Peritoneal dialysis: Status report in South and South East Asia

BACKGROUND

Peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) is largely underutilized globally. We analyzed PD utilization, impact of economic status, projected growth and impact of state policy(s) on PD growth in South Asia and Southeast Asia (SA&SEA) region.

METHODS

The National Nephrology Societies of the region responded to a questionnaire on KRT practices. The responses were based on the latest registry data, acceptable community-based studies and societal perceptions. The representative countries were divided into high income and higher-middle income (HI & HMI) and low income and lower-middle income (LI & LMI) groups.

RESULTS

Data provided by 15 countries showed almost similar percentage of GDP as health expenditure (4%-7%). But there was a significant difference in per capita income (HI & HMI -US$ 28 129 vs. LI & LMI - US$ 1710.2) between the groups. Even after having no significant difference in monthly cost of haemodialysis (HD) and PD in LI & LMI countries, they have poorer PD utilization as compared to HI & HMI countries (3.4% vs. 10.1%); the reason being lack of formal training/incentives and time constraints for the nephrologist while lack of reimbursement and poor general awareness of modalities has been a snag for the patients. The region expects ≥10% PD growth in the near future. Hong Kong and Thailand with 'PD first' policy have the highest PD utilization.

CONCLUSION

Important deterrents to PD underutilization were lack of PD centric policies, lackadaisical patient/physician's attitude, lack of structured patient awareness programs, formal training programs and affordability.

Cost-analysis of persistent hyperkalaemia in non-dialysis chronic kidney disease patients under nephrology care in Italy

AIM

In patients with chronic kidney disease (CKD), hyperkalaemia (HK) (potassium level ≥ 5.0 mEq/L) is associated with poor clinical outcomes. This study provides novel insights by comparing management costs of CKD patients with normokalaemia vs those with persistent HK regularly followed in renal clinics in Italy.

METHODS

To this aim, a Markov model over life-time horizon was developed. Time to end-stage renal disease (ESRD) and time to death in CKD patients were derived from an observational multi-centre database including 1665 patients with non-dialysis CKD stage 1-5 under nephrology care in Italy (15 years follow-up). Resource use for CKD and HK management was obtained from the observational database, KDIGO international guidelines, and clinical expert opinion.

RESULTS

Results showed that patients with normokalaemia vs persistent HK brought an average per patient lifetime cost-saving of €16 059 besides delayed onset of ESRD by 2.29 years and increased survival by 1.79 years with increment in total survival and dialysis-free survival in normokalaemia that decreased from early to advanced disease. Cost-saving related to normokalaemia increased at more advanced CKD; however, it was already evident at early stage (3388.97€ at stage 1-3a). OWSA confirmed cost-saving associated with normokalaemia across all parameter variations.

DISCUSSION AND CONCLUSION

This model is the first to simulate the impact of HK in non-dialysis CKD patients on economic and clinical outcomes using real-world data from nephrology clinics. In these patients, persistent HK results into higher lifetime costs, besides poorer clinical outcomes, that are evident since the early stages of CKD. Maintaining normokalaemia should therefore be of main concern in CKD treatment planning to improve long-term economic and clinical outcomes.

Effect of nephrology referrals and multidisciplinary care programs on renal replacement and medical costs on patients with advanced chronic kidney disease: A retrospective cohort study

Evidence-based studies have revealed outcomes in patients with chronic kidney disease that differed depending on the design of care delivery. This study compared the effects of 3 types of nephrology care: multidisciplinary care (MDC), nephrology care, and non-nephrology care. We studied their effects on the risks of requiring dialysis and the differences between these methods had on long-term medical resource utilization and costs.We conducted a retrospective cohort study involving patients with an estimated glomerular filtration rate of (eGFR) ≤45 mL/min/1.73 m from 2005 to 2007. Patients were divided into MDC, non-MDC, and non-nephrology referral groups. Between-group differences with regard to the risk of requiring dialysis and annual medical utilization and costs were evaluated using a 5-year follow-up period.In total, 661 patients were included. After other covariates and the competing risk of death were taken into account, we observed a significant (56%) reduction in the incidence of dialysis in both the MDC and non-MDC groups relative to the non-nephrology referral group. Costs were markedly lower in the MDC group relative to the other groups (average savings: US$ 830 per year; 95% confidence interval: 367-1295; P < .001).For patients without nephrology referrals, MDC can substantially reduce their risk of developing end-stage renal disease and lower their medical costs. We therefore strongly advocate that all patients with an eGFR of ≤45 mL/min/1.73 m should be referred to a nephrologist and receive MDC.

