Cost of hemodialysis in a public sector tertiary hospital of India

Perceived barriers to peritoneal dialysis utilization amongst South Asian nephrologists

Peritoneal dialysis (PD) is a well-established modality for kidney replacement therapy (KRT) globally, offering benefits such as better preservation of residual kidney function, improved quality of life, and reduced resource requirements. Despite these advantages, the global utilization of PD remains suboptimal, particularly in South Asia (SA), where a significant gap in PD delivery exists. This study aims to uncover the perceived barriers hindering PD utilization among nephrologists in SA. This is a cross-sectional survey involving 732 nephrologists from SA region. . The majority of respondents (44.7%) reported initiating less than six PD cases annually, reflecting low PD utilization. Cost and financial reimbursement policies emerged as major barriers, with 44.3% considering PD more expensive than haemodialysis (HD). Accessibility, negative attitudes toward PD, and fear of complications were identified as critical factors influencing PD adoption. The study also highlighted variations in PD costs among SA countries, emphasizing the need for tailored health economic strategies. This analysis provides insights into the multifaceted challenges faced by SA nephrologists in promoting PD and underscores the importance of targeted interventions.

Cost-benefit analysis of haemodialysis in patients with end-stage kidney disease in Abuja, Nigeria

BACKGROUND

Significant gaps in scholarship on the cost-benefit analysis of haemodialysis exist in low-middle-income countries, including Nigeria. The study, therefore, assessed the cost-benefit of haemodialysis compared with comprehensive conservative care (CCC) to determine if haemodialysis is socially worthwhile and justifies public funding in Nigeria.

METHODS

The study setting is Abuja, Nigeria. The study used a mixed-method design involving primary data collection and analysis of secondary data from previous studies. We adopted an ingredient-based costing approach. The mean costs and benefits of haemodialysis were derived from previous studies. The mean costs and benefits of CCC were obtained from a primary cross-sectional survey. We estimated the benefit-cost ratios (BCR) and net benefits to determine the social value of the two interventions.

RESULTS

The net benefit of haemodialysis (2,251.30) was positive, while that of CCC was negative (-1,197.19). The benefit-cost ratio of haemodialysis was 1.09, while that of CCC was 0.66. The probabilistic and one-way sensitivity analyses results demonstrate that haemodialysis was more cost-beneficial than CCC, and the BCRs of haemodialysis remained above one in most scenarios, unlike CCC's BCR.

CONCLUSION

The benefit of haemodialysis outweighs its cost, making it cost-beneficial to society and justifying public funding. However, the National Health Insurance Authority requires additional studies, such as budget impact analysis, to establish the affordability of full coverage of haemodialysis.

Healthcare Cost of Cochlear Implantation in India

Making evidence-based policy decisions is challenging when there is a lack of information, especially when deciding provider payment rates for publicly funded health insurance plans. Therefore, the goal of this study was to estimate the cost of a cochlear implant operation in a tertiary care setting in India. We also looked at the patients' out-of-pocket (OOP) expenses for the cochlear implant surgery. From the perspectives of the patients and the healthcare systems, we assessed the financial costs of the cochlear implantation procedure. A bottom-up pricing model was used to assess the cost that the healthcare system would bear for a cochlear implant procedure. Information on all the resources (both capital and ongoing) required to offer cochlear implantation services for hearing loss was gathered over the course of a year. 120 individuals with hearing loss who had cochlear implantation surgery disclosed their out-of-pocket (OOP) costs, which included both direct medical and non-medical expenses. All costs for the budgetary year 2018-2019 were anticipated. The unit health system spent ₹ 151($2), ₹ 578($7.34) and ₹ 37,449($478) on ear exams, audiological evaluations, and cochlear implant surgeries, respectively. Per bed-day in the otolaryngology ward, hospitalization cost ₹ 202($2.6), or ₹ 1211($15.5). The estimated average out-of-pocket cost for a cochlear implant operation was ₹ 682,230($8710). Our research can be used to establish package rates for publicly funded insurance plans in India, plan the growth of public sector hearing care services, and do cost-effectiveness assessments on various hearing care models.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04389-7.

Role of Doppler Evaluation in Assessing the Maturation of the Arteriovenous Fistula for Hemodialysis: An Observational Study

Introduction Arteriovenous fistulas (AVFs) are the preferred type of vascular access for hemodialysis due to their lower risk of complications. This study aimed to determine the role of Doppler evaluation in assessing AVF. Materials and methods We conducted an 18-month prospective observational study of 33 hemodialysis patients who underwent a procedure for the creation of AVF at the Department of Radio-Diagnosis at Sri Devaraj Urs Academy of Higher Education and Research. Patients were evaluated using color Doppler ultrasound. Participants underwent a careful history and clinical examination to diagnose the disease. All relevant parameters were documented in a structured study proforma. AVF maturation was assessed postoperatively at four weeks using Doppler ultrasound color flow evaluation by looking for vascular components (flow volume, vein, and arterial diameter). Data were analyzed using CoGuide V 1.0.3 Statistical Software (CoGuide, Bangalore, India). Results A total of 33 patients, with a mean age of 54.6 ± 7.8 years, were evaluated. Of the 33 participants, 24 (72.7%) were male, and nine (27.3%) were female. The majority (47%, n=16) of participants had diabetes mellitus, eight (24%) had hypertension, and 10 (29%) had both diabetes mellitus and hypertension. A brachiocephalic fistula was created in 45.5% of participants, and 33.33% had radiocephalic anastomoses. Five participants were diagnosed with AVF complications: two had a pseudoaneurysm, and three had a cephalic vein thrombus. Clinical and demographic characteristics (age, vascular components, and complications) were not significantly related to AVF maturation. Conclusions Doppler ultrasound plays an important role in selecting vessels for AVF preoperatively and assessing AVF maturation postoperatively, thus reducing the primary fistula failure rate. The findings suggest that Doppler evaluation can be a reliable tool for assessing AVF maturation and predicting surgical success, which could help healthcare providers make informed decisions about the best course of treatment for their patients. Continued research is warranted in this area to further understand the role of Doppler ultrasound in evaluating AVF surgery.

Willingness to pay for haemodialysis among patients with chronic kidney disease in Abuja, Nigeria

BACKGROUND

Evidence of willingness to pay for kidney replacement therapy is scarce in low-middle-income countries, including Nigeria's Formal Sector Social Health Insurance Programme. The study, therefore, assessed the willingness to pay for haemodialysis among chronic kidney disease patients in Abuja, Nigeria.

METHODS

The study adopted a cross-sectional survey design. We used the contingent valuation method to estimate the maximum stated willingness to pay (WTP) for haemodialysis among end-stage kidney disease (ESKD) patients. We obtained informed written consent from respondents before data collection. The socio-demographic characteristics and willingness to pay data were summarized using descriptive statistics. We evaluated the mean differences in respondents' WTP using Mann-Whitney and Kruskal-Wallis tests. All variables that had p < 0.25 in the bivariate analysis were included in the Generalized Linear Model (gamma with link function) to determine the predictors of the WTP for one's and another's haemodialysis. The level of significance in the final model was ρ < 0.05.

