How are patients managing with the costs of care for chronic kidney disease in Australia? A cross-sectional study

Navigating Choices in Nephrology: The Role of Patient-Reported Outcomes and Preferences in Economic Evaluations and Decisions in Health Care

The increasing burden of chronic kidney disease (CKD) on the health care system highlights the need to prioritize services and manage the use of resources efficiently. Amid these financial constraints, key decision makers must weigh the impact of an intervention or program on health care expenditure when determining the allocation of limited resources. Patient-reported outcome measures (PROMs) are relevant in health economic decision-making within nephrology. Health-related quality of life, a patient-reported outcome, can provide data that inform economic evaluations of treatments for patients with CKD. PROMs help determine the value of different therapies by assessing their impact on patients' daily lives beyond clinical outcomes and can help policymakers make decisions about funding and reimbursement that consider the priorities and preferences of patients. Economic evaluations often employ cost-utility analyses, which use quality-adjusted life years as a key metric. Quality-adjusted life years combine both the quality and quantity of life lived, allowing for comparison of the effectiveness of different interventions in a standardized manner. By integrating utilities derived from PROMs, these analyses quantify the benefits of CKD treatments in terms of how patients feel and function. Furthermore, PROMs contribute to quality improvement initiatives by identifying areas where patient care can be enhanced, guiding the implementation of programs that improve health-related quality of life while maintaining cost-effectiveness. In value-based financing environments, the integration of PROMs ensures that patient-centered outcomes are prioritized, leading to more effective and equitable health care delivery. In this article, we discuss the role of PROMs in economic evaluations in CKD and provide an overview of approaches for using PROMs in economic evaluations to inform decision-making in nephrology.

Longitudinal associations between socioeconomic position and overall health of children with chronic kidney disease and their carers

BACKGROUND

Disadvantaged socioeconomic position (SEP) is an important predictor of poor health in children with chronic kidney disease (CKD). The time course over which SEP influences the health of children with CKD and their carers is unknown.

METHODS

This prospective longitudinal study included 377 children, aged 6-18 years with CKD (stages I-V, dialysis, and transplant), and their primary carers. Mixed effects ordinal regression was performed to assess the association between SEP and carer-rated child health and carer self-rated health over a 4-year follow-up.

RESULTS

Adjusted for CKD stage, higher family household income (adjusted odds ratio (OR) (95% CI) 3.3, 1.8-6.0), employed status of primary carers (1.7, 0.9-3.0), higher carer-perceived financial status (2.6, 1.4-4.8), and carer home ownership (2.2, 1.2-4.0) were associated with better carer-rated child health. Household income also had a differential effect on the carer's self-rated health over time (p = 0.005). The predicted probabilities for carers' overall health being 'very good' among lower income groups at 0, 2, and 4 years were 0.43 (0.28-0.60), 0.34 (0.20-0.51), and 0.25 (0.12-0.44), respectively, and 0.81 (0.69-0.88), 0.84 (0.74-0.91), and 0.88 (0.76-0.94) for carers within the higher income group.

CONCLUSIONS

Carers and their children with CKD in higher SEP report better overall child and carer health compared with those in lower SEP. Carers of children with CKD in low-income households had poorer self-rated health compared with carers in higher-income households at baseline, and this worsened over time. These cumulative effects may contribute to health inequities between higher and lower SEP groups over time. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information.

Socioeconomic Position and Health Among Children and Adolescents With CKD Across the Life-Course

Children and adolescents in families of lower socioeconomic position (SEP) experience an inequitable burden of reduced access to healthcare and poorer health. For children living with chronic kidney disease (CKD), disadvantaged SEP may exacerbate their considerable disease burden. Across the life-course, CKD may also compromise the SEP of families and young people, leading to accumulating health and socioeconomic disadvantage. This narrative review summarizes the current evidence on relationships of SEP with kidney care and health among children and adolescents with CKD from a life-course approach, including impacts of family SEP on kidney care and health, and bidirectional impacts of CKD on SEP. It highlights relevant conceptual models from social epidemiology, current evidence, clinical and policy implications, and provides directions for future research. Reflecting the balance of available evidence, we focus primarily on high-income countries (HICs), with an overview of key issues in low- and middle-income countries (LMICs). Overall, a growing body of evidence indicates sobering socioeconomic inequities in health and kidney care among children and adolescents with CKD, and adverse socioeconomic impacts of CKD. Dedicated efforts to tackle inequities are critical to ensuring that all young people with CKD have the opportunity to live long and flourishing lives. To prevent accumulating disadvantage, the global nephrology community must advocate for local government action on upstream social determinants of health; and adopt a life-course approach to kidney care that proactively identifies and addresses unmet social needs, targets intervening factors between SEP and health, and minimizes adverse socioeconomic outcomes across financial, educational and vocational domains.

Financial Toxicity in Renal Patients (FINTORE) Study: A Cross-Sectional Italian Study on Financial Burden in Kidney Disease-A Project Protocol

Financial toxicity (FT) refers to the negative impact of health-care costs on clinical conditions. In general, social determinants of health, especially poverty, socioenvironmental stressors, and psychological factors, are increasingly recognized as important determinants of non-communicable diseases, such as chronic kidney disease (CKD), and their consequences. We aim to investigate the prevalence of FT in patients at different stages of CKD treated in our universal health-care system and from pediatric nephrology, hemodialysis, peritoneal dialysis and renal transplantation clinics. FT will be assessed with the Patient-Reported Outcome for Fighting Financial Toxicity (PROFFIT) score, which was first developed by Italian oncologists. Our local ethics committee has approved the study. Our population sample will answer the sixteen questions of the PROFFIT questionnaire, seven of which are related to the outcome and nine the determinants of FT. Data will be analyzed in the pediatric and adult populations and by group stratification. We are confident that this study will raise awareness among health-care professionals of the high risk of adverse health outcomes in patients who have both kidney disease and high levels of FT. Strategies to reduce FT should be implemented to improve the standard of care for people with kidney disease and lead to truly patient-centered care.

