Changing Landscape for Peritoneal Dialysis: Optimizing Utilization.

The future growth of peritoneal dialysis (PD) will be directly linked to the shift in US healthcare to a value-based payment model due to PD's lower yearly cost, early survival advantage over in-center hemodialysis, and improved quality of life for patients treating their kidney disease in the home. Under this model, nephrology practices will need an increased focus on managing the transition from chronic kidney disease to end-stage renal disease (ESRD), providing patient education with the aim of accomplishing modality selection and access placement ahead of dialysis initiation. Physicians must expand their knowledge base in home therapies and work toward increased technique survival through implementation of specific practice initiatives that highlight PD catheter placement success, preservation of residual renal function, consideration of incremental PD, and competence in urgent start PD. Avoidance of both early and late PD technique failures is also critical to PD program growth. Large dialysis organizations must continue to measure and improve quality metrics for PD, expand their focus beyond the sole provision of PD to holistic patient care, and initiate programs to reduce PD hospitalization rates and encourage physicians to consider the benefits of PD as an initial modality for appropriate patients. New and innovative strategies are needed to address the main reasons for PD technique failure, improve the connectivity of the patient in the home, leverage home biometric data to improve overall outcomes, and develop PD cycler devices that lower patient treatment burden and reduce both treatment fatigue and treatment-dependent complications.

Health policies on dialysis modality selection: a nationwide population cohort study.

OBJECTIVES: In Taiwan, peritoneal dialysis (PD) and haemodialysis are fully accessible to patients with end-stage renal disease. However, the usage of PD is considered low in Taiwan. Since 2005, 4 major policies have been implemented by Taiwan's Ministry of Health and Welfare, namely a multidisciplinary predialysis care programme and usage increasing the PD incidence as a key performance indicator (KPI) for hospital accreditation, both of which were implemented in 2006; reimbursement of the glucose-free dialysate, icodextrin that was implemented in 2007; and insurance reimbursement for renting automated PD machines that was implemented in 2008. The aim of this study was to analyse the associations between the PD promotional policies and the actual PD selection rates. SETTING: We analysed data within the Taiwan Renal Registry Data System from 2006 to 2013, focusing on the PD incidence in relation to the timings of the 4 PD promotional policies; then we stratified the results according to age, sex and the presence of diabetes mellitus. PARTICIPANTS: From 2006 to 2013, 115 565 patients were enrolled in this study. The mean (SD) age of patients on PD was 54.6 (15.7) years. RESULTS: During the time frame in which the 4 PD promotional policies were implemented, the PD incidence increased from 12.8% in 2006 to 15.1% in 2009. The PD incidence started to decline in 2010 (13.8%) when the hospital accreditation policy was repealed. The 3 remaining policies were weakly associated with the PD incidence. The observational analysis determined that the patients' ages, sexes and diabetes mellitus incidence rates were relatively stable from 2006 to 2013. CONCLUSIONS: Of the 4 health policies intended to promote PD usage, using increasing the PD incidence as a KPI for hospital accreditation had the strongest association with the PD incidence.

Healthcare costs in chronic kidney disease and renal replacement therapy: a population-based cohort study in Sweden.

OBJECTIVE: To compare healthcare costs in chronic kidney disease (CKD) stage 4 or 5 not on dialysis (estimated glomerular filtration rate <30 mL/min/1.73m2), peritoneal dialysis, haemodialysis and in transplanted patients with matched general population comparators. DESIGN: Population-based cohort study. SETTING: Swedish national healthcare system. PARTICIPANTS: Prevalent adult patients with CKD 4 or 5 (n=1046, mean age 68 years), on peritoneal dialysis (n=101; 64 years), on haemodialysis (n=460; 65 years) and with renal transplants (n=825; 52 years) were identified in Stockholm County clinical quality registers for renal disease on 1 January 2010. 5 general population comparators from the same county were matched to each patient by age, sex and index year. PRIMARY AND SECONDARY OUTCOME MEASURES: Annual healthcare costs in 2009 incurred through inpatient and hospital-based outpatient care and dispensed prescription drugs ascertained from nationwide healthcare registers. Secondary outcomes were annual number of hospital days and outpatient care visits. RESULTS: Patients on haemodialysis had the highest mean annual cost (€87 600), which was 1.49 (95% CI 1.38 to 1.60) times that observed in peritoneal dialysis (€58 600). The mean annual cost was considerably lower in transplanted patients (€15 500) and in the CKD group (€9600). In patients on haemodialysis, outpatient care costs made up more than two-thirds (€62 500) of the total, while costs related to fluids ($29 900) was the largest cost component in patients on peritoneal dialysis (51%). Compared with their matched general population comparators, the mean annual cost (95% CI) in patients on haemodialysis, peritoneal dialysis, transplanted patients and patients with CKD was 45 (39 to 51), 29 (22 to 37), 11 (10 to 13) and 4.0 (3.6 to 4.5) times higher, respectively. CONCLUSIONS: The mean annual costs were ∼50% higher in patients on haemodialysis than in those on peritoneal dialysis. Compared with the general population, costs were substantially elevated in all groups, from 4-fold in patients with CKD to 11, 29 and 45 times higher in transplanted patients and patients on peritoneal dialysis and haemodialysis, respectively.

