The organization and financing of dialysis and kidney transplantation services in New Zealand

Australian and New Zealand Living Guideline cholesterol-lowering therapy for people with chronic kidney disease (CARI Guidelines): Reducing the evidence-practice gap

AIM

People with chronic kidney disease experience high rates of cardiovascular disease. Cholesterol-lowering therapy is a mainstay in the management but there is uncertainty in the treatment effects on patient-important outcomes, such as fatigue and rhabdomyolysis. Here, we summarise the updated CARI Australian and New Zealand Living Guidelines on cholesterol-lowering therapy in chronic kidney disease.

METHODS

We updated a Cochrane review and monitored newly published studies weekly to inform guideline development according to international standards. The Working Group included expertise from nephrology, cardiology, Indigenous Health, guideline development and people with lived experience of chronic kidney disease.

RESULTS

The guideline recommends people with chronic kidney disease (eGFR ≥15 mL/min/1.73 m2) and an absolute cardiovascular risk of 10% or higher should receive statin therapy (with or without ezetimibe) to reduce the risk of cardiovascular events and death (strong recommendation, moderate certainty evidence). The guidelines also recommends a lower absolute cardiovascular risk threshold (≥5%) for Aboriginal and Torres Strait Islander Peoples and Māori with chronic kidney disease to receive statin therapy (with or without ezetimibe) (strong recommendation, low certainty evidence). The evidence was actively surveyed from 2020-2023 and updated as required. No changes to guideline recommendations were made, with no new data on the balance and benefits of harms.

CONCLUSIONS

The development of living guidelines was feasible and provided the opportunity to update recommendations to improve clinical decision-making in real-time. Living guidelines provide the opportunity to transform chronic kidney disease guidelines.

Capacity for the management of kidney failure in the International Society of Nephrology Oceania and South East Asia (OSEA) region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA)

The International Society of Nephrology (ISN) region of Oceania and South East Asia (OSEA) is a mix of high- and low-income countries, with diversity in population demographics and densities. Three iterations of the ISN-Global Kidney Health Atlas (GKHA) have been conducted, aiming to deliver in-depth assessments of global kidney care across the spectrum from early detection of CKD to treatment of kidney failure. This paper reports the findings of the latest ISN-GKHA in relation to kidney-care capacity in the OSEA region. Among the 30 countries and territories in OSEA, 19 (63%) participated in the ISN-GKHA, representing over 97% of the region's population. The overall prevalence of treated kidney failure in the OSEA region was 1203 per million population (pmp), 45% higher than the global median of 823 pmp. In contrast, kidney replacement therapy (KRT) in the OSEA region was less available than the global median (chronic hemodialysis, 89% OSEA region vs. 98% globally; peritoneal dialysis, 72% vs. 79%; kidney transplantation, 61% vs. 70%). Only 56% of countries could provide access to dialysis to at least half of people with incident kidney failure, lower than the global median of 74% of countries with available dialysis services. Inequalities in access to KRT were present across the OSEA region, with widespread availability and low out-of-pocket costs in high-income countries and limited availability, often coupled with large out-of-pocket costs, in middle- and low-income countries. Workforce limitations were observed across the OSEA region, especially in lower-middle-income countries. Extensive collaborative work within the OSEA region and globally will help close the noted gaps in kidney-care provision.

Payment systems for dialysis and their effects: a scoping review

BACKGROUND

End stage renal disease (ESRD) is a major health concern and a large drain on healthcare resources. A wide range of payment methods are used for management of ESRD. The main aim of this study is to identify current payment methods for dialysis and their effects.

METHOD

In this scoping review Pubmed, Scopus, and Google Scholar were searched from 2000 until 2021 using appropriate search strategies. Retrieved articles were screened according to predefined inclusion criteria. Data about the study characteristics and study results were extracted by a pre-structured data extraction form; and were analyzed by a thematic analysis approach.

RESULTS

Fifty-nine articles were included, the majority of them were published after 2011 (66%); all of them were from high and upper middle-income countries, especially USA (64% of papers). Fee for services, global budget, capitation (bundled) payments, and pay for performance (P4P) were the main reimbursement methods for dialysis centers; and FFS, salary, and capitation were the main methods to reimburse the nephrologists. Countries have usually used a combination of methods depending on their situations; and their methods have been further developed over time specially from the retrospective payment systems (RPS) towards the prospective payment systems (PPS) and pay for performance methods. The main effects of the RPS were undertreatment of unpaid and inexpensive services, and over treatment of payable services. The main effects of the PPS were cost saving, shifting the service cost outside the bundle, change in quality of care, risk of provider, and modality choice.

CONCLUSION

This study provides useful insights about the current payment systems for dialysis and the effects of each payment system; that might be helpful for improving the quality and efficiency of healthcare.