RESULTS

About 88.3% and 64.8% of ESKD patients were willing to pay for personal and altruistic haemodialysis, correspondingly. The mean annual WTP for haemodialysis for one's and altruistic haemodialysis was USD25,999.06 and USD 1539.89, respectively. Private hospital patients were likelier to pay for their haemodialysis (β = 0.39, 95%CI: 0.21 to 0.57, p < 0.001). Patients attending public-private partnership hospitals were less likely to pay for altruistic haemodialysis than those attending public hospitals (β = -1.65, 95%CI: -2.51 to -0.79, p < 0.001).

CONCLUSIONS

The willingness to pay for haemodialysis for themselves and others was high. The type of facility ESKD patients attended influenced their willingness to pay for haemodialysis. The findings highlight the need for policies to enhance affordable and equitable access to haemodialysis in Nigeria through pre-payment mechanisms and altruistic financing strategies.

Cost analysis of the management of end-stage renal disease patients in Abuja, Nigeria

BACKGROUND

Although the treatment for end-stage renal disease (ESRD) under Nigeria's National Health Insurance Authority is haemodialysis (HD), the cost of managing ESRD is understudied in Nigeria. Therefore, this study estimated the provider and patient direct costs of haemodialysis and managing ESRD in Abuja, Nigeria.

METHOD

The study was a cross-sectional survey from both healthcare provider and consumer perspectives. We collected data from public and private tertiary hospitals (n = 6) and ESRD patients (n = 230) receiving haemodialysis in the selected hospitals. We estimated the direct providers' costs using fixed and variable costs. Patients' direct costs included drugs, laboratory services, transportation, feeding, and comorbidities. Additionally, data on the sociodemographic and clinical characteristics of patients were collected. The costs were summarized in descriptive statistics using means and percentages. A generalized linear model (gamma with log link) was used to predict the patient characteristics associated with patients' cost of haemodialysis.

RESULTS

The mean direct cost of haemodialysis was $152.20 per session (providers: $123.69; and patients: $28.51) and $23,742.96 annually (providers: $19,295.64; and patients: $4,447.32). Additionally, patients spent an average of $2,968.23 managing comorbidities. The drivers of providers' haemodialysis costs were personnel and supplies. Residing in other towns (HD:β = 0.55, ρ = 0.001; ESRD:β = 0.59, ρ = 0.004), lacking health insurance (HD:β = 0.24, ρ = 0.038), attending private health facility (HD:β = 0.46, ρ < 0.001; ESRD: β = 0.75, ρ < 0.001), and greater than six haemodialysis sessions per month (HD:β = 0.79, ρ < 0.001; ESRD: β = 0.99, ρ < 0.001) significantly increased the patient's out-of-pocket spending on haemodialysis and ESRD.

CONCLUSION

The costs of haemodialysis and managing ESRD patients are high. Providing public subsidies for dialysis and expanding social health insurance coverage for ESRD patients might reduce the costs.

Cost-effectiveness of population-based screening for microalbuminuria in people with type 2 diabetes mellitus in India

OBJECTIVES

Patients with diabetes have a higher risk of developing chronic kidney disease (CKD). Early detection of CKD through microalbuminuria screening, followed by treatment, delays the progression of CKD. We evaluated the cost-effectiveness of population-based screening of microalbuminuria among normotensive type 2 diabetes mellitus patients aged >40 years compared with no screening scenario using a decision tree combined with the Markov model.

METHODS

We considered two scenarios: Scenario I - dipstick microalbuminuria followed by spot-urine albumin-creatinine ratio (ACR) and serum creatinine in sequence; Scenario II - spot urine ACR plus serum creatinine. A mathematical cohort of the target population was simulated over a lifetime horizon with an annual cycle. Data for the model were obtained from secondary resources. The incremental cost-effectiveness ratios (ICERs) were estimated for screening scenarios compared to nonscreening scenario, along with sensitivity analyses.

RESULTS

The discounted ICER per quality-adjusted life years gained for annual microalbuminuria screening in the normotensive diabetic population in India were ₹ 24,114 (US$ 308) and ₹ 13,790 (US$ 176) for scenarios I and II, respectively. Annual screening by scenarios I and II resulted in a reduction of 180 and 193 end-stage renal disease (ESRD) cases per 100,000 population, respectively, resulting in a cost saving of ₹ 12.3 and 13.3 Crore spent on ESRD management over 10 years. Both scenarios were also cost-effective even at the screening frequencies of 5 and 10 yearly.

CONCLUSION

Microalbuminuria screening was cost-effective at the threshold of one-time GDP per capita in India.

The Experience of Living with a Chronic Illness: A Qualitative Study among End-Stage Renal Disease Patients

The prevalence of End-Stage Renal Disease (ESRD) has been rising over time and substantially affects morbidity and mortality. ESRD requires lifelong treatment, and as a result, patients experience multiple physical and psychosocial stressors. ESRD patients struggle to retain their jobs, social lives, financial flexibility, and diet restrictions of liquids and solid foods. The present study aims to understand the experiences of ESRD patients undergoing hemodialysis. The study was conducted at Eldho Mor Baselious Dialysis Center in Perumbavoor, Kerala, in the hemodialysis outpatient unit. The Biopsychosocial model was used as the theoretical framework of the study. As the goal of the study was to investigate the inner experiences of ESRD patients, a qualitative research approach was employed. Twelve respondents were selected for the study using purposive sampling, and the data were organized and analyzed using Colaizzi's descriptive phenomenological method. Four theme categories emerged from data analysis: decline in physical function, psychosocial distress, economic hardships, and impact on the support system. The study shows that ESRD patients experience significant psychosocial and health-related issues. The role of the clinical social worker is vital as there is a need for social work interventions to resolve the psychosocial issues of patients with ESRD.

Review on kidney diseases: types, treatment and potential of stem cell therapy

Renal disorders are an emerging global public health issue with a higher growth rate despite progress in supportive therapies. In order to find more promising treatments to stimulate renal repair, stem cell-based technology has been proposed as a potentially therapeutic option. The self-renewal and proliferative nature of stem cells raised the hope to fight against various diseases. Similarly, it opens a new path for the treatment and repair of damaged renal cells. This review focuses on the types of renal diseases; acute and chronic kidney disease-their statistical data, and the conventional drugs used for treatment. It includes the possible stem cell therapy mechanisms involved and outcomes recorded so far, the limitations of using these regenerative medicines, and the progressive improvement in stem cell therapy by adopting approaches like PiggyBac, Sleeping Beauty, and the Sendai virus. Specifically, about the paracrine activities of amniotic fluid stem cells, renal stem cells, embryonic stem cells, mesenchymal stem cell, induced pluripotent stem cells as well as other stem cells.

Out-of-pocket expenditures, catastrophic household finances, and quality of life among hemodialysis patients in Kerala, India

INTRODUCTION

Kidney replacement therapy in chronic kidney disease patients can result in catastrophic health costs, pushing them into poverty in lower middle-income countries. There are only limited studies from India focusing on the financial hardship of these patients. Data on direct nonmedical and indirect cost of hemodialysis (HD) are also limited. This study aims to find the different components of cost for HD and its association with quality of life (QOL) among HD patients.

METHODS

Primary objective was to find the cost of HD, which include direct medical, direct nonmedical and indirect cost. Secondary objective was to study whether the ratio of out-of-pocket (OOP) payments for HD to household income can affect the QOL. The QOL was assessed using EQ-5D-5L instrument. Catastrophic health care expenditure was defined as OOP health care expenditure exceeding 40% of the household income and distress financing as borrowing money or selling assets to meet the OOP expenditure for treatment.