Out-of-pocket expenditure, need, utilisation, and private health insurance in the Australian healthcare system

Despite widespread public service provision, public funding, and private health insurance (PHI), 20% of all healthcare expenditure across the OECD is covered by out-of-pocket expenditure (OOPE). This creates an equity concern for the increasing number of individuals with chronic conditions and greater need, particularly if higher need coincides with lower income. Theoretically, individuals may mitigate OOPE risk by purchasing PHI, replacing variable OOPE with fixed expenditure on premiums. Furthermore, if PHI premiums are not risk-rated, PHI may redistribute some of the financial burden from less healthy PHI holders that have greater need to healthier PHI holders that have less need. We investigate if the burden of OOPE for individuals with greater need increases less strongly for individuals with PHI in the Australian healthcare system. The Australian healthcare system provides public health insurance with full, partial, or limited coverage, depending on the healthcare service used, and no risk rating of PHI premiums. Using data from the Household, Income and Labour Dynamics in Australia survey we find that individuals with PHI spend a greater share of their disposable income on OOPE and that the difference in OOPE share between PHI and non-PHI holders increases with greater need and utilisation, contrary to the prediction that PHI may mitigate OOPE. We also show that OOPE is a greater concern for poorer individuals for whom the difference in OOPE by PHI is the greatest.

Financial toxicity experienced by rural Australian families with chronic kidney disease

AIM

Chronic kidney disease (CKD) and its treatment places a financial burden on healthcare systems and households worldwide, yet little is known of its financial impact, on those who reside in rural settings. We aimed to quantify the financial impacts and out-of-pocket expenditure experienced by adult rural patients with CKD in Australia.

METHODS

A web based structured survey was completed between November 2020 and January 2021. English speaking participants over 18 years of age, diagnosed with CKD stages 3-5, those receiving dialysis or with a kidney transplant, who lived in a rural location in Australia.

RESULTS

In total 77 (69% completion rate) participated. The mean out of pocket expenses were 5056 AUD annually (excluding private health insurance costs), 78% of households experienced financial hardship with 54% classified as experiencing financial catastrophe (out-of-pocket expenditure greater than 10% of household income). Mean distances to access health services for all rural and remote classifications was greater than 50 kilometres for specialist nephrology services and greater than 300 kilometres for transplanting centres. Relocation for a period greater than 3 months to access care was experienced by 24% of participants.

CONCLUSION

Rural households experience considerable financial hardship due to out-of-pocket costs in accessing treatment for CKD and other health-related care, raising concerns about equity in Australia, a high-income country with universal healthcare.

Health inequity associated with financial hardship among patients with kidney failure

Financial hardship is a common challenge among patients with kidney failure and may have negative health consequences. Therefore, financial status is regarded as an important determinant of health, and its impact needs to be investigated. This cross-sectional study aimed to identify the differences in patient-reported and clinical outcomes among kidney failure patients with different financial status. A total of 354 patients with kidney failure were recruited from March to June 2017 at two hospitals in Hong Kong. The Dialysis Symptoms Index and Kidney Disease Quality of Life-36 were used to evaluate patient-reported outcomes. Clinical outcomes were retrieved from medical records and assessed using the Karnofsky Performance Scale (functional status) and Charlson Comorbidity Index (comorbidity level). Patients were stratified using two dichotomised variables, employment status and income level, and their outcomes were compared using independent sample t-tests and Mann-Whitney U-tests. In this sample, the employment rate was 17.8% and the poverty rate was 61.2%. Compared with other patients, increased distress of specific symptoms and higher healthcare utilization, in terms of more emergency room visits and longer hospital stays, were found in patients with poorer financial status. Low-income patients reported a decreased mental quality of life. Financially underprivileged patients experienced health inequity in terms of impaired outcomes. Attention needs to be paid to these patients by providing financial assessments and interventions. Additional research is warranted to confirm these findings and understand the experience of financial hardship and health equity.

Real price of health-experiences of out-of-pocket costs in Australia: protocol for a systematic review

INTRODUCTION

Australians have substantial out-of-pocket (OOP) health costs compared with other developed nations, even with universal health insurance coverage. This can significantly affect access to care and subsequent well-being, especially for priority populations including those on lower incomes or with multimorbidity and chronic illness. While it is known that high OOP healthcare costs may contribute to poorer health outcomes, it is not clear exactly how these expenses are experienced by people with chronic illnesses. Understanding this may provide critical insights into the burden of OOP costs among this population group and may highlight policy gaps.

METHOD AND ANALYSIS

A systematic review of qualitative studies will be conducted using Pubmed, CINAHL Complete (EBSCO), Cochrane Library, PsycINFO (Ovid) and EconLit from date of inception to June 2022. Primary outcomes will include people's experiences of OOP costs such as their preferences, priorities, trade-offs and other decision-making considerations. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and methodological appraisal of included studies will be assessed using the Critical Appraisal Skills Programme. A narrative synthesis will be conducted for all included studies.

ETHICS AND DISSEMINATION

Ethics approval was not required given this is a systematic review that does not include human recruitment or participation. The study's findings will be disseminated through conferences and symposia and shared with consumers, policymakers and service providers, and published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022337538.

Clinicians' perspectives on equity of access to dialysis and kidney transplantation for rural people in Australia: a semistructured interview study

OBJECTIVES

People with chronic kidney disease requiring dialysis or kidney transplantation in rural areas have worse outcomes, including an increased risk of hospitalisation and mortality and encounter many barriers to accessing kidney replacement therapy. We aim to describe clinicians' perspectives of equity of access to dialysis and kidney transplantation in rural areas.

DESIGN

Qualitative study with semistructured interviews.

SETTING AND PARTICIPANTS

Twenty eight nephrologists, nurses and social workers from 19 centres across seven states in Australia.