Cost-Effectiveness of Home Hemodialysis With Bedside Portable Dialysis Machine "DIMI" in the United Arab Emirates

Background and objective

The incidence and prevalence of patients requiring renal replacement therapies (RRTs) are increasing worldwide and a large number of these patients die prematurely due to the unavailability of treatment. While in-center hemodialysis remains the most commonly practiced modality globally, more and more patients find it unsuitable due to their frail condition, difficulty in ambulation, and time lost in traveling, etc. Such patients find the self-administered or nurse-assisted home hemodialysis (NAHHD) more suitable. The costly and recurring nature of these therapies prompted us to evaluate and compare the cost-effectiveness aspect of these two treatment modalities. Thus, the aim of the study was to investigate if home hemodialysis (HHD) with a portable hemodialysis machine was cost-effective in comparison to in-center hemodialysis for patients of end-stage renal failure (ESRF) in the United Arab Emirates (UAE). This is the first study of its kind to be conducted in the UAE.

Methodology

The study topic was developed based on an informal inquiry from the health regulator of Abu Dhabi if HHD was cost-effective compared to in-center hemodialysis with an emphasis on a portable dialysis machine. No such head-to-head study performed in the UAE was available. Hence, a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) design was chosen as the investigative method. An outline of the study was drafted, and a literature search of Science of Web, PubMed, and Cochrane Evidence was performed using the keywords "Home Hemodialysis", "home-based Dialysis", "Cost-effectiveness of Dialysis", "Cost-effectiveness of renal replacement therapy", etc. A review of the article titles was performed to include the articles relevant to the cost of RRTs and the economic burden of ESRF. Full text and abstracts of those articles were retrieved, studied, and, the articles that were found not relevant were excluded. The remaining articles were studied and used in the evidence synthesis. DIMI was chosen to represent a standard type of recently developed portable dialysis machines.

Results

It was interesting to find out during the review that HHD and in-center hemodialysis had been developed simultaneously but the former had eventually fallen out of favor. The review revealed that HHD is not only as effective as in-center hemodialysis but is also associated with better survival benefits over the latter. Several studies have found it to be significantly cost-effective compared to in-center hemodialysis. Newer types of HHD machines make it easier for the patients or their family/caregivers to administer it safely and effectively at home and while traveling. They have regenerated interest in HHD and the Medicare administration in the USA has already decided to make use of it at a more frequent rate.

Conclusion

Based on the evidence in the available literature, HHD is cost-effective when compared to in-center hemodialysis in terms of survival benefits, quality of life (QoL) of patients, and monetary savings. Newer portable bedside dialysis machines provide better safety and have simplified the procedure of hemodialysis, making HHD more acceptable to patients and caregivers. We believe HHD should be the preferred modality of treatment instead of in-center hemodialysis, and that applies to UAE too.

Do remote dialysis services really cost more? An economic analysis of hospital and dialysis modality costs associated with dialysis services in urban, rural and remote settings

Background

Rates of end-stage kidney disease in Australia are highest in the Northern Territory (NT), with the burden of disease heaviest in remote areas. However, the high cost of delivering dialysis services in remote areas has resulted in centralisation, requiring many people to relocate for treatment. Patients argue that treatment closer to home improves health outcomes and reduces downstream healthcare use. Existing dialysis cost studies have not compared total health care costs associated with treatment in different locations.

Objective

To estimate and compare, from a payer perspective, the observed health service costs (all cause hospital admissions, emergency department presentations and maintenance dialysis) associated with different dialysis models in urban, rural and remote locations.

Methods

Using cost weights attributed to diagnostic codes in the NT Department of Health’s hospital admission data set (2008–2014), we calculated the mean (SD) total annual health service costs by dialysis model for 995 dialysis patients. Generalized linear modeling with bootstrapping tested the marginal cost differences between different explanatory variables to estimate ‘best casemix’/‘worst casemix’ cost scenarios.

Results

The mean annual patient hospital expenditure was highest for urban models at $97 928 (SD $21 261) and $43 440 (SD $5 048) and lowest for remote at $19 584 (SD $4 394). When combined with the observed maintenance dialysis costs, expenditure was the highest for urban models at $148 510 (SD $19 774). The incremental cost increase of dialysing in an urban area, compared with a rural area, for a relocated person from a remote area, was $5 648 more and increased further for those from remote and very remote areas to $10 785 and $15 118 respectively.

Conclusions

This study demonstrates that dialysis treatment in urban areas for relocated people has health and cost implications that maybe greater than the cost of remote service delivery. The study emphasises the importance of considering all health service costs and cost consequences of service delivery models.

