurologists showed an increased risk of diabetic nephropathy by 4 folds. At the hospital level, patients with diabetes visiting primary care clinics had a lower risk of diabetic nephropathy with an OR of 0.584 than those visiting hospitals of other higher levels. Regarding the repeat time level, the patients who had a higher COC score and participated in the P4P program had a reduced diabetic nephropathy risk with an OR of 0.339 and 0.775, respectively.Diabetes control necessitates long-term care involving the patients' healthcare providers for the management of their conditions to reduce the risk of diabetic nephropathy. Indeed, most contributing factors are related to patients, but we cannot eliminate the optimal outcomes related to good relationships with healthcare providers and participation in the P4P program.
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Affiliation(s)
- Kuomeng Liao
- Department of endocrinology and metabolism, Zhongxiao Branch, Taipei City Hospital, Taipei, Taiwan
| | - Kuan-Chia Lin
- Preventive Medicine Center, National Yang Ming University, Taipei, Taiwan, R.O.C
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan, R.O.C
| | - Shang-Jyh Chiou
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, R.O.C
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13
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Vanorio-Vega I, Constantinou P, Tuppin P, Couchoud C. Additional cost of end-stage kidney disease in diabetic patients according to renal replacement therapy modality: a systematic review. RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00346-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractThe prevalence of end-stage kidney disease (ESKD) is growing worldwide; the survival of these patients requires renal replacement therapy (RRT, a complex and costly treatment). Over 20% of the patients that start RTT had diabetes. Limited evidence on the effect of comorbidities on the cost of RRT exists. This review summarizes the available evidence on the effect of diabetes mellitus (DM) on the cost of RRT. Electronic databases were searched using key words that combined RRT with DM and cost. References were identified with title, abstract, and full-text screening. The studies included were published in English and presented data on the cost of RRT in ESKD patients with comparison between DM status. Seventeen studies were included in this review. The crude and adjusted cost of care estimates for patients on dialysis was generally higher for DM patients. The cost of care of ESKD patients differed according to various treatment modalities and these differences, mainly driven by inpatient costs. Overall, we found an increased cost of RRT care in patients with DM regardless of the type of treatment. Future analysis of the effects of multiple comorbidities should be considered to better understand the effect of DM on the cost of RRT.
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14
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van Oosten MJM, Logtenberg SJJ, Leegte MJH, Bilo HJG, Mohnen SM, Hakkaart-van Roijen L, Hemmelder MH, de Wit GA, Jager KJ, Stel VS. Age-related difference in health care use and costs of patients with chronic kidney disease and matched controls: analysis of Dutch health care claims data. Nephrol Dial Transplant 2021; 35:2138-2146. [PMID: 31598728 PMCID: PMC7716809 DOI: 10.1093/ndt/gfz146] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 06/19/2019] [Indexed: 12/31/2022] Open
Abstract
Background The financial burden of chronic kidney disease (CKD) is increasing due to the ageing population and increased prevalence of comorbid diseases. Our aim was to evaluate age-related differences in health care use and costs in Stage G4/G5 CKD without renal replacement therapy (RRT), dialysis and kidney transplant patients and compare them to the general population. Methods Using Dutch health care claims, we identified CKD patients and divided them into three groups: CKD Stage G4/G5 without RRT, dialysis and kidney transplantation. We matched them with two controls per patient. Total health care costs and hospital costs unrelated to CKD treatment are presented in four age categories (19–44, 45–64, 65–74 and ≥75 years). Results Overall, health care costs of CKD patients ≥75 years of age were lower than costs of patients 65–74 years of age. In dialysis patients, costs were highest in patients 45–64 years of age. Since costs of controls increased gradually with age, the cost ratio of patients versus controls was highest in young patients (19–44 years). CKD patients were in greater need of additional specialist care than the general population, which was already evident in young patients. Conclusion Already at a young age and in the earlier stages of CKD, patients are in need of additional care with corresponding health care costs far exceeding those of the general population. In contrast to the general population, the oldest patients (≥75 years) of all CKD patient groups have lower costs than patients 65–74 years of age, which is largely explained by lower hospital and medication costs.