RESULTS

We identified five themes: the tyranny of distance (with subthemes of overwhelming burden of travel, minimising relocation distress, limited transportation options and concerns for patient safety on the roads); supporting navigation of health systems (reliance on local champions, variability of health literacy, providing flexible models of care and frustrated by gatekeepers); disrupted care (without continuity of care, scarcity of specialist services and fluctuating capacity for dialysis); pervasive financial distress (crippling out of pocket expenditure and widespread socioeconomic disadvantage) and understanding local variability (lacking availability of safe and sustainable resources for dialysis, sensitivity to local needs and dependence on social support).

CONCLUSIONS

Clinicians identified geographical barriers, dislocation from homes and financial hardship to be major challenges for patients in accessing kidney replacement therapy. Strategies such as telehealth, outreach services, increased service provision and patient navigators were suggested to improve access.

Association between Financial Hardship and Symptom Burden in Patients Receiving Maintenance Dialysis: A Systematic Review

BACKGROUND

Many patients on maintenance dialysis experience financial hardship. Existing studies are mainly cost analyses that quantify financial hardship in monetary terms, but an evaluation of its impact is also warranted. This review aims to explore the definition of financial hardship and its relationship with symptom burden among patients on dialysis.

METHODS

A literature search was conducted in November 2020, using six electronic databases. Studies published in English that examined the associations between financial hardship and symptom burden were selected. Two reviewers independently extracted data and appraised the studies by using the JBI Critical Appraisal Checklists.

RESULTS

Fifty cross-sectional and seven longitudinal studies were identified. Studies used income level, employment status, healthcare funding, and financial status to evaluate financial hardship. While relationships between decreased income, unemployment, and overall symptom burden were identified, evidence suggested that several symptoms, including depression, fatigue, pain, and sexual dysfunction, were more likely to be associated with changes in financial status.

CONCLUSION

Our findings suggest that poor financial status may have a negative effect on physical and psychological well-being. However, a clear definition of financial hardship is warranted. Improving this assessment among patients on dialysis may prompt early interventions and minimize the negative impact of financial hardship.

Perspectives on ability to work from patients' receiving dialysis and caregivers: analysis of data from the global SONG initiative

BACKGROUND

Patients receiving dialysis have low employment rates, which compounds poorer health and socioeconomic outcomes. Reasons for under- and unemployment remain underexplored. We aimed to describe the perspectives of patients receiving hemodialysis (HD) or peritoneal dialysis (PD) and their caregivers on ability to work.

METHODS

Data was derived from adult patients' and caregivers' responses from 26 focus groups, two international Delphi surveys and two consensus workshops conducted through the Standardized Outcomes in Nephrology (SONG-HD) and SONG-PD programs. Our secondary thematic analysis identified concepts around ability to work.

RESULTS

Five hundred four patients and 146 caregivers from 86 countries were included. We identified five themes: financial pressures and instability (with subthemes of rationing the budget with increased expenditure, losing financial independence and threatened job security); struggling to meet expectations (burdened by sociocultural norms and striving to protect independence); contending with upheaval of roles and responsibilities (forced to establish a new routine to accommodate work, symptoms disrupting work, prioritizing work and other duties, and adjusting to altered capacity to work); enabling flexibility and control (employment driving decisions about dialysis modality and schedule, workplace providing occupational safety and adaptability, requiring organizational support and planning for a future career); and finding purpose and value (accepting and redefining identity, pride and fulfillment, and protecting mental well-being).

CONCLUSIONS

Employment enabled patients to maintain their identity, independence, financial security and mental health. Symptom burden, workplace inflexibility and juggling roles are major challenges. Interventions addressing motivation, workplace flexibility and safety, and establishing goals and routines could support patients' capacities to work, thereby improving overall well-being and productivity.

Developing economic measures for Aboriginal and Torres Strait Islander families on out-of-pocket healthcare expenditure

Objective Out-of-pocket healthcare expenditure (OOPHE) has a significant impact on marginalised households. The purpose of this study was to modify a pre-existing OOPHE survey for Aboriginal and Torres Strait Islander households with children. Methods The OOPHE survey was derived through a scoping review, face and content validity, including judgement quantification with content experts. Exploratory factor analyses determined factor numbers for construct validity. Repeatability through test-retest processes and reliability was assessed through internal consistency. Results The OOPHE survey had 168 items and was piloted on 67 Aboriginal and Torres Strait Islander parents. Construct validity assessment generated a 62-item correlation matrix with a three-factor model. Across these factors, item loadings varied, 10 items with high correlations (>0.70) and 20 with low correlations (<0.40). OOPHE survey retest was conducted with 47 families, where 43 items reached slight to fair levels of agreement. Conclusion The low level of item loadings to factors in the OOPHE survey indicates interconnectedness across the three-factor model, and reliability results suggest systemic differences. Impeding factors may include cohort homogeneity and survey length. It is unknown how cultural and social nuances specific to Aboriginal and Torres Strait Islander households impacts on results. Further work is warranted. What is known about the topic? Out-of-pocket healthcare expenditure (OOPHE) are expenses not covered by universal taxpayer-funded health insurance. In elderly Australians or those with chronic conditions, OOPHE can cause substantial burden and financial hardship and, in the most extreme cases, induce bankruptcy. Despite higher hospital admissions and disease burden, little is known about how OOPHE impacts Aboriginal and Torres Strait Islander families. Additionally, in Australia, no OOPHE survey tools have been appropriately assessed; this includes for use with Aboriginal and Torres Strait Islander families. What does this paper add? This pilot study modified a pre-existing Australian OOPHE survey for use with Aboriginal and Torres Strait Islander households with children. Knowledge interface methodology was used to bring together Indigenous knowledges with quantitative survey methods. This was critical to ensuring Indigenous knowledges were central to the overall pilot study across item creation, participant focus, outcome contextualisation, interpretation, and resetting dominant norms. Outcomes have demonstrated pertinent points for future work in this area, such as the complexities in developing robust, culturally safe and specific surveys, which reach ideal psychometric levels of validity and reliability for Aboriginal and Torres Strait Islander communities. Certainly, it raises questions for current and future research using surveys in Aboriginal and Torres Strait Islander communities, which are generic and not purpose-built. What are the implications for practitioners? We recommend that OOPHE surveys should be developed with Aboriginal and Torres Strait Islander families from the outset, so they can include important contextual factors for Aboriginal and Torres Strait Islander households.