FINDINGS

Of the 152 patients enrolled for the study, 103 (67.8%) were males. Mean age was 60.9 ± 12.5 years. Monthly OOP expenditure for dialysis was USD 478.4 (362.6-663.6) of which direct nonmedical and indirect expenses constitute USD 115.6 (88.4-292.4). Median percentage of household income spent for dialysis was 194.5 (IQR 128-297). One hundred and forty-two (93.4%) had catastrophic healthcare expenditure and 76 (50%) had distressing health care expenditure. On multivariable linear regression, proportion of total household income spend for dialysis was associated with poor QOL in patients undergoing HD; coefficient = -0.04 (95% CI -0.008 - 0.092), p = 0.039.

DISCUSSION

Nonmedical direct and indirect cost is substantial among patients undergoing HD. Nine of 10 patients had catastrophic health care expenditure, which pushed 50% of the patients to distress financing.

Switching from high-flux dialysis to hemodiafiltration: Cost-consequences for patients, providers, and payers

Hemodiafiltration (HDF) achieves a more efficient reduction of the uremic toxic load compared to standard high-flux hemodialysis (HF-HD) by virtue of the combined diffusive and convective clearances of a broad spectrum of uremic retention solutes. Clinical trials and registry data suggest that HDF improves patient outcomes. Despite the acknowledged need to improve survival rates of dialysis patients and the survival benefit HDF offers, there is little to no utilization in some countries (such as the US) in prescribing HDF to their patients. In this analysis, we present the healthcare value-based case for HDF (relative to HF-HD) from the patient, provider, and payor perspectives. The improved survival and reduced morbidity observed in studies conducted outside the US, as well as the reduced hospitalization, are attractive for each stakeholder. We also consider the potential barriers to greater utilization of HDF therapies, including unfounded concerns regarding additional costs of HDF, e.g., for the preparation and microbial testing of quality of substitution fluids. Ultrapure fluids are easily attainable and prepared from dialysis fluids using established "online" (OL) technologies. OL-HDF has matured to a level whereby little additional effort is required to safely implement it as all modern machine systems are today equipped with the OL-HDF functionality. Countries already convinced of the advantages of HF-HD are thus well positioned to make the transition to OL-HDF to achieve further clinical and associated economic benefits. Healthcare systems struggling to cope with the increasing demand for HD therapies would therefore, like patients, be beneficiaries in the long term with increased usage of OL-HDF for end stage kidney disease patients.

Accessibility and quality of haemodialysis services in an urban setting in South India: a qualitative multiperspective study

OBJECTIVE

To explore the accessibility and quality of existing haemodialysis services in an urban setting.

SETTING

The study was conducted in Bangalore city, India.

PARTICIPANTS

A total of 28 stakeholders including 2 nephrologists, 7 duty doctors, 13 dialysis technicians and 6 patients on long-term haemodialysis were selected from 20 dialysis centres in Bangalore city.

DESIGN AND METHODS

Qualitative study using in-depth interviews. A thematic analysis was done using the Availability, Accessibility, Acceptability and Quality Framework of WHO and the Bruce's Quality of Care Framework.

RESULTS

The study found several gaps with regard to the access and quality of existing services for patients with end-stage kidney disease (ESKD). The charges for dialysis sessions across settings displayed a wide variance. Patients often started dialysis services in private and later shifted to government and non-governmental organisations-run centres and reduced the number of weekly dialysis sessions due to financial constraints. Most standalone dialysis centres did not have the facilities to manage any emergencies. Most centres did not admit patients with hepatitis or HIV. The quality of care in dialysis centres seemed to be variable and most centres were managed solely by dialysis technicians. There were no psychosocial interventions available to the patients irrespective of the settings. Cost-cutting practices such as employing underqualified technicians, reusing dialysis equipment and using substandard water for dialysis were common.

CONCLUSION

The study highlights the need for more financial and personnel investments in ESKD care in India to ensure optimal care for the growing patient population. The study points towards the need for comprehensive management practices, including diet counselling and psychosocial support. While there are comprehensive guidelines on the establishment and management of dialysis services, more policy attention needs to be on effective implementation of these, to ensure better accessibility and quality of existing services.

Peritoneal dialysis-first initiative in India: a cost-effectiveness analysis

BACKGROUND

The increasing burden of kidney failure (KF) in India necessitates provision of cost-effective kidney replacement therapy (KRT). We assessed the comparative cost-effectiveness of initiating KRT with peritoneal dialysis (PD) or haemodialysis (HD) in the Indian context.

METHODS

The cost and clinical effectiveness of starting KRT with either PD or HD were measured in terms of life years (LYs) and quality-adjusted life years (QALYs) using a mathematical Markov model. Complications such as peritonitis, vascular access-related complications and blood-borne infections were considered. Health system costs, out-of-pocket expenditures borne by patients and indirect costs were included. Two scenarios were considered: Scenario 1 (real-world scenario)-as per the current cost and utilization patterns; Scenario 2 (public programme scenario)-use in the public sector as per Pradhan Mantri National Dialysis Programme (PMNDP) guidelines. The lifetime costs and health outcomes among KF patients were assessed.

RESULTS

The mean QALYs lived per KF person with PD and HD were estimated to be 3.3 and 1.6, respectively. From a societal perspective, a PD-first policy is cost-saving as compared with an HD-first policy in both Scenarios 1 and 2. If only the costs directly attributable to patient care (direct costs) are considered, the PD-first treatment policy is estimated to be cost-effective only if the price of PD consumables can be brought down to INR70/U.

CONCLUSIONS

PD as initial treatment is a cost-saving option for management of KF in India as compared with HD first. The government should negotiate the price of PD consumables under the PMNDP.

Safety and utility of kidney biopsy in patients with estimated glomerular filtration rate < 30 ml/min/1.73 m2

AIM

Kidney biopsy (KBx) is the gold standard for evaluation of kidney disease, but is associated with a higher risk of complications in patients with reduced glomerular filtration rate (GFR). We studied the safety and utility of KBx in patients with eGFR <30 ml/min/1.73 m2 .

METHODS

Consecutive adult patients with eGFR <30 ml/min/1.73 m2 , who were planned for a KBx and consented to participate were prospectively enrolled. Patients with solitary/transplant kidney or acute kidney injury were excluded. Haemoglobin was checked on the day of KBx and repeated 18-24 h later along with a screening ultrasound. Post-KBx complications were noted and their risk-factors analysed. The utility of the KBx was graded as effecting significant, some, or no change to subsequent management.

RESULTS

Of the 126 patients included, 75% were male, 27.7% were diabetic, and the median eGFR was 13.5 ml/min/1.73m2 . Major complications occurred in 5.6%. Peri-renal haematomas were detected in 37.3%, and haematomas ≥2 cm were significantly more frequent in those with eGFR <15 ml/min/1.73 m2 (29.2% vs. 13%, p = .032). Dialysis was a risk factor, while pre KBx blood transfusion, diabetes and higher serum albumin were protective against any complication. KBx was more likely to make a significant difference in management in those with eGFR 15-29 ml/min/1.73m2 (44.1% vs. 11.1%, p < .001). Increasing age, lower serum creatinine and albumin were independently associated with KBx utility.