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Affiliation(s)
- Manon J M van Oosten
- Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | | | | | - Henk J G Bilo
- Diabetes Research Center, Isala Hospital, Zwolle, The Netherlands.,Department of Internal Medicine, University Medical Center, Groningen, The Netherlands.,Faculty of Medicine, Groningen University, Groningen, The Netherlands
| | - Sigrid M Mohnen
- Centre for Nutrition, Prevention and Health Services, National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | - Leona Hakkaart-van Roijen
- Erasmus School of Health Policy & Management, Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Marc H Hemmelder
- Dutch Renal Registry, Nefrovisie, Utrecht, The Netherlands.,Department of Internal Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - G Ardine de Wit
- Centre for Nutrition, Prevention and Health Services, National Institute of Public Health and the Environment, Bilthoven, The Netherlands.,Juliuscentre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Kitty J Jager
- Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Vianda S Stel
- Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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15
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Pöhlmann J, Norrbacka K, Boye KS, Valentine WJ, Sapin H. Costs and where to find them: identifying unit costs for health economic evaluations of diabetes in France, Germany and Italy. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:1179-1196. [PMID: 33025257 PMCID: PMC7561572 DOI: 10.1007/s10198-020-01229-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 08/26/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Health economic evaluations require cost data as key inputs. Many countries do not have standardized reference costs so costs used often vary between studies, thereby reducing transparency and transferability. The present review provided a comprehensive overview of cost sources and suggested unit costs for France, Germany and Italy, to support health economic evaluations in these countries, particularly in the field of diabetes. METHODS A literature review was conducted across multiple databases to identify published unit costs and cost data sources for resource items commonly used in health economic evaluations of antidiabetic therapies. The quality of unit cost reporting was assessed with regard to comprehensiveness of cost reporting and referencing as well as accessibility of cost sources from published cost-effectiveness analyses (CEA) of antidiabetic medications. RESULTS An overview of cost sources, including tariff and fee schedules as well as published estimates, was developed for France, Germany and Italy, covering primary and specialist outpatient care, emergency care, hospital treatment, pharmacy costs and lost productivity. Based on these sources, unit cost datasets were suggested for each country. The assessment of unit cost reporting showed that only 60% and 40% of CEAs reported unit costs and referenced them for all pharmacy items, respectively. Less than 20% of CEAs obtained all pharmacy costs from publicly available sources. CONCLUSIONS This review provides a comprehensive account of available costs and cost sources in France, Germany and Italy to support health economists and increase transparency in health economic evaluations in diabetes.
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Affiliation(s)
- J Pöhlmann
- Ossian Health Economics and Communications, Basel, Switzerland
| | | | - K S Boye
- Eli Lilly and Company, Indianapolis, IN, USA
| | - W J Valentine
- Ossian Health Economics and Communications, Basel, Switzerland
| | - H Sapin
- Lilly France, 24 Bd Vital Bouhot, CS 50004, 92521, Neuilly-sur-Seine Cedex, France.
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16
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Canaud B, Kooman JP, Selby NM, Taal MW, Francis S, Maierhofer A, Kopperschmidt P, Collins A, Kotanko P. Dialysis-Induced Cardiovascular and Multiorgan Morbidity. Kidney Int Rep 2020; 5:1856-1869. [PMID: 33163709 PMCID: PMC7609914 DOI: 10.1016/j.ekir.2020.08.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
Hemodialysis has saved many lives, albeit with significant residual mortality. Although poor outcomes may reflect advanced age and comorbid conditions, hemodialysis per se may harm patients, contributing to morbidity and perhaps mortality. Systemic circulatory "stress" resulting from hemodialysis treatment schedule may act as a disease modifier, resulting in a multiorgan injury superimposed on preexistent comorbidities. New functional intradialytic imaging (i.e., echocardiography, cardiac magnetic resonance imaging [MRI]) and kinetic of specific cardiac biomarkers (i.e., Troponin I) have clearly documented this additional source of end-organ damage. In this context, several factors resulting from patient-hemodialysis interaction and/or patient management have been identified. Intradialytic hypovolemia, hypotensive episodes, hypoxemia, solutes, and electrolyte fluxes as well as cardiac arrhythmias are among the contributing factors to systemic circulatory stress that are induced by hemodialysis. Additionally, these factors contribute to patients' symptom burden, impair cognitive function, and finally have a negative impact on patients' perception and quality of life. In this review, we summarize the adverse systemic effects of current intermittent hemodialysis therapy, their pathophysiologic consequences, review the evidence for interventions that are cardioprotective, and explore new approaches that may further reduce the systemic burden of hemodialysis. These include improved biocompatible materials, smart dialysis machines that automatically may control the fluxes of solutes and electrolytes, volume and hemodynamic control, health trackers, and potentially disruptive technologies facilitating a more personalized medicine approach.