Financial Hardship Among Nonelderly Adults With CKD in the United States

RATIONALE & OBJECTIVE

The burden of financial hardship among individuals with chronic kidney disease (CKD) has not been extensively studied. Therefore, we describe the scope and determinants of financial hardship among a nationally representative sample of adults with CKD.

STUDY DESIGN

Cross-sectional.

SETTING & PARTICIPANTS

Nonelderly adults with CKD from the 2014-2018 National Health Interview Survey.

EXPOSURE

Sociodemographic and clinical characteristics.

OUTCOME

Financial hardship based on medical bills and consequences of financial hardship (high financial distress, food insecurity, cost-related medication nonadherence, delayed/forgone care due to cost). Financial hardship was categorized into 3 levels: no financial hardship, financial hardship but able to pay bills, and unable to pay bills at all. Financial hardship was then modeled in 2 different ways: (1) any financial hardship (regardless of ability to pay) versus no financial hardship and (2) inability to pay bills versus no financial hardship and financial hardship but able to pay bills.

ANALYTICAL APPROACH

Nationally representative estimates of financial hardship from medical bills were computed. Multivariable logistic regression models were used to examine the associations of sociodemographic and clinical factors with the outcomes of financial hardship based on medical bills.

RESULTS

A total 1,425 individuals, representing approximately 2.1 million Americans, reported a diagnosis of CKD within the past year, of whom 46.9% (95% CI, 43.7%-50.2%) reported experiencing financial hardship from medical bills; 20.9% (95% CI, 18.5%-23.6%) reported inability to pay medical bills at all. Lack of insurance was the strongest determinant of financial hardship in this population (odds ratio, 4.06 [95% CI, 2.18-7.56]).

LIMITATIONS

Self-reported nature of CKD diagnosis.

CONCLUSIONS

Approximately half the nonelderly US population with CKD experiences financial hardship from medical bills that is associated strongly with lack of insurance. Evidence-based clinical and policy interventions are needed to address these hardships.

Inequality in out of pocket fees, government funding and utilisation of maternal health services in Australia

This study aimed to assess the distribution of service utilisation, out-of-pocket fees and government funding for maternal health care in Australia by socioeconomic group. A large linked administrative dataset was utilised. Women were grouped into socioeconomic quintiles using an area-based measure of socioeconomic status. Descriptive statistics were used to quantify the distribution of number of services, out of pocket fees, and government funding by socioeconomic quintile. Needs-adjusted concentration indices (CI_NA) were utilised to quantify inequity. The mean out of pocket fees for women of least socioeconomic advantage was $1,026 and for women of most socioeconomic advantage the mean was $2,432 (CI_NA 0.093, 95% CI: 0.088 - 0.098). However, use of many services were higher for women of most socioeconomic advantage: private obstetrician (CI_NA: 0.035, 95% CI: 0.032 - 0.038), other specialist services (CI_NA: 0.089, 95%CI: 0.083 - 0.094), and diagnostic and pathology tests (CI_NA: 0.027, 95%CI: 0.025 - 0.030). Federal government funding through Medicare was distributed towards women of most socioeconomic advantage (CI_NA: 0.036, 95%CI: 0.033 - 0.039); whereas government public hospital funding was skewed towards women of least socioeconomic advantage (CI_NA: -0.05, 95%CI: -0.057 - -0.046). Future policy changes in Australia's healthcare system need to ensure that women of least socioeconomic advantage have adequate access to maternity and early childhood care, and out of pocket fees are not an access barrier.

Out-of-pocket spending among a cohort of Australians living with gout

OBJECTIVE

To measure the direct and indirect out-of-pocket (OOP) costs borne by Australians with gout.

METHODS

A cross-sectional, Australia-wide, web-based survey was conducted over 12 months between May 2017 and April 2018. Participants were recruited via advertisements in doctors' clinics and healthcare organizations' websites, and social media platforms such as Facebook and Twitter. Survey questions collected information about participants' OOP spending on direct medical and non-medical gout-related healthcare costs. Participant demographics, gout status, healthcare sought, workdays lost to due gout and health-related quality of life were also collected.

RESULTS

Seventy-nine patients with gout completed the survey; 70 (89%) were male, and on average were 56 (SD 16) years of age and had gout for 14 (SD 12) years. For this cohort, the median total OOP direct medical cost was AU$200 per year (interquartile range [IQR]: AU$60-AU$570). Sixty (76%) people with gout reported being affected by gout during work; however, only 0.25 (IQR: 0-3) days of work (approximately $60) were lost due to gout in a year. Nine percent (n = 7) of participants experienced cost-related treatment attrition and 33% reported economic hardship (n = 26). Participants who experienced economic hardship or cost-related treatment attrition had higher median total gout-related direct costs than those who did not.

CONCLUSION

In Australia, gout has an OOP financial cost and reduces work productivity. The presence of cost-related treatment attrition among people with gout indicates that financial costs may be a significant barrier to seeking treatment for a subset of patients with gout.

Patients' and caregivers' perspectives on access to kidney replacement therapy in rural communities: systematic review of qualitative studies

OBJECTIVE

Patients with chronic kidney disease (CKD) requiring kidney replacement therapy (KRT) in rural communities encounter many barriers in accessing equitable care and have worse outcomes compared with patients in urban areas. This study aims to describe the perspectives of patients and caregivers on access to KRT in rural communities to inform strategies to maximise access to quality care, and thereby reduce disadvantage, inequity and improve health outcomes.

SETTING

18 studies (n=593 participants) conducted across eight countries (Australia, Canada, the UK, New Zealand, Ghana, the USA, Tanzania and India).