CONCLUSION

KBx is relatively safe in severe kidney disease but its risk to benefit balance needs to be carefully considered when eGFR is <15 ml/min/1.73m2 .

Uptake of next-generation sequencing in children with end-stage renal disease secondary to focal segmental glomerulosclerosis and parental decision for kidney transplantation-Experience from a low resource setting: A Retrospective Cohort Study

BACKGROUND

Transplantation is the optimal modality for children with ESRD. High risk of disease recurrence and graft loss with FSGS, and its financial implications, may result in families refusing transplantation. Deceased donation is often preferred for FSGS, but access is limited in many low- and middle-income group countries (LMIC; per capita gross national income between $1026 and $3995). As FSGS secondary to an underlying genetic etiology has low recurrence risk, we hypothesized that in LMIC such as India, families with children in ESRD secondary to FSGS with proven pathogenic mutation are more likely to consent for transplantation than those with unknown etiology.

METHODS

Prospective cross-sectional study with retrospective chart review was undertaken (March 2011 and February 2019) to identify children with ESRD from FSGS. The objective was to ascertain NGS uptake and findings, parental decision for transplantation, and transplant outcome.

RESULTS

28 children with FSGS started transplant workup, and 15 (54%) families agreed for NGS testing. Pathogenic mutation (NPHS1 x 2, WT1 x 2, COL4A3 x 2, CD2AP, CRB2, COL4A5, INF 2, ACTN4, NPHP4: 1 each) was identified in 12 (80%). 92% (11/12) agreed to proceed with transplantation in contrast to 13% (2/16) who either did not undergo NGS testing or had no pathogenic mutation identified (P = .001). No disease recurrences were noted in those with a known pathogenic mutation.

CONCLUSION

In LMIC, NGS results are useful in transplant discussions with families for children with ESRD secondary to FSGS.

Shared Decision-Making, Advance Care Planning for Chronic Kidney Disease Patients

Advance care planning (ACP) is a process by which clinicians together with patients and families reflect on and outline care goals to inform current and future care. ACP or shared decision-making is not only about key medical decisions, such as decision about continuing dialysis, or agreement for “not for resuscitation” order when in hospital. The importance of its role in chronic kidney disease (CKD) patients is less known and not being well practiced in our country. When done well, it involves enhancement of final days, weeks, and months with positive decisions about family relationships, resolution of conflict, and living well until end of life, improved quality of life, decreased anxiety and depression among family members, reduced hospitalizations, increased uptake of hospice and palliative care services, and care that concurs with patient preferences. It lays out a set of relationships, values, and processes for approaching end-of-life decisions for the patient. It also includes attention to ethical, psychosocial, and spiritual issues relating to starting, continuing, withholding, and stopping dialysis. This workshop was done to sensitize ACP as a standard of care intervention in the management of CKD in our country.

International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in South Asia

Information about disease burden and the available infrastructure and workforce to care for patients with kidney disease was collected for the second edition of the International Society of Nephrology Global Kidney Health Atlas. This paper presents findings for the 8 countries in the South Asia region. The World Bank categorizes Afghanistan and Nepal as low-income; Bangladesh, Bhutan, India, and Pakistan as lower-middle-income; and Sri Lanka and the Maldives as upper-middle-income countries. The prevalence of chronic kidney disease (CKD) in South Asia ranged from 5.01% to 13.24%. Long-term hemodialysis and long-term peritoneal dialysis are available in all countries, but Afghanistan lacks peritoneal dialysis services. Kidney transplantation was available in all countries except Bhutan and Maldives. Hemodialysis was the dominant modality of long-term dialysis, peritoneal dialysis was more expensive than hemodialysis, and kidney transplantation overwhelmingly depended on living donors. Bhutan provided public funding for kidney replacement therapy (dialysis and transplantation); Sri Lanka, India, Pakistan, and Bangladesh had variable funding mechanisms; and Afghanistan relied solely on out-of-pocket expenditure. There were shortages of health care personnel across the entire region. Reporting was variable: Afghanistan and Sri Lanka have dialysis registries but publish no reports, whereas Bangladesh has a transplant registry. South Asia has a large, but poorly documented burden of CKD. Diabetes and hypertension are the major causes of CKD throughout the region with a higher prevalence of infectious causes in Afghanistan and a high burden of CKD of an unknown cause in Sri Lanka and parts of India. The extent and quality of care delivery is suboptimal and variable. Sustainable strategies need to be developed to address the growing burden of CKD in the region.

Factors Influencing Scales of Burden, Coping Mechanisms, and Quality of Life in Caregivers of Hemodialysis Patients in Andhra Pradesh, India

Background:

Evaluation of factors influencing scales of burden, coping mechanisms, and quality of life (QOL) in caregivers of hemodialysis (HD) patients may lead to the revision of interventions aimed at the betterment of QOL of caregivers of HD patients. In this study, we investigated the influence of demographic, social, and clinical variables on burden, coping mechanisms, and QOL in caregivers of HD patients.

Methods:

In this prospective study, 150 caregivers of HD patients were recruited. Assessment of burden, coping strategies, and QOL were made by the Zarit Burden Interview, Revised Ways of Coping, and Short Form-36 QOL. The role of age, gender, and social and clinical variables on these constructs was investigated using multivariate analysis of variance.

Results:

The mean age was 43.86 ± 1.11 years. Males outnumbered females. Most were Hindu, married, primary school educated, unemployed, spouses, caring the patients, and suffering from chronic diseases for <5 years. In multivariate analysis of variance, effect of age on physical functioning (PF), general health (GH), and physical component summary (PCS) score (P < 0.01); gender on burden, distancing, seeking social support, role limitation due to emotional problem, and pain (P < 0.05); role limitations due to physical health, energy/fatigue (EF), emotional well-being, PCS, and mental component summary (MCS) score (P < 0.01); religion on PF (P < 0.05); marital status on burden and GH (P < 0.05); PF and PCS (P < 0.01); relationship of caregiver with the patient on PCS (P < 0.05); EF and MCS (P < 0.01); and presence of chronic diseases on GH and social functioning (P < 0.01) were observed.

Conclusion:

The role of demographic, social, and clinical variables should be taken into consideration while initiating therapies for reducing the burden and improving the QOL of caregivers.

Population-based comparison of chronic kidney disease prevalence and risk factors among adults living in the Punjab, Northern India and the USA (2013-2015)

OBJECTIVES

India is witnessing a disturbing growth in non-communicable diseases (NCDs), including chronic kidney disease (CKD). Recently, a WHO STEPS survey was conducted in the state of Punjab, India to collect data from the adult population on NCD risk factors. We sought to compare the prevalence of CKD and its risk factors between this large state in northern India and the USA.

SETTING

Samples were drawn from both locations, Punjab, India and the USA, using multistage stratified sampling designs to collect data representative of the general population.

PARTICIPANTS

Data from 2002 participants in the Punjab survey (2014-2015) and 5057 in the USA (National Health and Nutrition Examination Survey (NHANES; 2013-2014), between the ages of 18-69 years were examined.

PRIMARY AND SECONDARY OUTCOME MEASURES

Modified Poisson regression was employed to compare prevalence between the two samples for markers of CKD and its risk factors. All analyses used sampling weights.