The financial impact of increasing home-based high dose haemodialysis and peritoneal dialysis.

BACKGROUND: Evidence suggests that high dose haemodialysis (HD) may be associated with better health outcomes and even cost savings (if conducted at home) versus conventional in-centre HD (ICHD). Home-based regimens such as peritoneal dialysis (PD) are also associated with significant cost reductions and are more convenient for patients. However, the financial impact of increasing the use of high dose HD at home with an increased tariff is uncertain. A budget impact analysis was performed to investigate the financial impact of increasing the proportion of patients receiving home-based dialysis modalities from the perspective of the England National Health Service (NHS) payer. METHODS: A Markov model was constructed to investigate the 5 year budget impact of increasing the proportion of dialysis patients receiving home-based dialysis, including both high dose HD at home and PD, under the current reimbursement tariff and a hypothetically increased tariff for home HD (£575/week). Five scenarios were compared with the current England dialysis modality distribution (prevalent patients, 14.1% PD, 82.0% ICHD, 3.9% conventional home HD; incident patients, 22.9% PD, 77.1% ICHD) with all increases coming from the ICHD population. RESULTS: Under the current tariff of £456/week, increasing the proportion of dialysis patients receiving high dose HD at home resulted in a saving of £19.6 million. Conducting high dose HD at home under a hypothetical tariff of £575/week was associated with a budget increase (£19.9 million). The costs of high dose HD at home were totally offset by increasing the usage of PD to 20-25%, generating savings of £40.0 million - £94.5 million over 5 years under the increased tariff. Conversely, having all patients treated in-centre resulted in a £172.6 million increase in dialysis costs over 5 years. CONCLUSION: This analysis shows that performing high dose HD at home could allow the UK healthcare system to capture the clinical and humanistic benefits associated with this therapy while limiting the impact on the dialysis budget. Increasing the usage of PD to 20-25%, the levels observed in 2005-2008, will totally offset the additional costs and generate further savings.

Can dialysis patients be accurately identified using healthcare claims data?

BACKGROUND: While health insurance claims data are often used to estimate the costs of renal replacement therapy in patients with end-stage renal disease (ESRD), the accuracy of methods used to identify patients receiving dialysis - especially peritoneal dialysis (PD) and hemodialysis (HD) - in these data is unknown. METHODS: The study population consisted of all persons aged 18 - 63 years in a large US integrated health plan with ESRD and dialysis-related billing codes (i.e., diagnosis, procedures) on healthcare encounters between January 1, 2005, and December 31, 2008. Using billing codes for all healthcare encounters within 30 days of each patient's first dialysis-related claim ("index encounter"), we attempted to designate each study subject as either a "PD patient" or "HD patient." Using alternative windows of ± 30 days, ± 90 days, and ± 180 days around the index encounter, we reviewed patients' medical records to determine the dialysis modality actually received. We calculated the positive predictive value (PPV) for each dialysis-related billing code, using information in patients' medical records as the "gold standard." RESULTS: We identified a total of 233 patients with evidence of ESRD and receipt of dialysis in healthcare claims data. Based on examination of billing codes, 43 and 173 study subjects were designated PD patients and HD patients, respectively (14 patients had evidence of PD and HD, and modality could not be ascertained for 31 patients). The PPV of codes used to identify PD patients was low based on a ± 30-day medical record review window (34.9%), and increased with use of ± 90-day and ± 180-day windows (both 67.4%). The PPV for codes used to identify HD patients was uniformly high - 86.7% based on ± 30-day review, 90.8% based on ± 90-day review, and 93.1% based on ± 180-day review. CONCLUSIONS: While HD patients could be accurately identified using billing codes in healthcare claims data, case identification was much more problematic for patients receiving PD.

Costs and added value of haemodialysis and peritoneal dialysis outsourcing agreements.