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Affiliation(s)
- Bernard Canaud
- Montpellier University, Montpellier, France
- GMO, FMC, Bad Homburg, Germany
| | - Jeroen P. Kooman
- Maastricht University Medical Centre, Department of Internal Medicine, Maastricht, Netherlands
| | - Nicholas M. Selby
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, UK
| | - Maarten W. Taal
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, UK
| | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, UK
| | | | | | | | - Peter Kotanko
- Renal Research Institute, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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17
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van Oosten MJM, Logtenberg SJJ, Edens MA, Hemmelder MH, Jager KJ, Bilo HJG, Stel VS. Health claims databases used for kidney research around the world. Clin Kidney J 2020; 14:84-97. [PMID: 33564408 PMCID: PMC7857833 DOI: 10.1093/ckj/sfaa076] [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] [Received: 02/11/2020] [Accepted: 04/07/2020] [Indexed: 12/16/2022] Open
Abstract
Health claims databases offer opportunities for studies on large populations of patients with kidney disease and health outcomes in a non-experimental setting. Among others, their unique features enable studies on healthcare costs or on longitudinal, epidemiological data with nationwide coverage. However, health claims databases also have several limitations. Because clinical data and information on renal function are often lacking, the identification of patients with kidney disease depends on the actual presence of diagnosis codes only. Investigating the validity of these data is therefore crucial to assess whether outcomes derived from health claims data are truly meaningful. Also, one should take into account the coverage and content of a health claims database, especially when making international comparisons. In this article, an overview is provided of international health claims databases and their main publications in the area of nephrology. The structure and contents of the Dutch health claims database will be described, as well as an initiative to use the outcomes for research and the development of the Dutch Kidney Atlas. Finally, we will discuss to what extent one might be able to identify patients with kidney disease using health claims databases, as well as their strengths and limitations.
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Affiliation(s)
- Manon J M van Oosten
- Department of Medical Informatics, Amsterdam UMC, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Mireille A Edens
- Diabetes Research Center and Department of Epidemiology and Statistics, Isala Hospital, Zwolle, The Netherlands
| | - Marc H Hemmelder
- Dutch Renal Registry (Renine), Nefrovisie Foundation, Utrecht, The Netherlands.,Department of Internal Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Kitty J Jager
- Department of Medical Informatics, Amsterdam UMC, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk J G Bilo
- Diabetes Research Center and Department of Epidemiology and Statistics, Isala Hospital, Zwolle, The Netherlands.,Department of Internal Medicine, University Medical Center, Groningen, The Netherlands.,Faculty of Medicine, Groningen University, Groningen, The Netherlands
| | - Vianda S Stel
- Department of Medical Informatics, Amsterdam UMC, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
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18
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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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19
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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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20
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Scheurlen KM, Probst P, Kopf S, Nawroth PP, Billeter AT, Müller-Stich BP. Metabolic surgery improves renal injury independent of weight loss: a meta-analysis. Surg Obes Relat Dis 2019; 15:1006-1020. [DOI: 10.1016/j.soard.2019.03.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/10/2019] [Accepted: 03/03/2019] [Indexed: 02/05/2023]
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21
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Fabbian F, Verzola A, Napoli N, De Giorgi A, Comai G, La Manna G, Gallerani M, Manfredini R, Rodríguez-Borrego MA, López-Soto PJ. Impact of hospital admissions subsequent to renal transplantation on Italian regional resources: a retrospective study in the Italian region of Emilia-Romagna. MINERVA UROL NEFROL 2019; 71:612-618. [PMID: 30654602 DOI: 10.23736/s0393-2249.19.03280-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Aim of this retrospective study was to investigate costs and resource consuming, expressed by diagnosis related groups (DRG), related only to hospitalizations of renal transplant recipients (RTRs) for all causes in the Region Emilia Romagna (RER) in Italy. METHODS We included all hospital admissions of RTRs (International Classification of Diseases 9th Revision, Clinical Modification [ICD-9-CM] code V420) between 2001 and 2015. We calculated number of admissions, RTRs and inhabitants of RER for each year, mean age, length of stay (LOS) in the hospital as total number of days, mean and median days, mean value of DRG and costs of admissions during the 15-year period of the study. RESULTS RTRs admitted in the 15 years study period were 9,197 and mean age 56.6±1.6 years. Admissions were 14,558, and mean rate of admitted RTRs (*100,000) was 14.21. Total, mean and median LOS were 122,966, 8.7 and 6 days, respectively. Total costs of admissions during the study period were €72,717,232 with mean DRG values of €3,409. Number of admissions and total number of days required for RTRs as well as mean age of admitted patients increased from 2001 to 2015, however mean and median LOS remained stable. CONCLUSIONS Costs due to admissions of RTRs appeared to gradually increase in the long term probably due to the increasing number of admissions and increasing mean age of admitted RTRs.