RESULTS

The average age in the Punjab sample was significantly lower than the USA (38.3 vs 42.5 years, p<0.0001). While smoking and obesity were higher in the USA, hypertension was much more common in Punjab (48.2% vs 33.4%, p<0.0001). Significant differences were seen in the prevalence of CKD, with lower prevalence of eGFR <60 mL/min/1.73 m² (2.0% vs 3.8%, p<0.0001), but markedly higher prevalence of albuminuria (46.7% vs 8.9%, p<0.0001) in Punjab. These differences could not be explained by traditional risk factors such as diabetes and hypertension.

CONCLUSIONS

We report a strikingly high prevalence of albuminuria in Punjab, India, compared with the USA. This requires further study and may have enormous public health implications for future burden of progressive CKD, end-stage kidney disease, morbidity, mortality and specifically for elevated risk or presence of cardiovascular disease in the northern state of Punjab, India.Funding came from the National Health Mission, Punjab, India, JST and the Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Building Capacity for Evidence-Informed Priority Setting in the Indian Health System: An International Collaborative Experience

India's rapid economic growth has been accompanied by slower improvements in population health. Given the need to reconcile the ambitious goal of achieving Universal Coverage with limited resources, a robust priority-setting mechanism is required to ensure that the right trade-offs are made and the impact on health is maximised. Health Technology Assessment (HTA) is endorsed by the World Health Assembly as the gold standard approach to synthesizing evidence systematically for evidence-informed priority setting (EIPS). India is formally committed to institutionalising HTA as an integral component of the EIPS process. The effective conduct and uptake of HTA depends on a well-functioning ecosystem of stakeholders adept at commissioning and generating policy-relevant HTA research, developing and utilising rigorous technical, transparent, and inclusive methods and processes, and a strong multisectoral and transnational appetite for the use of evidence to inform policy. These all require myriad complex and complementary capacities to be built at each level of the health system . In this paper we describe how a framework for targeted and locally-tailored capacity building for EIPS, and specifically HTA, was collaboratively developed and implemented by an international network of priority-setting expertise, and the Government of India.

Out-of-pocket payments by end-stage kidney disease patients on regular hemodialysis: Cost of illness analysis, experience from Sudan

INTRODUCTION

In Sudan, the number of end-stage kidney disease (ESKD) patients receiving hemodialysis (HD) is growing. Patients and their families incur a high out-of-pocket expenditure (OOPE), given that HD treatment is expensive. There are limited data about OOP spending on HD in the country. This study aims to explore patients' OOP expense on direct medical and nonmedical goods and services and to which extent they can be predicted from sociodemographic characteristics, health insurance status, comorbidity, and accommodation change.

METHODS

This is descriptive a cross-sectional study conducted in Ibn Sina Hospital. One hundred and thirty patients undergo regular HD were randomly selected.

FINDINGS

Among the study participants (130), the median of the overall total OOP (direct medical and direct nonmedical) spending per patients per year was found to be US$ 3859.1 (interquartile range [IQR]: 2298.1-6261.1). As for the medians OOP expenditure on direct medical and nonmedical costs, they were found to be US$ 2327.6 (IQR: 1421.5-3804.8) and US$ 1096 (IQR: 715.2-2345.2), respectively. The direct medical expenditure (355,586 US$) accounted for 60% of the overall total expenses.

DISCUSSION

Medications and investigations were the primary drivers of direct medical spending. Higher OOPE rates were found among those with one or more of these factors; uninsured patients, patient with comorbidity, female gender, and over 40 years aged. The multivariate analysis showed that the significant predictors of direct medical expenditure were health insurance and comorbid conditions, where as the predictors for direct nonmedical expenditure were accommodation change and gender. This study results in a better understanding of OOP spending on direct medical and nonmedical services and its associated predictors among HD patients within the context of Sudan. Further research is needed in this area.

Ckj consolidation among Q1 Urology and Nephrology journals

The Clinical Kidney Journal (ckj) impact factor from Clarivate’s Web of Science for 2019 was 3.388. This consolidates ckj among journals in the top 25% (first quartile, Q1) in the Urology and Nephrology field according to the journal impact factor. The manuscripts contributing the most to the impact factor focused on chronic kidney disease (CKD) epidemiology and evaluation, CKD complications and their management, cost-efficiency of renal replacement therapy, pathogenesis of CKD, familial kidney disease and the environment–genetics interface, onconephrology, technology, SGLT2 inhibitors and outcome prediction. We provide here an overview of the hottest and most impactful topics for 2017–19.

Estimating the Unit Costs of Healthcare Service Delivery in India: Addressing Information Gaps for Price Setting and Health Technology Assessment

BACKGROUND

India's flagship National Health insurance programme (AB-PMJAY) requires accurate cost information for evidence-based decision-making, strategic purchasing of health services and setting reimbursement rates. To address the challenge of limited health service cost data, this study used econometric methods to identify determinants of cost and estimate unit costs for each Indian state.

METHODS

Using data from 81 facilities in six states, models were developed for inpatient and outpatient services at primary and secondary level public health facilities. A best-fit unit cost function was identified using guided stepwise regression and combined with data on health service infrastructure and utilisation to predict state-level unit costs.

RESULTS

Health service utilisation had the greatest influence on unit cost, while number of beds, facility level and the state were also good predictors. For district hospitals, predicted cost per inpatient admission ranged from 1028 (313-3429) Indian Rupees (INR) to 4499 (1451-14,159) INR and cost per outpatient visit ranged from 91 (44-196) INR to 657 (339-1337) INR, across the states. For community healthcare centres and primary healthcare centres, cost per admission ranged from 412 (148-1151) INR to 3677 (1359-10,055) INR and cost per outpatient visit ranged from 96 (50-187) INR to 429 (217-844) INR.

CONCLUSION

This is the first time cost estimates for inpatient admissions and outpatient visits for all states have been estimated using standardised data. The model demonstrates the usefulness of such an approach in the Indian context to help inform health technology assessment, budgeting and forecasting, as well as differential pricing, and could be applied to similar country contexts where cost data are limited.

Quality of Life of End Stage Renal Disease Patients Undergoing Dialysis in Southern Part of Kerala, India: Financial Stability and Inter-dialysis Weight Gain as Key Determinants

Background: Quality of Life (QoL) reflects the quality and outcome of healthcare along with key indicators of performance such as mortality and morbidity.

Objective: The aim of the study was to measure the QoL among patients with End Stage Renal Disease (ESRD) on maintenance hemodialysis and to understand various correlates of QoL.

Methods: A total of 95 ESRD patients from three dialysis centres in Southern districts of Kerala were interviewed. QoL was measured using vernacular version of World Health Organization Quality Of Life – Brief Version (WHOQOL-BREF) questionnaire.

Results: The mean age of the patients was 56.2 ± 13 years and 73.7% were males. Mean converted scores for overall QoL was 42.37 ± 21.3 and Health-related QoL (HRQoL) was 43.3 ± 18.3, indicating poor QoL. Males had significantly higher physical domain scores (p < 0.03). Occupation, income and Socio-economic Status (SES) influenced overall HRQoL while better income and higher SES predicted better scores in psychological and environmental domains.

Conclusion: Patients with better control over inter-dialysis weight gain (≤1600 g) had significantly higher scores. This study highlights the importance of using QoL tools in assessing the QoL of patients and the factors contributing to it.