Why are hospitalisations too long? A simple checklist for identifying the main social barriers to hospital discharge from a nephrology ward

The present increase in life span has been accompanied by an even higher increase in the burden of comorbidity. The challenges to healthcare systems are enormous and performance measures have been introduced to make the provision of healthcare more cost-efficient. Performance of hospitalisation is basically defined by the relationship between hospital stay, use of hospital resources, and main diagnosis/diagnoses and complication(s), adjusted for case mix. These factors, combined in different indexes, are compared with the performance of similar hospitals in the same and other countries. The reasons why an approach like this is being employed are clear.Cutting costs cannot be the only criteria, in particular in elderly, high-comorbidity patients: in this population, although social issues are important determinants of hospital stay, they are rarely taken into account or quantified in evaluations. Quantifying the impact of the "social barriers" to care can serve as a marker of the overall quality of treatment a network provides, and point to specific out-of-hospital needs, necessary to improve in-hospital performance. We therefore propose a simple, empiric medico-social checklist that can be used in nephrology wards to assess the presence of social barriers to hospital discharge and quantify their weight.Using the checklist should allow: identifying patients with social frailty that could complicate hospitalisation and/or discharge; evaluating the social needs of patient and entourage at the beginning of hospitalisation, adopting timely procedures, within the partnership with out-of-hospital teams; facilitating prioritization of interventions by social workers.The following ten items were empirically identified: reason for hospitalisation; hospitalisation in relation to the caregiver's problems; recurrent unplanned hospitalisations or early re-hospitalisation; social/family isolation; presence of a dependent relative in the patient's household; lack of housing or unsuitable housing/accommodation; loss of autonomy; lack of economic resources; lack of a safe environment; evidence of physical or psychological abuse.The simple tool here described needs validation; the present proposal is aimed at raising attention on the importance of non-medical issues in medical organisation in our specialty, and is open to discussion, to allow its refinement.

The Medicare Access and CHIP Reauthorization Act: Implications for Nephrology

In response to rising Medicare costs, Congress passed the Medicare Access and Children's Health Insurance Program Reauthorization Act in 2015. The law fundamentally changes the way that health care providers are reimbursed by implementing a pay for performance system that rewards providers for high-value health care. As of the beginning of 2017, providers will be evaluated on quality and in later years, cost as well. High-quality, cost-efficient providers will receive bonuses in reimbursement, and low-quality, expensive providers will be penalized financially. The Centers for Medicare and Medicaid Services will evaluate provider costs through episodes of care, which are currently in development, and alternative payment models. Although dialysis-specific alternative payment models have already been implemented, current models do not address the transition of patients from CKD to ESRD, a particularly vulnerable time for patients. Nephrology providers have an opportunity to develop cost-efficient ways to care for patients during these transitions. Efforts like these, if successful, will help ensure that Medicare remains solvent in coming years.

The cost-saving effect and prevention of medication errors by clinical pharmacist intervention in a nephrology unit