RESULTS

We identified five themes: uncertainty in navigating healthcare services (with subthemes of struggling to absorb information, without familiarity and exposure to options, grieving former roles and yearning for cultural safety); fearing separation from family and home (anguish of homesickness, unable to fulfil family roles and preserving sense of belonging in community); intense burden of travel and cost (poverty of time, exposure to risks and hazards, and taking a financial toll); making life-changing sacrifices; guilt and worry in receiving care (shame in taking resources from others, harbouring concerns for living donor, and coping and managing in isolation).

CONCLUSION

Patients with CKD in rural areas face profound and inequitable challenges of displacement, financial burden and separation from family in accessing KRT, which can have severe consequences on their well-being and outcomes. Strategies are needed to improve access and reduce the burden of obtaining appropriate KRT in rural communities.

A Systematic Review of Screening Tests for Chronic Kidney Disease: An Accuracy Analysis

This systematic review was conducted to assess the diagnostic accuracy of chronic kidney disease screening tests in the general population. MEDLINE, EMBASE, Web of Science, Scopus, The Cochrane Library and ProQuest databases were searched for English-language publications up to November 2016. Two reviewers independently screened studies and extracted study data in standardized tables. Methodological quality was assessed using the QUADAS-2 tool. Sensitivity and specificity of all available screening methods were identified through included studies. Ten out of 1349 screened records included for final analysis. Sensitivities of the dipstick test with a cutoff value of trace were ranged from 37.1% to 69.4% and specificities from 93.7% to 97.3% for the detection of ACR>30 mg/g. The diagnostic sensitivities of the UAC>10 mg/dL testing was shown to vary from 40% to 87%, and specificities ranged from 75% to 96%. While the sensitivities of ACR were fluctuating between 74% and 90%, likewise the specificities were between 77% and 88%. Sensitivities for C-G, Grubb and Larsson equations were 98.9%, 86.2%, and 70.1% respectively. In the meantime the study showed specificities of 84.8%, 84.2% and 90.5% respectively for these equations. Individual studies were highly heterogeneous in terms of target populations, type of screening tests, thresholds used to detect CKD and variations in design. Results pointed to the superiority of UAC and dipstick over the other tests in terms of all parameters involved. The diversity of methods and thresholds for detection of CKD, necessitate considering the cost parameter along with the effectiveness of tests to scale-up an efficient strategy.

Economic burden and cost-utility analysis of three renal replacement therapies in ESRD patients from Yunnan Province, China

PURPOSE

To compare the economic burden and cost-utility analysis of the renal replacement therapies, including hemodialysis (HD), peritoneal dialysis (PD), and allograft kidney transplantation (KT) among end-stage renal disease (ESRD) patients from Yunnan Province, China.

METHODS

Multistage stratified random sampling method was used to select presentative sample of 298 patients from four hospitals in Yunnan Province. The two-step model was applied to calculate a direct economic burden; the human capital approach was used to analyze the indirect economic burden. SF-36 scale was applied to assess the quality of life, while the improving score of quality of life was used to evaluate the cost-utility score.

RESULTS

A total of 298 patients were analyzed, including 108 HD patients, 91 PD patients and 99 KT patients. The mean unit economic expenses of HD, PD, and KT were $11,783.6 ± 402.63, $11,059.8 ± 709.51, and $21,151.1 ± 11,419.57, respectively. Based on the cost-utility analysis, the cost of improving one unit of quality of life in KT, PD, and HD was $599.86, $1373.89 and $2021.20, respectively; a significant difference was observed between the KT group and the HD or PD group (P < 0.05).

CONCLUSIONS

The economic burden of ESRD in Yunnan was substantial. The cost-utility was the best in the renal transplantation group. Kidney transplantation is still recommended as the first approach for patients with ESRD, followed by PD.

End-stage renal disease-financial costs and years of life lost in Panama: a cost-analysis study

OBJECTIVES

Central America is a region with an elevated burden of chronic kidney disease (CKD); however, the cost of treatment for end-stage renal disease (ESRD) remains an understudied area. This study aimed to investigate the direct costs associated with haemodialysis (HD) and peritoneal dialysis (PD) in public and private institutions in Panama in 2015, to perform a 5-year budget impact analysis and to calculate the years of life lost (YLL) due to CKD.

DESIGN

A retrospective cost-analysis study using hospital costs and registry-based data.

SETTING

Data on direct costs were derived from the public and private sectors from two institutions from Panama. Data on CKD-related mortality were obtained from the National Mortality Registry.

METHODS

A budget impact analysis was performed from the payer perspective, and five scenarios were estimated, with the assumption that the mix of dialysis modality use shifts towards a greater use of PD over time. The YLL due to CKD was calculated using data recorded between 1 January 2015 and 31 December 2015. The linear method was utilised for the analyses with the population aged 20-77 years old.

RESULTS

In 2015, the total costs for dialysis in the public sector ranged from ~US$7.9  million (PD) to US$62  million (HD). The estimated costs were higher in the scenario in which a decrease in PD was assumed. The average annual loss due to CKD was 25 501 808.40 US$-YLL.

CONCLUSION

ESRD represents a major challenge for Panama. Our results suggest that an increased use of PD might provide an opportunity to substantially lower overall ESRD treatment costs.

Global costs attributed to chronic kidney disease: a systematic review

SUMMARY The aim of this study is to discuss the global costs attributed to chronic kidney disease (CKD) and its impact on healthcare systems of developing countries, such as Brazil. This is a systematic review based on data from PubMed/Medline, using the key words “costs” and “chronic kidney disease”, in January 2017. The search was also done in other databases, such as Scielo and Google Scholar, aiming to identify regional studies related to this subject, published in journal not indexed in PubMed. Only papers published from 2012 on were included. Studies on CKD costs and treatment modalities were prioritized. The search resulted in 392 articles, from which 291 were excluded because they were related to other aspects of CKD. From the 101 remaining articles, we have excluded the reviews, comments and study protocols. A total of 37 articles were included, all focusing on global costs related to CKD. Despite methods and analysis were diverse, the results of these studies were unanimous in alerting for the impact (financial and social) of CKD on health systems (public and private) and also on family and society. To massively invest in prevention and measures to slow CKD progression into its end-stages and, then, avoid the requirement for dialysis and transplant, can represent a huge, and not yet calculated, economy for patients and health systems all over the world.