BACKGROUND: Despite the discrepancy in results from Spanish studies on the costs of dialysis, it is assumed that peritoneal dialysis (PD) is more efficient than haemodialysis (HD). OBJECTIVES: To analyse the costs and added value of HD and PD outsourcing agreements in Galicia, the medical transport for HD and the relationship between the cost of the agreement and the cost of consumables used in continuous ambulatory peritoneal dialysis (CAPD) with bicarbonate. METHODS: The cost of the outsourcing agreements and the staff was obtained from official publications. The cost of PD and medical transport were calculated using health service data for one month and extrapolating it to one year. The cost of CAPD consumables was provided by the suppliers. The added value was calculated from the investments generated for each agreement treating 40 patients. RESULTS: Expressed as patient/year, the mean costs for treatment were €21595 and €25664 in HD and PD, respectively. Medical transport varied between €3323 and €6338, while those of the CAPD agreement and consumables were €19268 and €12057, respectively. The added value was greater with the HD agreement, especially considering the jobs created. CONCLUSIONS: One cannot generalise that the cost of PD, which is significantly influenced by prescriptions, is lower than that of HD. It would be appropriate to review the additional cost to consumables in the CAPD agreement. The added value generated by dialysis agreements should be considered in future studies and in health planning. More controlled studies are needed to better understand this issue.

Peritoneal dialysis in developing countries.

Peritoneal dialysis (PD) is acknowledged worldwide as a well-accepted form of renal replacement therapy (RRT) for end-stage renal disease (ESRD). Ideally, PD should be the preferred modality of RRT for ESRD in developing countries due to its many inherent advantages. Some of these are cost savings (especially if PD fluids are manufactured locally or in a neighboring country), superior rehabilitation and quality of life (QOL), home-based therapy even in rural settings, avoidance of hospital based treatment and the need for expensive machinery, and freedom from serious infections (hepatitis B and C). However, this is not the ground reality, due to certain preconceived notions of the health care givers and governmental agencies in these countries. With an inexplicable stagnation or decline of PD numbers in the developed world, the future of PD will depend on its popularization in Latin America and in Asia especially countries such as China and India, with a combined population of 2.5 billion and the two fastest growing economies worldwide. A holistic approach to tackle the issues in the developing countries, which may vary from region to region, is critical in popularizing PD and establishing PD as the first-choice RRT for ESRD. At our center, we have been pursuing a 'PD first' policy and promoting PD as the therapy of choice for various situations in the management of renal failure. We use certain novel strategies, which we hope can help PD centers in other developing countries working under similar constraints. The success of a PD program depends on a multitude of factors that are interlinked and inseparable. Each program needs to identify its strengths, special circumstances, and deficiencies, and then to strategize accordingly. Ultimately, teamwork is the 'mantra' for a successful outcome, the patient being central to all endeavors. A belief and a passion for PD are the fountainhead and cornerstone on which to build a quality PD program.

[Phosphorus (P) chelant in dialysis: efficacy and cost. Peritoneal dialysis solutions]. / Quelantes de fósforo (P) en diálisis: eficacia y coste. Soluciones de diálisis peritoneal.

Sevelamer use has a high prevalence, and half of patients are treated with this noncalcium binder. Two randomized studies appeared in 2007 that compared the efficacy of sevelamer over calcium salts. In the more statistically potent of the two studies, no differences were found in mortality between the sevelamer and calcium groups, except for a benefit in favor of sevelamer in patients older than 65 years. In the other less statistically potent study, lower mortality was observed in the sevelamer group. Both studies have various deficiencies and a timely meta-analysis of the two studies appearing that same year concluded that there was no significant evidence demonstrating a superior efficacy of sevelamer over calcium salts. Therefore, generalized extension of its use as a first-line binder is not recommended. However, its use can be assessed in specific clinical situations. With regard to the cost-benefit ratio, as there is no evidence that greater clinical benefits are obtained with sevelamer than with calcium salts, prudence and moderation in its use are needed because of the high cost/benefit ratio demonstrated. Otherwise, we will contribute to increasing the already very high treatment cost in these patients, with one of the highest costs per life year gained in medicine. The cost/benefit ratio of sevelamer remains unattractive from an economic point of view, even if dialysis and transplant are excluded in these patients.

Peritoneal dialysis in India: current status and challenges.