Key points for decision makers

Relocation for dialysis treatment has serious health and economic consequences. Relocated people have low dialysis attendance and high hospital costs in urban areas. While remote dialysis service models are more expensive than urban models, the comparative cost differences are significantly reduced when all health service costs are included. The delivery of equitable and accessible dialysis service models requires a holistic approach that incorporates the needs of the patient; hence dialysis cost studies must consider the full range of cost impacts beyond the dialysis treatments alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06612-z.

Most people requiring ongoing treatment for end-stage kidney disease in the Northern Territory (NT) identify as Aboriginal with the majority residing in areas classified as remote or very remote. Unlike other jurisdictions in Australia, haemodialysis in a satellite unit is the most common form of treatment. However, there is a geographic mismatch between demand and service provision, with services centralised in urban areas. Patients and communities have long advocated for services at or closer to home, maintaining that the consequences of relocation and dislocation have far reaching health, psychosocial and economic ramifications. We analysed retrospective hospital data for 995 maintenance dialysis patients, stratified by the model of care they received in urban, rural and remote locations. Using cost weights attributed to diagnosis codes, we costed hospital admissions, emergency department presentations and maintenance dialysis attendances, to provide a mean total health service cost/patient/year for each model of care. We found that urban services were associated with low observed maintenance dialysis and high hospital costs, but the inverse was true for remote and very remote models. Remote models had high maintenance dialysis costs (due to expense of remote service delivery and good dialysis attendance) but low hospital usage and costs. When adjusted for other variables such as age, dialysis vintage and comorbidities, lower total hospital costs were associated with rural and remote service provision. In an environment of escalating demand and constrained budgets, this study underlines the need for policy decisions to consider the full cost consequences of different dialysis service models.

Growing home dialysis: The Ontario Renal Network Home Dialysis Initiative 2012-2019

The Ontario Renal Network (ORN), a provincial government agency in Ontario, Canada, launched an initiative in 2012 to increase home dialysis use province-wide. The initiative included a new modality-based funding formula, a standard mandatory informatics system, targets for prevalent home dialysis rates, the development of a 'network' of renal programmes with commitment to home dialysis and a culture of accountability with frequent meetings between ORN and each renal programme leadership to review their results. It also included funding of home dialysis coordinators, encouragement and funding of assisted peritoneal dialysis (PD), and support for catheter insertion and urgent start PD. Between 2012 and 2017, home dialysis use rose from 21.9% to 26.5% and then between 2017 and 2019 stabilised at 26% to 26.5%. Over 7 years, the absolute number of people on home dialysis increased 40% from 2222 to 3105, while the number on facility haemodialysis grew 11% from 7935 to 8767. PD prevalence rose from 16.6% to 20.9%, a relative increase of 25%. The initiative showed that a sustained multifaceted approach can increase home dialysis utilisation.

Burden in primary family caregivers caring for uremic patients on maintenance peritoneal dialysis

BACKGROUND

Managing the burden of care for patients with chronic debilitating diseases is an important issue. Herein, we assessed the burden in primary family members caring for uremic patients on maintenance peritoneal dialysis.

METHODS

One hundred seventy caregivers and 170 patients were recruited. Self-perceived scoring along the Zarit Caregiver Burden Scale (ZCBS), World Health Organization Five-item Well-Being Index (WHO-5), and Warwick-Edinburgh Mental Well-being Scale (WEMWBS) were determined for caregivers.

RESULTS

There was an inverse relationship between ZCBS and WHO-5 or WEMWBS scores in caregivers, suggesting that the higher the burden, the lesser the self-perceived well-being. One hundred two of 170 caregivers (60%) reported mild to moderate burden, indicating a common presence of mild to moderate caring-related mental and physical stress. Moreover, 31 caregivers (18.2%) reported moderate to severe burden. Several patient disease factors, including diabetes and frailty, increased caregiver burden, while insurance coverage and out-of-pocket medical costs were also positively correlated. Caregivers who lived with patients and spent longer hours in caring-related activities had higher burden scores, while regular exercise seemed to partially alleviate the burden.

CONCLUSION

Our study clearly showed that caring for patients with maintenance peritoneal dialysis caused physical, mental, and social burden in family caregivers, with the extent of the stress being influenced by patients' disease severity and other demographic factors in both patients and caregivers.

Cost of dialysis therapies in rural and remote Australia - a micro-costing analysis

BACKGROUND

Maintenance dialysis is a costly and resource intense activity. In Australia, inadequate health infrastructure and poor access to technically skilled staff can limit service provision in remote areas where many Aboriginal dialysis patients live. With most studies based on urban service provision, there is little evidence to guide service development. However permanent relocation to an urban area for treatment can have significant social and financial impacts that are poorly quantified. This study is part of a broader project to quantify the costs and benefits of dialysis service models in urban and remote locations in Australia's Northern Territory (NT).