Association of Poor Social Support and Financial Insecurity with Psychological Distress of Chronic Kidney Disease Patients Attending National Nephrology Unit in Sri Lanka

BACKGROUND

Chronic kidney disease (CKD) is associated with high morbidity and mortality. Hence, CKD patients are often in chronic psychological distress. The objective of the study was to describe factors associated with psychological distress of CKD patients attending National Nephrology Unit.

METHODS

A descriptive cross-sectional study was conducted among 382 CKD patients above 18 years of age applying systematic sampling. The data was collected using self-administered questionnaires to assess the psychological distress (GHQ-12), social support (SSQ6), coping strategies (BRIEFCOPE), pain (0 to 10 numeric pain rating scale), and physical role limitation due to ill health (SF36QOL). Sociodemographic and disease-related data were collected using an interviewer administered questionnaire and a data extraction sheet. Multiple logistic regression was applied for determining the associated factors. The results were expressed as adjusted odds ratio (AOR) and 95% confidence intervals (95% CI).

RESULTS

Percentage of psychological distress was 55.2% (95% CI: 48.4% to 62%). Poor social support (AOR = 1.81, 95% CI: 1.14-2.88), low satisfaction with the social support received (AOR = 4.14, 95% CI: 1.59-10.78), stages IV and V of CKD (AOR = 2.67, 95% CI: 1.65-4.20), presence of comorbidities (AOR = 2.38, 95% CI: 1.21-4.67), within one year of diagnosis (AOR = 2.23, 95% CI: 1.36-3.67), low monthly income (AOR = 2.26, CI: 1.26-4.06), higher out-of-pocket expenditure per month (AOR = 1.75, 95% CI: 1.75-1.99), and being a female (AOR = 2.95, 95% CI: 1.79-4.9) were significantly associated with psychological distress.

CONCLUSIONS

More than half of the CKD patients were psychologically distressed. Factors such as financial and social support will be worth considering early because of their modifiability.

The economic burden of kidney disorders in Korea

AIMS

To estimate the economic burden of kidney disorders in Korea.

MATERIALS AND METHODS

The economic burden of kidney disorders was estimated using a prevalence-based approach. Related kidney diseases in patients with kidney disorders (RPWKD) were defined using codes from the tenth International Classification of Disease (E70-E90, F30-F48, F60-F69, F90-F99, K65-K67, N00-N08, N17-N19, and N30-N39). All diseases in patients with kidney disorders (APWKD) were defined as kidney disorders that involved all disease codes. Economic costs were divided into direct costs (medical costs and non-medical costs) and indirect costs (productivity loss because of morbidity and premature mortality).

RESULTS

The prevalence of kidney disorders increased from 0.08% (2008) to 0.11% (2011). The total economic burden of RPWKD also substantially increased from $898.9 million (2008) to $1.43 billion (2011). This ∼59.4% increase in the economic burden was equal to 0.12% of the Korean gross domestic product. The economic burden of APWKD also increased during the study period: $1.06 billion (2008), $1.23 billion (2009), $1.44 billion (2010), and $1.46 billion (2011).

CONCLUSIONS

The present study provides the first data regarding the economic burden of kidney disorders in Korea. The findings support the need for early intervention services and prevention programs to prevent, identify, and manage kidney disorders.

Impact of CKD on Household Income

Introduction

The impact of chronic kidney disease (CKD) on income is unclear. We sought to determine whether CKD severity, serious adverse events, and CKD progression affected household income.

Methods

Analyses were undertaken in a prospective cohort of adults with moderate-to-severe CKD in the Study of Heart and Renal Protection (SHARP), with household income information available at baseline screening and study end. Logistic regressions, adjusted for sociodemographic characteristics, smoking, and prior diseases at baseline, estimated associations during the 5-year follow-up, among (i) baseline CKD severity, (ii) incident nonfatal serious adverse events (vascular or cancer), and (iii) CKD treatment modality (predialysis, dialysis, or transplanted) at study end and the outcome “fall into relative poverty.” This was defined as household income <50% of country median income.

Results

A total of 2914 SHARP participants from 14 countries were included in the main analysis. Of these, 933 (32%) were in relative poverty at screening; of the remaining 1981, 436 (22%) fell into relative poverty by study end. Compared with participants with stage 3 CKD at baseline, the odds of falling into poverty were 51% higher for those with stage 4 (odds ratio [OR]: 1.51; 95% confidence interval [CI]: 1.09–2.10), 66% higher for those with stage 5 (OR: 1.66; 95% CI: 1.11–2.47), and 78% higher for those on dialysis at baseline (OR: 1.78, 95% CI: 1.22–2.60). Participants with kidney transplant at study end had approximately half the risk of those on dialysis or those with CKD stages 3 to 5.

Conclusion

More advanced CKD is associated with increased odds of falling into poverty. Kidney transplantation may have a role in reducing this risk.