Medication errors may lead to adverse drug events (ADEs), which endangers patient safety and increases healthcare-related costs. The on-ward deployment of clinical pharmacists has been shown to reduce preventable ADEs, and save costs. The purpose of this study was to evaluate the ADEs prevention and cost-saving effects by clinical pharmacist deployment in a nephrology ward.This was a retrospective study, which compared the number of pharmacist interventions 1 year before and after a clinical pharmacist was deployed in a nephrology ward. The clinical pharmacist attended ward rounds, reviewed and revised all medication orders, and gave active recommendations of medication use. For intervention analysis, the numbers and types of the pharmacist's interventions in medication orders and the active recommendations were compared. For cost analysis, both estimated cost saving and avoidance were calculated and compared.The total numbers of pharmacist interventions in medication orders were 824 in 2012 (preintervention), and 1977 in 2013 (postintervention). The numbers of active recommendation were 40 in 2012, and 253 in 2013. The estimated cost savings in 2012 and 2013 were NT$52,072 and NT$144,138, respectively. The estimated cost avoidances of preventable ADEs in 2012 and 2013 were NT$3,383,700 and NT$7,342,200, respectively. The benefit/cost ratio increased from 4.29 to 9.36, and average admission days decreased by 2 days after the on-ward deployment of a clinical pharmacist.The number of pharmacist's interventions increased dramatically after her on-ward deployment. This service could reduce medication errors, preventable ADEs, and costs of both medications and potential ADEs.

Clinical Integration of Billing for a Pediatric Nephrology and Transplant Program

Purpose

To develop and implement a billing process that fully integrates all activities of a pediatric nephrology and transplant program, by facilitating and coordinating data from patients, physicians, hospitals, and third-party billing services to maximize revenues.

Methods

Financial operations were analyzed via a randomized audit of patient charts that focused on office procedures and revenue collection. Results based on monthly reports documenting revenue received and outstanding, procedures billed, and patient registration accuracy.

Results

The combination of improvements in patient registration, chart documentation, new billing sheets with procedure and diagnosis codes, physician in-service education, upgraded charges, and the recredentialing of all practice physicians realized an increase in revenue collections from 18% in 2000 to 89% in 2001.

Conclusion

The need to integrate and coordinate information is vital for both billing accuracy and revenue collections. Integration of clinical services and billing procedures has maximized performance, profitability, and accuracy while decreasing administrative time and costs.

Trends in nephrology practice

The analysis of this benchmarking data tells us several things. Nephrology practices are more complex. Physicians are generating more RVUs for less money and a greater percentage of income is coming from things other than direct patient care. Practices have responded partly by becoming larger and looking for revenue stream diversification. The ability to predict the financial future from the historical data is problematic. We know from the most recent survey that a significant number of nephrology practices are already participating in accountable care organizations, shared savings programs, and even risk sharing contracts. We know that the incentive for participation in government quality reporting programs and meaningful use is transitioning from the carrot to the stick and that reductions in reimbursement will be applied to those who are unsuccessful. In order to take on the challenges and complexity that the future holds, successful nephrology practices will likely be larger, more sophisticated and tightly aligned with all stakeholders in the pursuit to provide high quality, low cost care to patients with kidney disease.

[Organizational models in the Italian nephrology, dialysis and transplantation network]

In this article, the Italian Society of Nephrology discusses the recent statement of the Italian National Government regarding the 'The definition of the structure and technological standards of hospital health care' and suggests a new model of organization of the Italian Nephrology, Dialysis and Transplantation Network. In particular, the Italian Society of Nephrology proposes the presence of a nephrologist as part of the Emergency Hospital Network, to oversee all extracorporeal replacement treatments taking place in Intensive Care Units. Finally, this article recommends the cooperation of the nephrologist with primary health care teams and general practitioners as a move to prevent the complications of chronic kidney disease, thus improving short-term and long-term survival outcomes and reducing the costs to the National Health System.

Clinical research in pediatric nephrology: challenges, and strategies to address them

There are many obstacles to conducting meaningful clinical research studies in children with kidney disease. This review describes some of the challenges facing clinical investigators in pediatric nephrology, and proposes strategies to overcome them. Four broad categories of challenges are considered: inadequate power, funding issues, ethical issues and practical barriers. Power is influenced not just by sample size, but also by population heterogeneity and the outcome chosen; these issues are discussed in detail. Ethical issues and practical barriers of particular relevance to pediatric studies are considered. Examples of successful multicenter studies are provided. In addition, some of the strengths and limitations of existing registry data are highlighted.