METHODS

We undertook a micro-costing analysis of dialysis service delivery costs in urban, rural and remote areas in the NT from the payer perspective. Recurrent maintenance costs (salaries, consumables, facility management and transportation) as well as capital costs were included. Missing and centralised costs were standardised; results were inflated to 2017 values and reported in Australian dollars.

RESULTS

There was little difference between the average annual cost for urban and rural services with respective median costs of $85,919 versus $84,629. However remote service costs were higher ($120,172 - $124,492), driven by higher staff costs. The inclusion of capital costs did not add substantially to annual costs. Annual home haemodialysis costs ($42,927) were similar to other jurisdictions despite the significant differences in program delivery and payment of expenses not traditionally borne by governments. Annual peritoneal dialysis costs ($58,489) were both higher than home and in-centre haemodialysis by recent national dialysis cost studies.

CONCLUSION

The cost drivers for staffed services were staffing models and patient attendance rates. Staff salaries and transport costs were significantly higher in remote models of care. Opportunities to reduce expenditure exist by encouraging community supported services and employing local staff. Despite the delivery challenges of home haemodialysis including high patient attrition, the program still provides a cost benefit compared to urban staffed services. The next component of this study will examine patient health service utilisation and costs by model of care to provide a more comprehensive analysis of the overall cost of providing services in each location.

Economic Burden of ESRD to the Malaysian Health Care System

Introduction

Prevalence of chronic kidney disease (CKD) in Malaysia is 9.07% of the total population, of which 0.36% are at stage 5 CKD or end-stage renal disease (ESRD). Public-private partnership has improved accessibility of renal replacement therapies (RRT), especially dialysis, in Malaysia, but the economic burden of the existing RRT financing mechanism, which is predominantly provided by the public sector, has never been quantified.

Methods

Primary data were collected through a standardized survey, and secondary data analysis was used to derive estimates of the ESRD expenditure.

Results

Total annual expenditure of ESRD by the public sector has grown 94% within a span of 7 years, from Malaysian Ringgit [MYR] 572 million (US dollars [USD] 405 million, purchasing power parity [PPP] 2010) in 2010 to MYR 1.12 billion (USD 785 million, PPP 2016) in 2016. The total ESRD expenditure in 2010 constituted 2.95% of the public sector’s total health expenditure, whereas in 2016, the proportion has increased to 4.2%. Only 6% of ESRD expenditure was spent on renal transplantation, and the remaining 94% was spent on dialysis.

Conclusion

The share of ESRD expenditure in total health expenditure for the public sector is considered substantial given only a small proportion of the population is affected by the disease. The rapid increase in expenditure relative to the national total health expenditure should warrant the relevant authorities about sustainability of the existing financing mechanism of ESRD and the importance to institutionalize more drastic preventive measures.

A comprehensive approach to assess the costs of renal replacement therapy for end-stage renal disease in France: the importance of age, diabetes status, and clinical events

OBJECTIVES

In the current pressured economic context, and to continue to treat the growing number of patients with high-quality standards, the first step is to have a better understanding of the costs related to end-stage renal disease (ESRD) treatment according to various renal replacement therapy, age, diabetes status, and clinical events.

METHODS

In order to estimate the direct costs of all adult ESRD patients, according to (RRT) modality, patient condition, and clinical events, data from the French national health insurance funds were used.

RESULTS

The mean monthly costs for the 47,862 stable prevalent patients (73 % of the population) varied substantially according to treatment modality (from 7300€ for in-center hemodialysis to 1100€ for a functioning renal graft) and to clinical event (8300€ for the first month of dialysis, 11,000€ for the last month before death, 22,800€ for the first month after renal transplantation). Mean monthly costs varied according to diabetic status and to age to a lesser extent.

CONCLUSIONS

These results demonstrate, for the first time in France and in Europe, the importance of a dynamic view of renal care and the bias likely when comparing treatments in cross-sectional studies.

To dialyse or delay: a qualitative study of older New Zealanders' perceptions and experiences of decision-making, with stage 5 chronic kidney disease

BACKGROUND

Issues related to renal replacement therapy in elderly people with end stage kidney disease (ESKD) are complex. There is inadequate empirical data related to: decision-making by older populations, treatment experiences, implications of dialysis treatment and treatment modality on quality of life, and how these link to expectations of ageing.

STUDY POPULATION

Participants for this study were selected from a larger quantitative study of dialysis and predialysis patients aged 65 years or older recruited from three nephrology services across New Zealand. All participants had reached chronic kidney disease (CKD) stage 5 and had undergone dialysis education but had not started dialysis or recently started dialysis within the past 6 months.