Short Hairpin RNA Knockdown of Connective Tissue Growth Factor by Ultrasound-Targeted Microbubble Destruction Improves Renal Fibrosis

The purpose of this study was to evaluate whether ultrasound-targeted microbubble destruction transfer of interfering RNA against connective tissue growth factor (CTGF) in the kidney would ameliorate renal fibrosis in vivo. A short hairpin RNA (shRNA) targeting CTGF was cloned into a tool plasmid and loaded onto the surface of a cationic microbubble product. A unilateral ureteral obstruction (UUO) model in mice was used to evaluate the effect of CTGF knockdown. Mice were administered the plasmid-carrying microbubble intravenously, and ultrasound was applied locally to the obstructed kidney. Mice undergoing a sham UUO surgery and untreated UUO mice were used as disease controls, and mice administered plasmid alone, plasmid with ultrasound treatment and microbubbles and plasmid without ultrasound were used as treatment controls. Mice were treated once and then evaluated at day 14. CTGF in the kidney was measured by quantitative reverse transcription polymerase chain reaction and Western blot. Expression of CTGF, transforming growth factor β1, α smooth muscle actin and type I collagen in the obstructed kidney was evaluated by immunohistochemistry. The cohort treated with plasmid-carrying microbubbles and ultrasound exhibited reduced mRNA and protein expression of CTGF (p < 0.01). Furthermore, CTGF gene silencing decreased the interstitial deposition of transforming growth factor β1, α smooth muscle actin and type I collagen as assessed in immunohistochemistry, as well as reduced renal fibrosis in pathologic alterations (p < 0.01). No significant changes in target mRNA, protein expression or disease pathology were observed in the control cohorts. A single treatment of ultrasound-targeted microbubble destruction is able to deliver sufficient shRNA to inhibit the expression of CTGF and provide a meaningful reduction in disease severity. This technique may be a potential therapy for treatment of renal fibrosis.

The household economic burden for acute coronary syndrome survivors in Australia

BACKGROUND

Studies of chronic diseases are associated with a financial burden on households. We aimed to determine if survivors of acute coronary syndrome (ACS) experience household economic burden and to quantify any potential burden by examining level of economic hardship and factors associated with hardship.

METHODS

Australian patients admitted to hospital with ACS during 2-week period in May 2012, enrolled in SNAPSHOT ACS audit and who were alive at 18 months after index admission were followed-up via telephone/paper survey. Regression models were used to explore factors related to out-of-pocket expenses and economic hardship.

RESULTS

Of 1833 eligible patients at baseline, 180 died within 18 months, and 702 patients completed the survey. Mean out-of-pocket expenditure (n = 614) in Australian dollars was A$258.06 (median: A$126.50) per month. The average spending for medical services was A$120.18 (SD: A$310.35) and medications was A$66.25 (SD: A$80.78). In total, 350 (51 %) of patients reported experiencing economic hardship, 78 (12 %) were unable to pay for medical services and 81 (12 %) could not pay for medication. Younger age (18-59 vs ≥80 years (OR): 1.89), no private health insurance (OR: 2.04), pensioner concession card (OR: 1.80), residing in more disadvantaged area (group 1 vs 5 (OR): 1.77), history of CVD (OR: 1.47) and higher out-of-pocket expenses (group 4 vs 1 (OR): 4.57) were more likely to experience hardship.

CONCLUSION

Subgroups of ACS patients are experiencing considerable economic burden in Australia. These findings provide important considerations for future policy development in terms of the cost of recommended management for patients.

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.

Dialysis outcomes in India: a pilot study

AIM

Long-term prospective studies of health outcomes for dialysis patients are common in many parts of the world but have been rare in India. As renal replacement therapy becomes more widespread and more affordable, the measurement of patient outcomes and comparison with national and international benchmarks will be a valuable tool in planning health services and demonstrating effective use of resources. To this end, we describe a pilot study of dialysis outcomes in India which could form the basis of a comprehensive national programme of data collection.

METHODS

One hundred incident patients commencing chronic haemodialysis in two north Indian nephrology centres will be followed prospectively for 12 months. Clinical outcome data will be collected comparable with that used by established dialysis registries in other countries. The economic impact of dialysis upon patients is central to the use of this treatment, so data will be collected on the direct and indirect costs of the treatment and the economic impact of dialysis on the patient and their family.

VALUE OF PROJECT

This prospective cohort study of dialysis outcomes in northern India is a pilot for the collection of similar comparative data in dialysis centres in different states across the country with a view to the development of a national dialysis registry. The information on the economic impact of dialysis on patients and their families will provide one of the first detailed insights into this critical aspect of dialysis services.

Family income is associated with quality of life in patients with chronic kidney disease in the pre-dialysis phase: a cross sectional study

BACKGROUND

Chronic kidney disease (CKD) is a condition of high prevalence in the general population mainly due to hypertension and diabetes mellitus. It is often associated with a high prevalence of complications and worse quality of life. The main objective of this study is to evaluate quality of life (QOL) using the generic instrument SF-36 in patients with CKD in pre-dialysis and identify the possible influence of the degree of renal function, hemoglobin level, age, gender, family income and level of education on QOL.

METHODS

A cross-sectional study was conducted and included 170 individuals (83 men) with a mean age of 57 ± 15 years who met the inclusion criteria and answered the SF-36. Laboratory tests and clinical and demographic data were obtained, and the glomerular filtration rate was estimated using the CKD-EPI formula.

RESULTS

The degree of renal function did not influence QOL. Women had lower scores in functional capacity, physical aspects, pain, and mental health. Patients younger than 47 years old showed better QOL in the functional capacity; however, their QOL was worse in terms of social aspects. Subjects with an income higher than 5.1 times the minimum wage had better QOL in the functional capacity, pain, social, physical and emotional roles, and mental health. Hemoglobin levels and education did not globally influence QOL.

CONCLUSION

Gender and age influenced QOL, but family income was the most important factor affecting QOL (6 out of 8 domains investigated by SF-36) in this sample of 170 individuals with CKD in pre-dialysis. These findings suggest that many efforts should be made to reduce the effect of these factors on quality of life in patients with CKD and reinforce the need for longitudinal studies and intervention.

Challenges of hemodialysis in Vietnam: experience from the first standardized district dialysis unit in Ho Chi Minh City

Background

Hemodialysis is an increasingly common treatment in Vietnam as the diagnosis of end stage renal disease continues to rise. To provide appropriate hemodialysis treatment for end-stage renal disease patients, we conducted a 1-year cross-sectional study to measure the prevalence of bloodborne infection and factors associated with non-compliant behaviors in hemodialysis patients.

