Economic evaluation of peritoneal dialysis and hemodialysis in Thai population with End-stage Kidney Disease.

BACKGROUND: This study aimed to conduct a cost-utility analysis of the "Peritoneal Dialysis (PD)-First" policy in 2008 under a universal health coverage scheme and hemodialysis (HD) in Thai patients with End-stage Kidney Disease (ESKD) using updated real-practice data. METHODS: Markov model was used to evaluate the cost-utility of two modalities, stratified into five age groups based on the first modality taken at 20, 30, 40, 50, and 60 years old from government and societal perspectives. Input parameters related to clinical aspects and cost were obtained from 15 hospitals throughout Thailand and Thai Renal Replacement Therapy databases. Both costs and outcomes were discounted at 3%, adjusted to 2021, and converted to USD (1 USD = 33.57 Thai Baht). One-way analysis and probabilistic sensitivity analysis were performed to assess the uncertainty surrounding model parameters. RESULTS: From the government perspective, compared to PD-first policy, the incremental cost-effectiveness ratio (ICER) was between 19,434 and 23,796 USD per QALY. Conversely, from a societal perspective, the ICER was between 31,913 and 39,912 USD per QALY. Both are higher than the willingness to pay threshold of 4,766 USD per QALY. CONCLUSION: By applying the updated real-practice data, PD-first policy still remains more cost-effective than HD-first policy at the current willingness to pay. However, HD gained more quality-adjusted life years than PD. This information will assist clinicians and policymakers in determining the future direction of dialysis modality selection and kidney replacement therapy reimbursement policies for ESKD patients.

Cost-Utility Analysis of Dapagliflozin as an Add-on to Standard of Care for Patients with Chronic Kidney Disease in Thailand.

INTRODUCTION: Chronic kidney disease (CKD) creates a significant economic burden on patients and society. The DAPA-CKD trial reports the benefit of dapagliflozin in CKD patients; however, its cost-effectiveness is unknown in Thailand. This study evaluated the cost-utility of dapagliflozin in addition to standard of care (SoC) compared with SoC alone in CKD patients. METHODS: A Markov model was employed to estimate lifetime costs, life-years, and quality-adjusted life-year (QALY), with the modeled population aligned to the baseline characteristics of a DAPA-CKD trial, from a societal perspective. Effectiveness inputs were obtained from the DAPA-CKD trial. Costs and most utility data were gathered from published studies conducted in Thailand. Costs and benefits were discounted at 3% per annum. A series of sensitivity analyses were performed. RESULTS: Over a lifetime horizon, add-on dapagliflozin was estimated to increase life-years by 0.34 and QALY by 0.30 in comparison with SoC alone (7.13 vs. 6.78 years, 5.10 vs. 4.80 QALYs). Total cost was lower under dapagliflozin treatment than SoC treatment (648,413 THB vs. 689,284 THB or 20,947.64 USD vs. 22,268.01 USD). Cost saving occurred as a result of the lower costs of dialysis and KT. The findings were robust to the changes of inputs. CONCLUSIONS: On the basis of the DAPA-CKD trial, the add-on dapagliflozin results in cost saving compared favorably with SoC alone in Thailand. The benefit of dapagliflozin in delayed CKD progression is that it reduces the requirement for dialysis and KT, which can offset the costs of dapagliflozin and early CKD treatment.

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-Utility Analysis of Dapagliflozin as an Add-On to Standard Treatment for Patients with Type 2 Diabetes and High Risk of Cardiovascular Disease in Thailand.

INTRODUCTION: Diabetes treatment has incurred financial burden. We examined the cost-utility of adding dapagliflozin to the standard treatment for treating type 2 diabetes (T2DM) with cardiovascular risk in a Thai context. METHODS: A two-part model, decision tree and Markov models, was developed to capture the benefits in terms of heart failure (HF) and chronic kidney disease. The model was used to estimate the lifetime costs and outcomes from a societal perspective. Costs were based on local data while the transitional probabilities and utilities were derived from the DECLARE-TIMI 58 clinical trial and published studies. Future costs and outcomes were discounted at an annual rate of 3%. The results were reported as incremental cost-effectiveness ratios (ICER). One-way and probabilistic sensitivity analyses were performed to investigate parameter uncertainty. RESULTS: The increased cost of adding dapagliflozin from 8707 USD to 14,455 USD was associated with an increase in quality-adjusted life years (QALYs) from 9.28 to 9.58, yielding an ICER of 18,988 USD/QALY. Compared with the standard treatment, the dapagliflozin group acquired more clinical benefits in terms of fewer HF hospitalizations and macroalbuminuria. Sensitivity analyses revealed that with high prevalence of diabetic nephropathy of 29.4-43.9%, the ICER would decline to 5591-8014 USD/QALY. CONCLUSION: On the basis of the DECLARE study with low incidence of T2DM complications and 4.2 years of median follow-up duration, the add-on dapagliflozin results in an ICER of 18,988 USD/QALY, which exceeds the local threshold of 5310 USD/QALY. Dapagliflozin would show better value for money in the context of high prevalence of T2DM complications.

Impact of National Economy and Policies on End-Stage Kidney Care in South Asia and Southeast Asia.

BACKGROUND: The association between economic status and kidney disease is incompletely explored even in countries with higher economy (HE); the situation is complex in lower economies (LE) of South Asia and Southeast Asia (SA and SEA). METHODS: Fifteen countries of SA and SEA categorized as HE and LE, represented by the representatives of the national nephrology societies, participated in this questionnaire and interview-based assessment of the impact of economic status on renal care. RESULTS: Average incidence and prevalence of end-stage kidney disease (ESKD) per million population (pmp) are 1.8 times and 3.3 times higher in HE. Hemodialysis is the main renal replacement therapy (RRT) (HE-68%, LE-63%). Funding of dialysis in HE is mainly by state (65%) or insurance bodies (30%); out of pocket expenses (OOPE) are high in LE (41%). Highest cost for hemodialysis is in Brunei and Singapore, and lowest in Myanmar and Nepal. Median number of dialysis machines/1000 ESKD population is 110 in HE and 53 in LE. Average number of machines/dialysis units in HE is 2.7 times higher than LE. The HE countries have 9 times more dialysis centers pmp (median HE-17, LE-02) and 16 times more nephrologist density (median HE-14.8 ppm, LE-0.94 ppm). Dialysis sessions >2/week is frequently followed in HE (84%) and <2/week in LE (64%). "On-demand" hemodialysis (<2 sessions/week) is prevalent in LE. Hemodialysis dropout rates at one year are lower in HE (12.3%; LE 53.4%), death being the major cause (HE-93.6%; LE-43.8%); renal transplants constitute 4% (Brunei) to 39% (Hong Kong) of the RRT in HE. ESKD burden is expected to increase >10% in all the HE countries except Taiwan, 10%-20% in the majority of LE countries. CONCLUSION: Economic disparity in SA and SEA is reflected by poor dialysis infrastructure and penetration, inadequate manpower, higher OOPE, higher dialysis dropout rates, and lesser renal transplantations in LE countries. Utility of RRT can be improved by state funding and better insurance coverage.