METHODOLOGY

Serial qualitative interviews were undertaken to explore the decision-making processes and subsequent treatment experiences of patients with ESKD.Analytical approach: A framework method guided the iterative process of analysis. Decision-making codes were generated within NVivo software and then compared with the body of the interviews.

RESULTS

Interviews were undertaken with 17 participants. We observed that decision-making was often a fluid process, rather than occurring at a single point in time, and was heavily influenced by perceptions of oneself as becoming old, social circumstances, life events and health status.

LIMITATIONS

This study focuses on participants' experiences of decision-making about treatment and does not include perspectives of their nephrologists or other members of the nephrology team.

CONCLUSIONS

Older patients often delay dialysis as an act of self-efficacy. They often do not commit to a dialysis decision following predialysis education. Delaying decision-making and initiating dialysis were common. This was not seen by participants as a final decision about therapy. Predialysis care and education should be different for older patients, who will delay decision-making until the time of facing obvious uraemic symptoms, threatening blood tests or paternalistic guidance from their nephrologist.

TRIAL REGISTRATION NUMBER

Australasian Clinical Trials Registry ACTRN 12611000024943; results.

The economic considerations of patients and caregivers in choice of dialysis modality

Introduction Broader adoption of home dialysis could lead to considerable cost savings for health services. Globally, however, uptake remains low. The aim of this study was to describe patient and caregiver perspectives of the economic considerations that influence dialysis modality choice, and elicit policy-relevant recommendations. Methods Semistructured interviews with predialysis or dialysis patients and their caregivers, at three hospitals in New Zealand. Interview transcripts were analyzed thematically. Findings 43 patients and 9 caregivers (total n = 52) participated. The three themes related to economic considerations were: (i) productivity losses associated with changes in employment; (ii) the need for personal subsidization of home dialysis expenses; and (iii) the role of socio-economic disadvantage as a barrier to home dialysis. Patients weighed the flexibility of home dialysis which allowed them to remain employed, against time required for training and out-of-pocket costs. Patients saw the lack of reimbursement of home dialysis costs as unjust and suggested that reimbursement would incentivize home dialysis uptake. Social disadvantage was a barrier to home dialysis as patients' housing was often unsuitable; they could not afford the additional treatment costs. Home hemodialysis was considered to have the highest out-of-pocket costs and was sometimes avoided for this reason. Discussion Our data suggests that economic considerations underpin the choices patients make about dialysis treatments, however these are rarely reported. To promote home dialysis, strategies to improve employment retention and housing, and to minimize out-of-pocket costs, need to be addressed directly by healthcare providers and payers.

A Global Overview of the Impact of Peritoneal Dialysis First or Favored Policies: An Opinion

Given the ever-increasing burden of end-stage renal disease (ESRD) in a global milieu of limited financial and health resources, interested parties continue to search for ways to optimize dialysis access. Government and payer initiatives to increase access to renal replacement therapies (RRTs), particularly peritoneal dialysis (PD) and hemodialysis (HD), may have meaningful impacts from clinical and health-economic perspectives; and despite similar clinical and humanistic outcomes between the two dialysis modalities, PD may be the more convenient and resource-conscious option. This review assessed country-specific PD-First/Favored policies and their associated background, implementation, and outcomes. It was found that barriers to policy-implementation are broadly associated with government policy, economics, provider or healthcare professional education, modality-related factors, and patient-related factors. Notably, the success of a given country's PD-Favored policy was inversely associated with the extent of HD infrastructure. It is hoped that this review will provide a foundation across countries to share lessons learned during the development and implementation of PD-First/Favored policies.

Patient and caregiver preferences for home dialysis-the home first study: a protocol for qualitative interviews and discrete choice experiments

INTRODUCTION

The number of patients requiring dialysis continues to increase worldwide imposing a substantial social and economic burden on patients, their families and healthcare systems. Compared with facility-based dialysis, dialysis performed by the patient at home is associated with higher quality of life, freedom, survival and reduced healthcare costs. International guidelines recommend suitable patients are offered a choice of dialysis modality, including home-based dialysis. Predialysis education and offering patients choice increase home dialysis uptake, yet the factors that patients and families are willing to trade off in making decisions about dialysis location are not well understood. The Home First study will explore patients' and caregivers' beliefs, attitudes and preferences regarding dialysis education and decision-making with regards to dialysis options; to identify key attributes which influence their decision-making, and to quantify the relative value of these attributes.