Methods

One hundred forty-two patients were tested for hepatitis B virus (HBV) surface antigen and hepatitis C virus (HCV) core antigen. They provided demographic, medical and dialysis information. Non-compliant behaviors were obtained from their medical records.

Results

Overall, 99 % of patients reused their dialyzers and 46 % had arteriovenous fistula on admission. Both HBV and HCV equally accounted for 8 % of patients and concurrent infection accounted for 1 %. Non-compliance rates of dietary and medication were 39 and 27 % respectively. 42 % of patients missed hemodialysis session, 8 % were verbally or physically abusive and 9 % were non-cooperative. Of the 54 % catheterized patients, 7 % improperly cared for their dialysis access. Dietary non-adherence was associated with male patients (p = 0.03) and medication non-adherence was associated with younger age (p = 0.05). Duration between diagnosis of chronic kidney disease and initiation of hemodialysis was associated with improper care of dialysis access (p = 0.04). Time on hemodialysis was associated with missed hemodialysis session (p = 0.007) and verbal or physical abuse (p = 0.01).

Conclusion

Health services need to provide safe practice for dialyzer reuse given the endemicity of hepatitis. We believe a national survey similar to ours about seroprevalence and infection control challenges would prepare Vietnam for providing safer satellite treatment units. Safe hemodialysis services should also comprise patient preparedness, education and counseling.

Co-payments for health care: what is their real cost?

Based on the premise that current trends in healthcare spending are unsustainable, the Australian Government has proposed in the recent Budget the introduction of a compulsory $7 co-payment to visit a General Practitioner (GP), alongside increased medication copayments. This paper is based on a recent submission to the Senate Inquiry into the impact of out-of-pocket costs in Australia. It is based on a growing body of evidence highlighting the substantial economic burden faced by individuals and families as a result of out-of-pocket costs for health care and their flow-on effects on healthcare access, outcomes and long-term healthcare costs. It is argued that a compulsory minimum co-payment for GP consultations will exacerbate these burdens and significantly undermine the tenets of universal access in Medicare. Alternative recommendations are provided that may help harness unsustainable health spending while promoting an equitable and fair health system.

The global impact of non-communicable diseases on households and impoverishment: a systematic review

The global economic impact of non-communicable diseases (NCDs) on household expenditures and poverty indicators remains less well understood. To conduct a systematic review and meta-analysis of the literature evaluating the global economic impact of six NCDs [including coronary heart disease, stroke, type 2 diabetes mellitus (DM), cancer (lung, colon, cervical and breast), chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD)] on households and impoverishment. Medline, Embase and Google Scholar databases were searched from inception to November 6th 2014. To identify additional publications, reference lists of retrieved studies were searched. Randomized controlled trials, systematic reviews, cohorts, case-control, cross-sectional, modeling and ecological studies carried out in adults and assessing the economic consequences of NCDs on households and impoverishment. No language restrictions. All abstract and full text selection was done by two independent reviewers. Data were extracted by two independent reviewers and checked by a third independent reviewer. Studies were included evaluating the impact of at least one of the selected NCDs and on at least one of the following measures: expenditure on medication, transport, co-morbidities, out-of-pocket (OOP) payments or other indirect costs; impoverishment, poverty line and catastrophic spending; household or individual financial cost. From 3,241 references, 64 studies met the inclusion criteria, 75% of which originated from the Americas and Western Pacific WHO region. Breast cancer and DM were the most studied NCDs (42 in total); CKD and COPD were the least represented (five and three studies respectively). OOP payments and financial catastrophe, mostly defined as OOP exceeding a certain proportion of household income, were the most studied outcomes. OOP expenditure as a proportion of family income, ranged between 2 and 158% across the different NCDs and countries. Financial catastrophe due to the selected NCDs was seen in all countries and at all income levels, and occurred in 6-84% of the households depending on the chosen catastrophe threshold. In 16 low- and middle-income countries (LMIC), 6-11% of the total population would be impoverished at a 1.25 US dollar/day poverty line if they would have to purchase lowest price generic diabetes medication. NCDs impose a large and growing global impact on households and impoverishment, in all continents and levels of income. The true extent, however, remains difficult to determine due to the heterogeneity across existing studies in terms of populations studied, outcomes reported and measures employed. The impact that NCDs exert on households and impoverishment is likely to be underestimated since important economic domains, such as coping strategies and the inclusion of marginalized and vulnerable people who do not seek health care due to financial reasons, are overlooked in literature. Given the scarcity of information on specific regions, further research to estimate impact of NCDs on households and impoverishment in LMIC, especially the Middle Eastern, African and Latin American regions is required.

The household economic burden of eating disorders and adherence to treatment in Australia

BACKGROUND

This study investigated the household economic burden of eating disorders and cost-related non-adherence to treatment in Australia.

METHODS

Multi-centre prospective observational study using a structured questionnaire. Ninety participants were recruited from two clinic settings in New South Wales, Australia and from the community using social media. The primary outcome measures were household economic burden of illness measured in terms of out-of-pocket expenditure, household economic hardship and cost-related non-adherence.

RESULTS

The pattern of out-of-pocket expenditure varied by diagnosis, with Bulimia Nervosa associated with the highest total mean expenditure (per three months). Economic hardship was reported in 96.7% of participants and 17.8% reported cost-related non-adherence. Those most likely to report cost-related non-adherence had a longer time since diagnosis. Cost-related non-adherence and higher out-of-pocket expenditure were associated with poorer quality of life, a more threatening perception of the impact of the illness and poor self-reported health.

CONCLUSIONS

This study is the first to empirically and quantitatively examine the household economic burden of eating disorders from the patient perspective. Results indicate that households experience a substantial burden associated with the treatment and management of an eating disorder. This burden may contribute to maintaining the illness for those who experience cost-related non-adherence and by negatively influencing health outcomes. Current initiatives to implement sustainable and integrated models of care for eating disorders should strive to minimise the economic impact of treatment on families.