With its ambulatory nature and freedom from complicated and expensive technology, chronic peritoneal dialysis (PD) is the ideal renal replacement therapy for resource-poor India. Despite being available for more than 15 years, PD has been limited in its growth because of economic factors, inadequate government policies, nephrologist bias, and lack of adequate pre-dialysis care. The number of patients initiated on therapy has increased in recent years, but the number of early dropouts remains high. Single-center studies suggest that contributors to poor outcome include gram-negative peritonitis, malnutrition, and failure to increase the dialysis dose as residual renal function declines. Development of a national PD registry and increased educational activities to position PD as part of integrated therapy for end-stage kidney disease would improve utilization of the PD modality.

Economic evaluation of palliative management versus peritoneal dialysis and hemodialysis for end-stage renal disease: evidence for coverage decisions in Thailand.

OBJECTIVE: To examine the value for money of including peritoneal dialysis (PD) or hemodialysis (HD) into the universal health insurance scheme of Thailand. METHODS: A probabilistic Markov model applied to end-stage renal disease (ESRD) patients aged 20 to 70 years was developed to examine the incremental cost-effectiveness ratio (ICER) of palliative care versus 1) providing PD as an initial treatment followed by HD if complications/switching occur; and 2) providing HD followed by PD if complications/switching occur. Input parameters were extracted from a national cohort, the Thailand Renal Replacement Therapy Registry, and systematic reviews, where possible. The study explored the effects of uncertainty around input parameters, presented as cost-effectiveness acceptability frontier, as well as the value of obtaining further information on chosen parameters, i.e., partial expected value of perfect information. RESULTS: Using a societal perspective, the average ICER of initial treatment with PD and the average ICER of initial treatment with HD were 672,000 and 806,000 Baht per quality-adjusted life-year (QALY) gained (52,000 and 63,000 purchasing power parity [PPP] US$/QALY) compared with palliative care. Providing treatments for younger ESRD patients resulted in a significant improvement of survival and gain of QALYs compared with the older aged group. The cost-effectiveness and cost-utility ratios of both options for the older age group were relatively similar. CONCLUSIONS: The results suggest that offering PD as initial treatment was a better choice than offering HD, but it would only be considered a cost-effective strategy if the social willingness-to-pay threshold was at or higher than 700,000 Baht per QALY (54,000 PPP US$/QALY) for the age 20 group and 750,000 Baht per QALY (58,000 PPP US$/QALY) for age 70 years.

Integrated end-stage renal disease care: the role of peritoneal dialysis.

This paper reviews the rationale behind the proposed policy of using peritoneal dialysis (PD) as the initial treatment modality in patients with end-stage renal disease (ESRD). The better preservation of residual renal function associated with PD is emphasized along with its potential cardiovascular benefits. The superior patient survival on PD, relative to hemodialysis, during the first 2 years on dialysis in both the United States and Canada is discussed, as are the potential advantages of PD in terms of hepatitis C prevention, anaemia management and quality of life. The lower cost of PD in association with these clinical advantages lead to the modality being more cost-effective in the early years on dialysis. The relatively high technique failure rate on PD, however, subsequently leads to an increasing need for haemodialysis. A policy of integrated dialysis care with PD first and then haemodialysis, as required, is advocated as a more cost-effective approach to ESRD in suitable patients.

Delivering adequacy in PD therapy.

Providing appropriate peritoneal dialysis is an ongoing challenge to renal care providers. As the residual renal function and the peritoneal permeability are likely to change with time, the dose provided by the PD regimen needs to be adjusted. Rather than waiting for clinical signs of underdialysis, the practising nephrologist and the PD nurse today have access to diagnostic tools to assist in the prescription of adequate therapy. Peritoneal dialysis prescription involves setting up a personalized dialysis schedule aimed at obtaining satisfactory clearance and ultrafiltration rates while respecting the patient's life-style as far as possible. The PD nurse has the most patient contact and thus plays a pivotal role with the other healthcare professionals in the care of the patients. As providers, it is our responsibility to inform the patients about their own care. As PD is a method of home dialysis, patients must have self responsiveness, technical and psycho social skills to deal well with the method.

Socioeconomic and health-care policies and peritoneal dialysis.

1. All ESRD treatments is expensive and a modality change adds considerably to that expense. 2. Ideally, the cost of ESRD therapy should be reported as the cost incurred for all aspects of the treatment to the health-care system. 3. Most studies show peritoneal dialysis to be less expensive than hemodialysis, but this can vary depending on the local costs of supplies and labor. 4. Strategic decisions with regard to new innovations should be made after a full analysis of all of the involved costs and savings that the innovation might introduce. 5. Economic factors and reimbursement rates appear to have an important impact on modality selection.