METHODS AND ANALYSIS

This study will use a mixed-methods approach to describe patient and caregiver preferences and views about the factors that influence their choice of home or facility-based dialysis. Face-to-face, semistructured interviews will be conducted with 30-40 patients and 10-15 caregivers. Thematic analysis of interview transcripts will be conducted. Additional to providing information on the perspectives and experiences of patients and caregivers, these analyses will also inform the design of discrete choice experiments (DCEs). We will undertake DCEs with approximately 150 patients and 150 caregivers to quantify preferences for home and facility dialysis.

ETHICS AND DISSEMINATION

The Hawke's Bay, Counties Manukau, and Capital Coast District Health Board Research Ethics Committees approved the study. Findings will be presented in national/international conferences and peer-reviewed journals. Dissemination to patients will take the form of presentations, newsletters and reports to support and community groups. Reports will be disseminated to funders and participating renal units and to the New Zealand Ministry of Health.

TRIAL REGISTRATION NUMBER

ACTRN12615000314527.

Increasing the uptake of peritoneal dialysis in New Zealand: a national survey

BACKGROUND

Peritoneal dialysis (PD) has been shown to offer a high quality of life and independence to patients. New Zealand (NZ) is a world leader in home dialysis, yet over the last decade, rates of PD have been steadily decreasing for unknown reasons.

OBJECTIVES

This paper reports on the findings of a national survey which explored the clinicians' perspectives on key factors that influence the rate of PD.

DESIGN

Ten multi-answer questions were asked of several groups of dialysis health professionals to assess factors that are barriers and enablers to PD, including patient choice of dialysis modality, information about PD and pre-dialysis education delivery. All NZ nephrologists, pre-dialysis and PD nurses were invited to complete an anonymous online survey. Responses were analysed to identify perceived barriers and enablers influencing the rate of PD uptake amongst incident dialysis patients.

RESULTS

Completed surveys were received from 52% of nephrologists, 100% of pre-dialysis nurses and 50% of PD nurses in NZ. In NZ, patients are offered a choice of dialysis modality with pre-dialysis nurses delivering the majority of education. The most frequently identified barriers to uptake of PD were lack of information about PD, established misconceptions about PD and late referrals to dialysis. Important enablers were early and frequent pre-dialysis education. The only two factors which were reported as very important contraindications to PD were dexterity and decreased cognitive function.

CONCLUSION

Early and frequent pre-dialysis education encourages patients to choose PD and enables early identification and resolution of barriers to the uptake of PD.

A prospective clinical trial of specialist renal nursing in the primary care setting to prevent progression of chronic kidney: a quality improvement report

Background

Early detection and effective management of risk factors can potentially delay progression of chronic kidney disease (CKD) to end-stage kidney disease, and decrease mortality and morbidity from cardiovascular (CV) disease. We evaluated a specialist nurse-led intervention in the primary care setting to address accepted risk factors in a study sample of adults at ‘high risk of CKD progression’, defined as uncontrolled type II diabetes and/or hypertension and a history of poor clinic attendance.

Methods

The study was a non-controlled quality improvement study with pre- and post- intervention comparisons to test feasibility and potential effectiveness. Patients within two primary care practices were screened and recruited to the study. Fifty-two patients were enrolled, with 36 completing 12-months follow-up. The intervention involved a series of sessions led by the nephrology Nurse Practitioner with assistance from practice nurses. These sessions included assessment, education and planned medication and lifestyle changes. The primary outcome measured was proteinuria (ACR), and the secondary outcomes estimated glomerular filtration rate (eGFR) and 5-year absolute CV risk. Several ‘intermediary’ secondary outcomes were also measured including: blood pressure, serum total cholesterol, glycosylated haemoglobin (HbA1c), body mass index (BMI), prevalence of active smoking, a variety of self-management domains, and medication prescription. Analysis of data was performed using linear and logistic regression as appropriate.

Results

There was a significant improvement in ACR (average decrease of −6.75 mg/mmol per month) over the course of the study. There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk. Blood pressure, serum total cholesterol, and HbA1c all decreased significantly. Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI. Self-management significantly improved across all relevant domains.

Conclusions

The results suggest that a collaborative model of care between specialist renal nurses and primary care clinicians may improve the management of risk factors for progression of CKD and CV death. Further larger, controlled studies are warranted to definitively determine the effectiveness and costs of this intervention.

Trial registration

Australian and New Zealand Clinical Trials Registry number: ACTRN12613000791730

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2296-15-155) contains supplementary material, which is available to authorized users.