A public–private partnership for dialysis provision in Ethiopia: a model for high-cost care in low-resource settings

Our purpose was to explore whether private–public partnerships (PPPs) can serve as a model for access to high-cost care in low-resource settings by examining a unique PPP providing haemodialysis services in a remote setting, investigating challenges and enablers. The study setting is a 500-bed teaching hospital serving a catchment population of 8 million in Northern Ethiopia. Based on local data collection, observation and in-depth interviews, we identified the impetus for the PPP, described the partnership agreement, reported outcomes after 6 years of activity and examined challenges that have arisen since the programme’s inception, including funding sustainability. The PPP was established in 2013 based on a decision by local leadership that treatment of patients with acute kidney injury (AKI) is a necessity rather than a luxury. A private partner was sought who could ensure service delivery as well as a reliable supply of consumables. The hospital contributions included infrastructure, personnel and sharing of maintenance costs. The partnership has facilitated uninterrupted haemodialysis service to 101 patients with AKI and 202 with chronic kidney disease. The former (&gt;50% cured) were mainly supported by charitable donations procured by the hospital’s leadership, while the latter were self-funded. The local university and community contributed to the charity. Utilization has increased yearly. Funding and logistical issues remain. In conclusion, this PPP enabled access to previously unavailable lifesaving care in Northern Ethiopia and could serve as a model for potential scale-up for haemodialysis provision in particular, and more broadly, high-cost care in low-resource settings. An ethical commitment to provide the service, combined with ongoing administrative and community involvement has contributed to its sustained success. Lack of affordability for most patients requiring chronic haemodialysis and reliance on charitable donations for treatment of patients with AKI pose challenges to long-term sustainability.

Enhanced prediction of hemoglobin concentration in a very large cohort of hemodialysis patients by means of deep recurrent neural networks

Erythropoiesis Stimulating Agents (ESAs) have become a standard anemia management tool for End Stage Renal Disease (ESRD) patients. However, dose optimization constitutes an extremely challenging task due to huge inter and intra-patient variability in the responses to ESA administration. Current data-based approaches to anemia control focus on learning accurate hemoglobin prediction models, which can be later utilized for testing competing treatment choices and choosing the optimal one. These methods, despite being proven effective in practice, present several shortcomings which this paper intends to tackle. Namely, they are limited to a small cohort of patients and, even then, they fail to provide suggestions when some strict requirements are not met (such as having a three month history prior to the prediction). Here, recurrent neural networks (RNNs) are used to model whole patient histories, providing predictions at every time step since the very first day. Furthermore, an unprecedented amount of data (∼110,000 patients from many different medical centers in twelve countries, without exclusion criteria) was used to train it, thus allowing it to generalize for every single patient. The resulting model outperforms state-of-the-art Hemoglobin prediction, providing excellent results even when tested on a prospective dataset. Simultaneously, it allows to bring the benefits of algorithmic anemia control to a very large group of patients.

Cost of Hemodialysis Treatment and Associated Factors Among End-Stage Renal Disease Patients at the Tertiary Hospitals of Addis Ababa City and Amhara Region, Ethiopia

Purpose

Hemodialysis is a renal replacement therapy for end-stage renal disease (ESRD) patients who consume substantial healthcare resources, which increases the economic burden. Plenty of factors affects the cost of hemodialysis treatment, particularly in resource-limited settings. Moreover, the demand for hemodialysis may decrease as the cost increases, but there is limited evidence in Ethiopia. Thus, this study aimed to estimate the cost of hemodialysis treatment among ESRD patients in the tertiary hospitals of Addis Ababa City and Amhara region, Ethiopia.

Patients and Methods

An institutional-based cross-sectional study was conducted among 172 ESRD patients undergoing hemodialysis treatment. A structured questionnaire and patients’ medical chart were used to estimate the costs, and the human capital approach was applied to calculate the indirect costs. A generalized linear model (GLM) was fitted after the modified park test to identify the associated factors. In the final GLM, a p-value of <0.05 and a 95% CI were used to declare the significant variables.

Results

The mean annual cost of hemodialysis treatment was 121,089.27ETB ($4466.59) ± 33,244.99 ($1226.29). The direct and indirect costs covered 77.0% and 23.0% of the total costs, respectively. Age (ex(b): 1.01, p-value <0.001), highest wealth status (ex(b): 1.09, p-value: 0.008), eight (ex(b): 1.27, p-value <0.001) and 12 visits/month (ex(b): 1.34, p-value <0.001), anemia (ex(b): 1.13, p-value <0.001), and comorbidity (ex(b): 1.09, p-value: 0.039) were the factors associated with the costs of hemodialysis treatment.

Conclusion

The annual cost of hemodialysis treatment among ESRD patients was high compared to the national per capita health expenditure, and two-thirds covered by the direct medical costs. Old age, high wealth status, more visits, anemia, and comorbidity were factors associated with the costs of hemodialysis. Therefore, the healthcare system must make a great effort for cost reduction and reduce the patients with kidney disease before they reach end-stages.

Increasing access to integrated ESKD care as part of universal health coverage

The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle-income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide.

Process evaluation of health system costing - Experience from CHSI study in India

Background

A national study, ‘Costing of healthcare services in India’ (CHSI) aimed at generating reliable healthcare cost estimates for health technology assessment and price-setting is being undertaken in India. CHSI sampled 52 public and 40 private hospitals in 13 states and used a mixed micro-costing approach. This paper aims to outline the process, challenges and critical lessons of cost data collection to feed methodological and quality improvement of data collection.

Methods

An exploratory survey with 3 components–an online semi-structured questionnaire, group discussion and review of monitoring data, was conducted amongst CHSI data collection teams. There were qualitative and quantitative components. Difficulty in obtaining individual data was rated on a Likert scale.

Results

Mean time taken to complete cost data collection in one department/speciality was 7.86(±0.51) months, majority of which was spent on data entry and data issues resolution. Data collection was most difficult for determination of equipment usage (mean difficulty score 6.59±0.52), consumables prices (6.09±0.58), equipment price(6.05±0.72), and furniture price(5.64±0.68). Human resources, drugs & consumables contributed to 78% of total cost and 31% of data collection time. However, furniture, overheads and equipment consumed 51% of time contributing only 9% of total cost. Seeking multiple permissions, absence of electronic records, multiple sources of data were key challenges causing delays.

Conclusions

Micro-costing is time and resource intensive. Addressing key issues prior to data collection would ease the process of data collection, improve quality of estimates and aid priority setting. Electronic health records and availability of national cost data base would facilitate conducting costing studies.

Developing the ethical framework of end-stage kidney disease care: from practice to policy

Ethical issues relating to end-stage kidney disease (ESKD) care are increasingly being discussed by clinicians and ethicists but are still infrequently considered at a policy level or in the education and training of health care professionals. In most lower-income countries, access to kidney replacement therapies such as dialysis is not universal, leading to overt or implicit rationing of resources and potential exclusion from care of those who are unable to sustain out-of-pocket payments. These circumstances create significant inequities in access to ESKD care within and between countries and impose emotional and moral burdens on patients, families, and health care workers involved in decision-making and provision of care. End-of-life decision-making in the context of ESKD care in all countries may also create ethical dilemmas for policy makers, professionals, patients, and their families. This review outlines several ethical implications of the complex challenges that arise in the management of ESKD care around the world. We argue that more work is required to develop the ethics of ESKD care, so as to provide ethical guidance in decision-making and education and training for professionals that will support ethical practice in delivery of ESKD care. We briefly review steps that may be required to accomplish this goal, discussing potential barriers and strategies for success.