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Affiliation(s)
- Fabio Fabbian
- Clinica Medica Unit, Department of Medical Sciences, Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Ferrara, Italy -
| | - Adriano Verzola
- Management Planning and Control Service, Sant'Anna University Hospital, Ferrara, Italy
| | - Nicola Napoli
- Management Planning and Control Service, Sant'Anna University Hospital, Ferrara, Italy
| | - Alfredo De Giorgi
- Department of Internal Medicine, Sant'Anna University Hospital, Ferrara, Italy
| | - Giorgia Comai
- Unit of Nephrology, Dialysis and Renal Transplant, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Unit of Nephrology, Dialysis and Renal Transplant, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Massimo Gallerani
- Department of Internal Medicine, Sant'Anna University Hospital, Ferrara, Italy
| | - Roberto Manfredini
- Clinica Medica Unit, Department of Medical Sciences, Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Ferrara, Italy
| | - María A Rodríguez-Borrego
- Department of Nursing, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Cordoba, Spain
| | - Pablo J López-Soto
- Department of Nursing, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Cordoba, Spain
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22
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Beaudry A, Ferguson TW, Rigatto C, Tangri N, Dumanski S, Komenda P. Cost of Dialysis Therapy by Modality in Manitoba. Clin J Am Soc Nephrol 2018; 13:1197-1203. [PMID: 30021819 PMCID: PMC6086697 DOI: 10.2215/cjn.10180917] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 05/14/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The prevalence of ESKD is increasing worldwide. Treating ESKD is disproportionately costly in comparison with its prevalence, mostly due to the direct cost of dialysis therapy. Here, we aim to provide a contemporary cost description of dialysis modalities, including facility-based hemodialysis, peritoneal dialysis, and home hemodialysis, provided with conventional dialysis machines and the NxStage System One. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We constructed a cost-minimization model from the perspective of the Canadian single-payer health care system including all costs related to dialysis care. The labor component of costs consisted of a breakdown of activity-based per patient direct labor requirements. Other costs were taken from statements of operations for the kidney program at Seven Oaks General Hospital (Winnipeg, Canada). All costs are reported in Canadian dollars. RESULTS Annual maintenance expenses were estimated as $64,214 for in-center facility hemodialysis, $43,816 for home hemodialysis with the NxStage System One, $39,236 for home hemodialysis with conventional dialysis machines, and $38,658 for peritoneal dialysis. Training costs for in-center facility hemodialysis, home hemodialysis with the NxStage System One, home hemodialysis with conventional dialysis machines, and peritoneal dialysis are estimated as $0, $16,143, $24,379, and $7157, respectively. The threshold point to achieve cost neutrality was determined to be 9.7 months from in-center hemodialysis to home hemodialysis with the NxStage System One, 12.6 months from in-center hemodialysis to home hemodialysis with conventional dialysis machines, and 3.2 months from in-center hemodialysis to peritoneal dialysis. CONCLUSIONS Home modalities have lower maintenance costs, and beyond a short time horizon, they are most cost efficient when considering their incremental training expenses. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_07_18_CJASNPodcast_18_8_F.mp3.