Finding a living kidney donor: experiences of New Zealand renal patients

A living donor kidney transplant (LDKT) is the preferred treatment for many people with end stage renal failure but there is a significant and growing gap between the number of people who might benefit from a transplant and those who receive one in New Zealand. International research suggests a range of barriers for patients in the journey to LDKT. One hundred and ninety-three patients on the New Zealand waiting list for a kidney transplant responded to a postal survey about live transplantation. While many patients are willing to discuss LDKT with family and friends, most are reluctant to go on to ask others directly to consider live donation. Patients who have not discussed LDKT with others are significantly less likely to have received even one offer from a potential donor. Pākehā and Māori are more likely to have received an offer to donate and to have had someone go on to be tested for compatibility than either Pacific or Other ethnic groups. Information gaps, ineffective donor recruitment strategies, donor incompatibility and donor medical unsuitability appear to be major barriers to LDKT. Many barriers are amenable to intervention and the implications for policy and practice are discussed. What is known about the topic? International studies suggest donor recruitment is difficult for patients and is a major barrier to LDKT. Incompatibility and medical unsuitability are barriers for many willing potential donors. There is no previous patient-centred NZ research on the barriers to living donor kidney transplantation (LDKT). What does this paper add? The paper provides evidence about patterns of donor recruitment activity amongst NZ patients, and suggests a strong relationship between discussing LDKT with family and friends, and receiving offers from potential donors. Asking potential donors directly to consider donation, as opposed to just discussing LDKT in general, does not seem to be associated with receiving more offers. Differences among ethnic groups can be seen. What are the implications for practitioners? Many of the barriers to LDKT are amenable to intervention, and possible options, such as support for donor recruitment and boosting NZ’s paired exchange scheme, are identified.

Exsanguination of a home hemodialysis patient as a result of misconnected blood-lines during the wash back procedure: a case report

Background

Home hemodialysis is common in New Zealand and associated with lower cost, improved survival and better patient experience. We present the case of a fully trained home hemodialysis patient who exsanguinated at home as a result of an incorrect wash back procedure.

Case presentation

The case involves a 67 year old male with a history of well controlled hypertension and impaired glucose tolerance. He commenced on peritoneal dialysis in 2006 following the development of end stage kidney failure secondary to focal segmental glomerulosclerosis. He transferred to hemodialysis due to peritoneal membrane failure in 2010, and successfully trained for home hemodialysis over a 20 week period. Following one month of uncomplicated dialysis at home, he was found deceased on his machine at home in the midst of dialysis. His death occurred during the wash back procedure performed using the “open circuit” method, and resulted from misconnection of the saline bag to the venous end of the extracorporeal blood circuit instead of the arterial end. This led to approximately 2.3L of his blood being pumped into the saline bag resulting in hypovolaemic shock and death from exsanguination.

Conclusions

Despite successful training, critical procedural errors can still be made by patients on home hemodialysis. In this case, the error involved misconnection of the saline bag for wash back. This case should prompt providers of home hemodialysis to review their training protocols and manuals. Manufacturers of dialysis machinery should be encouraged to design machines specifically for home hemodialysis, and consider distinguishing the arterial and venous ends of the extracorporeal blood circuit with colour coding or incompatible connectivity, to prevent occurrences such as these in the future.

Provision and quality of dialysis services in Libya

Dialysis is entirely funded by the public health care sector in Libya. Access to treatment is unrestricted for citizens but there is a lack of local information and no renal registry to gather national data. This cross-sectional study aimed to investigate dialysis provision and practice in Libyan dialysis facilities in 2009. A structured interview regarding dialysis capacity, staffing and methods of assessment of dialysis patients, and infection control measures was conducted with the medical directors of all 40 dialysis centers and 28 centers were visited. A total of 2417 adult patients were receiving maintenance dialysis in 40 centers, giving a population prevalence of approximately 624 per million. Most dialysis units were located in the northern part of the country and only 12.5% were free-standing units. Only three centers offered peritoneal dialysis. One hundred ninety-two hemodialysis rooms hosted 713 functioning hemodialysis stations, giving a ratio of one machine to 3.4 patients. Around half of centers operated only two dialysis shifts per day. Nephrologist/internist to patient ratio was 1:40 and nurse to patient ratio was 1:3.7. We found a wide variation in monitoring of dialysis patients, with dialysis adequacy assessed only in a minority. Separate rooms were allocated for chronic viral infection seropositive patients in 92.5% of the units. In general, the provision of dialysis is adequate but several areas for improvement have been identified, including a need for implementation of guidelines, recruitment of more nephrologists, and the development of more cost-effective alternatives such as peritoneal dialysis and transplantation.