Considerations on equity in management of end-stage kidney disease in low- and middle-income countries

Achievement of equity in health requires development of a health system in which everyone has a fair opportunity to attain their full health potential. The current, large country-level variation in the reported incidence and prevalence of treated end-stage kidney disease indicates the existence of system-level inequities. Equitable implementation of kidney replacement therapy (KRT) programs must address issues of availability, affordability, and acceptability. The major structural factors that impact equity in KRT in different countries are the organization of health systems, overall health care spending, funding and delivery models, and nature of KRT prioritization (transplantation, hemodialysis or peritoneal dialysis, and conservative care). Implementation of KRT programs has the potential to exacerbate inequity unless equity is deliberately addressed. In this review, we summarize discussions on equitable provision of KRT in low- and middle-income countries and suggest areas for future research.

Dialysis funding, eligibility, procurement, and protocols in low- and middle-income settings: results from the International Society of Nephrology collection survey

Dialysis provisions and end-stage kidney disease (ESKD) care represents an important challenge, particularly in low-resource settings. The purpose of this project was to survey nephrologists from low- and lower middle-income countries about their experiences in the following domains: (i) Dialysis funding and eligibility; (ii) dialysis-procurement mechanisms; (iii) clinical protocols for dialysis; (iv) monitoring of dialysis outcomes; and (v) barriers to care for ESKD. One hundred and twenty responses from 31 low- and middle-income countries, from 8 ISN regions, were included in the analysis. When stratified by World Bank country income status, responses were received from 7 low-income countries, 12 lower middle-income countries, and 12 upper middle-income countries. Eighty-eight documents from 18 countries were uploaded, including country or institutional guidelines, protocols, and standard operating procedures. The International Society of Nephrology aims to develop a set of guidance documents that put forward a considered approach to dialysis provisions and ESKD care within resource limitations. As an initial step in this project, local practitioners from low-resource settings were surveyed about their experiences with dialysis funding, eligibility, procurement and their use of guidance documents, and how practices and procedures may have been developed with adaptations to the local circumstances. In this manuscript we describe the methodology and the main findings from the survey using an integrated quantitative and qualitative approach.

Cost of antiretroviral treatment for HIV patients in two centres of North India

There is paucity of evidence on cost of antiretroviral therapy (ART) delivered through the public sector in India. Moreover, the Government of India is considering changing the criteria for introduction of ART to HIV patients, which is likely to have significant economic implications. In this paper, we assess the health system cost of ART services at two levels of health care delivery. Bottom-up costing was used to collect data on capital and recurrent resources consumed over a period of one year (April 2014–March 2015). Capital costs were annualized and shared costs apportioned to calculate annual and unit costs of providing ART care. Sensitivity analysis was undertaken to measure the extent of uncertainty in input prices. The annual per capita cost of ART therapy was INR 48,975 (USD738) in the Centre of Excellence (COE) and INR 24,954 (USD376) in the ART centre. Drugs contributed around 70% and 65% of total annual cost, followed by human resource (19% each) and capital cost (7%; 12%) in COE and ART centres, respectively. These provide a comprehensive assessment of the cost of ART care in India. The study estimates could be used for planning of services, as well as undertaking further cost-effectiveness studies.

Paying for Hemodialysis in Kerala, India: A Description of Household Financial Hardship in the Context of Medical Subsidy

INTRODUCTION

Many low- and middle-income countries are implementing strategies to increase dialysis availability as growing numbers of people reach end-stage renal disease. Despite efforts to subsidize care, the economic sustainability of chronic dialysis in these settings remains uncertain. We evaluated the association of medical subsidy with household financial hardship related to hemodialysis in Kerala, India, a state with high penetrance of procedure-based subsidies for patients on dialysis.

METHODS

Patients on maintenance hemodialysis at 15 facilities in Kerala were administered a questionnaire that ascertained demographics, dialysis details, and household finances. We estimated direct and indirect costs of hemodialysis, and described the use of medical subsidy. We evaluated whether presence of subsidy (private, charity, or government-sponsored) was associated with lower catastrophic health expenditure (defined as ≥40% of nonsubsistence expenditure spent on dialysis) or distress financing.

RESULTS

Of the 835 patients surveyed, 759 (91%) reported their households experienced catastrophic health expenditure, and 644 (77%) engaged in distress financing. Median dialysis-related expenditure was 80% (25th-75th percentile: 60%-90%) of household nonsubsistence expenditure. Government subsidies were used by 238 (29%) of households, 139 (58%) of which were in the lowest income category. Catastrophic health expenditure was present in 215 (90%) of households receiving government subsidy and 332 (93%) without subsidy.

CONCLUSIONS

Provision of medical subsidy in Kerala, India was not associated with lower rates of household financial hardship related to long-term hemodialysis therapy. Transparent counseling on impending costs and innovative strategies to mitigate household financial distress are necessary for persons with end-stage renal disease in resource-limited settings.

The new Clinical Kidney Journal, 4 years later

The February 2015 issue of ckj started a new era with renewed efforts to be useful to the training and practicing nephrologists and a new focus on Clinical and Translational Nephrology. Four years later, it has become a truly global journal with contributors and readers from all over the world. The increase in quality of the published material has resulted in a nearly exponential growth of citations. Since 2016, ckj is listed in the new Emerging Sources Citation Index (ESCI) database from Clarivate Analytics and from January 2019 it will be listed in the full Science Citation Index. ckj will therefore receive its first official impact factor based upon 2018 citation to 2016 and 2017 articles. While no official impact factor was awarded for 2017, the estimated impact factors calculated from data available in Clarivate's Web of Science database rose to 2.987 in 2017, which would correspond to an estimated journal impact factor percentile of 72.4% in the Urology and Nephrology field.

An International Analysis of Dialysis Services Reimbursement

BACKGROUND AND OBJECTIVES

The prevalence of patients with ESKD who receive extracorporeal kidney replacement therapy is rising worldwide. We compared government reimbursement for hemodialysis and peritoneal dialysis worldwide, assessed the effect on the government health care budget, and discussed strategies to reduce the cost of kidney replacement therapy.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Cross-sectional global survey of nephrologists in 90 countries to assess reimbursement for dialysis, number of patients receiving hemodialysis and peritoneal dialysis, and measures to prevent development or progression of CKD, conducted online July to December of 2016.

RESULTS

Of the 90 survey respondents, governments from 81 countries (90%) provided reimbursement for maintenance dialysis. The prevalence of patients per million population being treated with long-term dialysis in low- and middle-income countries increased linearly with Gross Domestic Product per capita (GDP per capita), but was substantially lower in these countries compared with high-income countries where we did not observe an higher prevalence with higher GDP per capita. The absolute expenditure for dialysis by national governments showed a positive association with GDP per capita, but the percent of total health care budget spent on dialysis showed a negative association. The percentage of patients on peritoneal dialysis was low, even in countries where peritoneal dialysis is better reimbursed than hemodialysis. The so-called peritoneal dialysis-first policy without financial incentive seems to be effective in increasing the utilization of peritoneal dialysis. Few countries actively provide CKD prevention.