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Affiliation(s)
- Alain Beaudry
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada; and
| | - Thomas W. Ferguson
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada; and
| | - Claudio Rigatto
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada; and
| | - Navdeep Tangri
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada; and
| | - Sandi Dumanski
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Paul Komenda
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada; and
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23
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Balkau B, Metzger M, Andreelli F, Frimat L, Speyer E, Combe C, Laville M, Jacquelinet C, Briançon S, Ayav C, Massy Z, Pisoni RL, Stengel B, Fouque D. Impact of sex and glucose-lowering treatments on hypoglycaemic symptoms in people with type 2 diabetes and chronic kidney disease. The French Chronic Kidney Disease - Renal Epidemiology and Information Network (CKD-REIN) Study. DIABETES & METABOLISM 2018; 45:175-183. [PMID: 29706470 DOI: 10.1016/j.diabet.2018.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 02/27/2018] [Accepted: 03/27/2018] [Indexed: 12/15/2022]
Abstract
AIM To describe current practices of glucose-lowering treatments in people with diabetes and chronic kidney disease (CKD), the associated glucose control and hypoglycaemic symptoms, with an emphasis on sex differences. METHODS Among the 3033 patients with CKD stages 3-5 recruited into the French CKD-REIN study, 645 men and 288 women had type 2 diabetes and were treated by glucose-lowering drugs. RESULTS Overall, 31% were treated only with insulin, 28% with combinations of insulin and another drug, 42% with non-insulin glucose-lowering drugs. In CKD stage 3, 40% of patients used metformin, 12% at stages 4&5, similar for men and women; in CKD stage 3, 53% used insulin, similar for men and women, but at stages 4&5, 59% of men and 77% of women used insulin. Patients were reasonably well controlled, with a median HbA1c of 7.1% (54mmol/mol) in men, 7.4% (57mmol/mol) in women (P=0.0003). Hypoglycaemic symptoms were reported by 40% of men and 59% of women; they were not associated with the estimated glomerular filtration rate, nor with albuminuria or with HbA1c in multivariable analyses, but they were more frequent in people treated with insulin, particularly with fast-acting and pre-mixed insulins. CONCLUSION Glucose-lowering treatment, HbA1c and hypoglycaemic symptoms were sex dependent. Metformin use was similar in men and women, but unexpectedly low in CKD stage 3; its use could be encouraged rather than resorting to insulin. Hypoglycaemic symptoms were frequent and need to be more closely monitored, with appropriate patient-education, especially in women.
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Affiliation(s)
- B Balkau
- CESP Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, UMRS 1018, Villejuif, France
| | - M Metzger
- CESP Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, UMRS 1018, Villejuif, France
| | - F Andreelli
- Diabetology, CHU Pitié-Salpétrière, APHP, Paris, France
| | - L Frimat
- Lorraine Univ, Paris-Descartes Univ, Apemac, EA 4360, Nancy, France; Nephrology Department, CHU de Nancy, Vandoeuvre-lès-Nancy, France
| | - E Speyer
- CESP Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, UMRS 1018, Villejuif, France
| | - C Combe
- Service de Néphrologie Transplantation Dialyse Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Inserm, U1026, Univ Bordeaux Segalen, Bordeaux, France
| | - M Laville
- Department of Nephrology, Centre Hospitalier Lyon Sud, Univ Lyon, UCBL, Carmen, Pierre-Bénite, France
| | - C Jacquelinet
- CESP Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, UMRS 1018, Villejuif, France; Agence de la Biomédecine, Saint-Denis, France
| | - S Briançon
- Inserm CIC-1433, CHRU Nancy, Clinical Epidemiology, Vandoeuvre-lès-Nancy, France
| | - C Ayav
- Inserm CIC-1433, CHRU Nancy, Clinical Epidemiology, Vandoeuvre-lès-Nancy, France
| | - Z Massy
- CESP Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, UMRS 1018, Villejuif, France; Nephrology Department, CHU Ambroise Paré, Boulogne, France
| | - R L Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, MI, United States
| | - B Stengel
- CESP Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, UMRS 1018, Villejuif, France.
| | - D Fouque
- Department of Nephrology, Centre Hospitalier Lyon Sud, Univ Lyon, UCBL, Carmen, Pierre-Bénite, France
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