International trends in erythropoietin use and hemoglobin levels in hemodialysis patients

Hemoglobin levels and the dose of erythropoiesis-stimulating agents (ESAs) have risen over time in hemodialysis patients within the United States. There are concerns that these trends may be driven by reimbursement policies that provide potential incentives to increase this use. To determine this we studied trends in the use of ESA and hemoglobin levels in hemodialysis patients and the relationship of these trends to the mode of reimbursement. Using the Dialysis Outcomes and Practice Patterns Study (DOPPS) database of hemodialysis we analyzed facility practices in over 300 randomly selected dialysis units in 12 countries. At each of three phases (years 1996-2001, 2002-2004, and 2005-present), we randomly selected over 7500 prevalent hemodialysis, hemofiltration, or hemodiafiltration patients. ESA usage rose significantly in every country studied except Belgium. All but Sweden demonstrated a substantial increase in hemoglobin levels. In 2005 more than 40% of patients had hemoglobin levels above the KDOQI upper target limit of 120 g/l in all but Japan. These trends appeared to be independent of the manner of reimbursement even though the United States is the only country with significant financial incentives promoting increased use of these agents. Thus, our study found that prescribing higher doses of ESAs and achieving higher hemoglobin levels by physicians reflects a broad trend across DOPPS countries regardless of the reimbursement policies.

The financing and organization of medical care for patients with end-stage renal disease in Sweden

The total health care expenditure as a percentage of the gross domestic product in Sweden is 9.2%, and health care is funded by global budgets almost entirely through general taxation. The prevalence rate of end-stage renal disease (ESRD) in Sweden is 756 per million. Fifty-two percent of ESRD patients have a functioning transplant. Almost all ESRD treatment facilities are public. Compared with other Dialysis Outcomes and Practice Patterns Study (DOPPS) countries, the salaries for both nephrologists and professional dialysis unit staff are low. Sweden's high cost per ESRD patient, relative to other DOPPS countries, may be a result of expensive and frequent hospitalizations and aggressive anemia treatment strategies.

Belgium's mixed private/public health care system and its impact on the cost of end-stage renal disease

Belgium has a mixed, public-private health care system, with state-organized reimbursements but private providers. The system is fee for service. For end-stage renal disease (ESRD), the fee-for-service system discourages preventive strategies, early referral to the nephrology unit, and the use of home-based therapies. The aging of the general population is reflected in the rapidly increasing number of very old dialysis patients, requiring more complicated and, therefore, more costly care. As dialysis costs increase, the ability to provide unrestricted access to dialysis treatment may be unsustainable. To aid in decision-making processes, nephrologists must be aware of financial and organizational issues.

International study of health care organization and financing: development of renal replacement therapy in Germany

The German health system represents the case of a global budget with negotiated fees and competing medical insurance companies. Physicians in private practice and non-profit dialysis provider associations provide most dialysis therapy. End-stage renal disease (ESRD) modalities are well integrated into the overall health care system. Dialysis therapy, independent of the mode of treatment, is reimbursed at a weekly flat rate. Mandatory health insurance covers health expenses, including those related to ESRD, for more than 90% of the population. Both employees and employers contribute to the premium for this insurance. Private medical insurance covers the remainder of the population. Access to treatment, including dialysis therapy, is uniformly available.

International Study of Health Care Organization and Financing for end-stage renal disease in France

The major features of ESRD management in France include the predominance of hemodialysis and the resulting competition for dialysis stations. In 2003, the prevalence of ESRD in France was 0.087%. Of the 52,000 ESRD patients, 30,882 were receiving dialysis and 21,233 had functioning renal transplants. The annual expenditure per ESRD patient in 2003 was estimated at euro40,975. Autodialysis, at euro49,133 per patient per year, was much less expensive than dialyzing in-center at either a public or private facility (euro111,006 and euro75,125, respectively). Transplant activity in France has rapidly increased in recent years, reaching 22 donors per million population in 2005.

End-stage renal disease and economic incentives: the International Study of Health Care Organization and Financing (ISHCOF)

End-stage renal disease (ESRD) is a debilitating, costly, and increasingly common condition. Little is known about how different financing approaches affect ESRD outcomes and delivery of care. This paper presents results from a comparative review of 12 countries with alternative models of incentives and benefits, collected under the International Study of Health Care Organization and Financing, a substudy within the Dialysis Outcomes and Practice Patterns Study. Variation in spending per ESRD patient is relatively small, but correlated with overall per capita health care spending. Remaining differences in costs and outcomes do not seem strongly linked to differences in incentives.

International Study of Health Care Organization and Financing of renal services in England and Wales

In England and Wales, the quantity and quality of renal services have improved significantly in the last decade. While acceptance rates for renal replacement therapy appear low by international standards, they are now commensurate with many other northern European countries. The major growth in renal services has been in hemodialysis, especially at satellite units. Health care is predominantly publicly funded through a tax-based National Health Service, and such funding has increased in the last 10 years. Improvements in health outcomes in England and Wales are expected to continue due to the recent implementation of standards, initiatives, and monitoring mechanisms for renal transplantation, vascular access, and patient transport.