CONCLUSIONS

In low- and middle-income countries, reimbursement of dialysis is insufficient to treat all patients with ESKD and has a disproportionately high effect on public health expenditure. Current reimbursement policies favor conventional in-center hemodialysis.

Characteristics of Burden, Coping Strategies, and Quality of Life: The Effect of Age, Gender, and Social Variables in Caregivers of Renal Transplanted Patients from Southern Andhra Pradesh, India

Background:

Evaluation of burden, coping strategies, and quality of life (QOL) in caregivers may lead to specific interventions to reduce the burden among caregivers.

Methods:

In this prospective study, characteristics of burden, coping strategies, and QOL in caregivers was investigated and also studied the effect of age, gender, and social variables on these concepts.

Results:

Mean burden score of the caregivers was 28.66 ± 2.02. Thirty percent of caregivers had mild-to-moderate burden followed by moderate-to-severe burden (20%). Seeking social support was the dominant coping strategy used by the caregivers. Role limitations due to the physical health (RLDPH) and role limitations due to emotional problem (RLDEP) were compromised subscales of QOL. The mean score of RLDPH (P = 0.007) and RLDEP (P = 0.014) were found to be significantly higher in males than that of females. Marital status, education, type of relationship with the patient, religion, occupation, and duration of care giving showed significant effect on burden, coping strategies, and QOL. Lower emotional well-being (P = 0.003) and escape avoidance (P = 0.000) in males and lower physical component (PC) (P = 0.002) in females and lower PC (P = 0.000) and escape avoidance (P = 0.001) were found to be the significant predictors of burden in caregivers of renal transplanted patients.

Conclusion:

Predictors of burden and QOL subscales varies by gender. Social and clinical variables influence the QOL subscales. Gender- and social group-specific interventions rather than global interventions may reduce the burden of caregivers.

An International Analysis of Dialysis Services Reimbursement

BACKGROUND AND OBJECTIVES

The prevalence of patients with ESKD who receive extracorporeal kidney replacement therapy is rising worldwide. We compared government reimbursement for hemodialysis and peritoneal dialysis worldwide, assessed the effect on the government health care budget, and discussed strategies to reduce the cost of kidney replacement therapy.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Cross-sectional global survey of nephrologists in 90 countries to assess reimbursement for dialysis, number of patients receiving hemodialysis and peritoneal dialysis, and measures to prevent development or progression of CKD, conducted online July to December of 2016.

RESULTS

Of the 90 survey respondents, governments from 81 countries (90%) provided reimbursement for maintenance dialysis. The prevalence of patients per million population being treated with long-term dialysis in low- and middle-income countries increased linearly with Gross Domestic Product per capita (GDP per capita), but was substantially lower in these countries compared with high-income countries where we did not observe an higher prevalence with higher GDP per capita. The absolute expenditure for dialysis by national governments showed a positive association with GDP per capita, but the percent of total health care budget spent on dialysis showed a negative association. The percentage of patients on peritoneal dialysis was low, even in countries where peritoneal dialysis is better reimbursed than hemodialysis. The so-called peritoneal dialysis-first policy without financial incentive seems to be effective in increasing the utilization of peritoneal dialysis. Few countries actively provide CKD prevention.

CONCLUSIONS

In low- and middle-income countries, reimbursement of dialysis is insufficient to treat all patients with ESKD and has a disproportionately high effect on public health expenditure. Current reimbursement policies favor conventional in-center hemodialysis.

Sub-national health accounts: Experience from Punjab State in India

INTRODUCTION

Public health spending in India has been traditionally one of the lowest globally. Punjab is one of the states with highest proportion of out-of-pocket expenditures for healthcare in India. We undertook this study to produce the sub-national health accounts (SNHA) for Punjab state in India.

METHODOLOGY

We used System of Health Accounts (SHA) 2011 framework for preparing health accounts for Punjab state. Data on health spending by government was obtained from concerned public sector departments both at state and central level. Estimates on Out-of-Pocket Expenditures (OOPE) expenditure were derived from National Sample Survey (NSS) 71st round data, Consumer Expenditure Survey (CES) data and Pharmatrac. Primary surveys were done for assessing health expenditure data by firms and non-governmental organizations. All estimates of healthcare expenditures reported in our paper pertain to 2013-14, and are reported in both Indian National Rupee (INR) and United States Dollar (US $),using average conversion rate of INR 60.50 per US $.

RESULTS

In 2013-14, the current health expenditures (CE) in Punjab was INR 134,680million (US $ 2245 million) which was 4.02% of its gross state domestic product (GSDP).However, public spending on health was 0.95% of GSDP i.e. 21% of the total health expenditure (THE), while 79% was private expenditure. In per capita terms, THE in Punjab was INR 4963 (US $ 82.03). In terms of functions, medical goods (41.6%) and curative care (37%) consumed larger share of expenditure in the Punjab state. Households spent 52% of expenditures for medicines and other pharmaceutical goods. Risk pooling mechanisms are being adopted to a lesser extent in the state.

CONCLUSION

The healthcare in Punjab is largely financed through private OOPE. Currently, public health spending in Punjab is inadequate to meet the healthcare demands of population, which is less than 1% of state's GSDP. Monitoring public resources is very important for better resource allocations. Health Accounts production is useful in order to assess future trends and impact of health financing policies on goals of universal health coverage and should be made a part of routine monitoring system both at national and sub-national level.

Cost analysis of implementing mHealth intervention for maternal, newborn & child health care through community health workers: assessment of ReMIND program in Uttar Pradesh, India

BACKGROUND

The main intervention under ReMiND program consisted of a mobile health application which was used by community health volunteers, called ASHAs, for counselling pregnant women and nursing mothers. This program was implemented in two rural blocks in Uttar Pradesh state of India with an overall aim to increase quality of health care, thereby increasing utilization of maternal & child health services. The aim of the study was to assess annual & unit cost of ReMiND program and its scale up in UP state.

METHOD AND MATERIALS

Economic costing was done from the health system and patient's perspectives. All resources used during designing & planning phase i.e., development of application; and implementation of the intervention, were quantified and valued. Capital costs were annualised, after assessing their average number of years for which a product could be used and accounting for its depreciation. Shared or joint costs were apportioned for the time value a resource was utilized under intervention. Annual cost of implementing ReMiND in two blocks of UP along and unit cost per pregnant woman were estimated. Scale-up cost for implementing the intervention in entire state was calculated under two scenarios - first, if no extra human resource were employed; and second, if the state government adopted the same pattern of human resource as employed under this program.

RESULTS

The annual cost for rolling out ReMiND in two blocks of district Kaushambi was INR 12.1 million (US $ 191,894). The annualised start-up cost constituted 9% of overall cost while rest of cost was attributed to implementation of the intervention. The health system program costs in ReMiND were estimated to be INR 31.4 (US $ 0.49) per capita per year and INR 1294 (US $ 20.5) per registered women. The per capita incremental cost of scale up of intervention in UP state was estimated to be INR 4.39 (US $ 0.07) when no additional supervisory staffs were added.

CONCLUSION

The cost of scale up of ReMiND in Uttar Pradesh is 6% of annual budget for 'reproductive and child health' line item under state budget, and hence appears to be financially sustainable.