Three years evaluation of peritoneal dialysis and hemodialysis absorption costing: perspective of the service provider compared to funds transfers from the public and private healthcare systems.

INTRODUCTION: 72% of renal replacement therapy (RRT) clinics in Brazil are private. However, regarding payment for dialysis therapy, 80% of the patients are covered by the Unified Health System (SUS) and 20% by private healthcare (PH). OBJECTIVES: To evaluate costs for peritoneal dialysis (PD) and hemodialysis (HD) from the perspective of the service provider and compare with fund transfers from SUS and private healthcare. METHODS: The absorption costing method was applied in a private clinic. Study horizon: January 2013 - December 2016. Analyzed variables: personnel, medical supplies, tax expenses, permanent assets, and labor benefits. The input-output matrix method was used for analysis. RESULTS: A total of 27,666 HD sessions were performed in 2013, 26,601 in 2014, 27,829 in 2015, and 28,525 in 2016. There were 264 patients on PD in 2013, 348 in 2014, 372 in 2015, and 300 in 2016. The mean monthly cost of the service provider was R$ 981.10 for a HD session for patients with hepatitis B; R$ 238.30 for hepatitis C; R$197.99 for seronegative patients; and R$ 3,260.93 for PD. Comparing to fund transfers from SUS, absorption costing yielded a difference of -269.7% for hepatitis B, +10.2% for hepatitis C, -2.0% for seronegative patients, and -29.8% for PD. For PH fund transfers, absorption costing for hepatitis B yielded a difference of -50.2%, +64.24% for hepatitis C, +56.27% for seronegative patients, and +48.26 for PD. CONCLUSION: The comparison of costs of dialysis therapy from the perspective of the service provider with fund transfers from SUS indicated that there are cost constraints in HD and PD.

Abdominal ultrasound augments the medical students' ability to identify free intraabdominal fluid.

OBJECTIVE: Free intra-abdominal fluid describes an accumulation of free fluid in the peritoneal cavity. It has different etiologies, but it frequently constitutes a meaningful clinical sign. In this study, the authors interrogate whether abdominal ultrasound augments the medical students' ability to identify free intra-abdominal fluid. METHODS: Thirty-one medical students without any previous formal ultrasound training were subjected to cognitive assessment before and after four and a half-hour of theoretical lecture and hands-on course about the diagnosis of free intra-abdominal fluid by physical examination and abdominal ultrasound. The hands-on sessions were done in healthy volunteers with a simulated peritoneal catheter and in patients treated with peritoneal dialysis with different amounts of dialysate in their cavity. RESULTS: The cognitive assessment before and after the course increased from 6.7±2.3 to 11.6±1.1 points (p<0.0001). The sensitivity, specificity, and accuracy in the diagnosis of free intra-abdominal fluid were higher when students used abdominal ultrasound. The students agree with the inclusion of abdominal ultrasound in the diagnose of free intra-abdominal fluid in the undergraduate curriculum. CONCLUSIONS: This study demonstrates that incorporating abdominal ultrasound is feasible and improves medical students' short-time competency in performing and interpreting the findings diagnostic of free intra-abdominal fluid.

Three years evaluation of peritoneal dialysis and hemodialysis absorption costing: perspective of the service provider compared to funds transfers from the public and private healthcare systems / Três anos de avaliação do custeio por absorção da diálise peritoneal e hemodiálise: perspectiva do prestador de serviços em comparação com o repasse de recursos dos sistemas de saúde público e privado

Abstract Introduction: 72% of renal replacement therapy (RRT) clinics in Brazil are private. However, regarding payment for dialysis therapy, 80% of the patients are covered by the Unified Health System (SUS) and 20% by private healthcare (PH). Objectives: To evaluate costs for peritoneal dialysis (PD) and hemodialysis (HD) from the perspective of the service provider and compare with fund transfers from SUS and private healthcare. Methods: The absorption costing method was applied in a private clinic. Study horizon: January 2013 - December 2016. Analyzed variables: personnel, medical supplies, tax expenses, permanent assets, and labor benefits. The input-output matrix method was used for analysis. Results: A total of 27,666 HD sessions were performed in 2013, 26,601 in 2014, 27,829 in 2015, and 28,525 in 2016. There were 264 patients on PD in 2013, 348 in 2014, 372 in 2015, and 300 in 2016. The mean monthly cost of the service provider was R$ 981.10 for a HD session for patients with hepatitis B; R$ 238.30 for hepatitis C; R$197.99 for seronegative patients; and R$ 3,260.93 for PD. Comparing to fund transfers from SUS, absorption costing yielded a difference of -269.7% for hepatitis B, +10.2% for hepatitis C, -2.0% for seronegative patients, and -29.8% for PD. For PH fund transfers, absorption costing for hepatitis B yielded a difference of -50.2%, +64.24% for hepatitis C, +56.27% for seronegative patients, and +48.26 for PD. Conclusion: The comparison of costs of dialysis therapy from the perspective of the service provider with fund transfers from SUS indicated that there are cost constraints in HD and PD.

Resumo Introdução: 72% das clínicas de terapia renal substitutiva (TRS) no Brasil são privadas. Entretanto, quanto ao pagamento da terapia dialítica, o Sistema Único de Saúde (SUS) cobre 80% dos pacientes e, a saúde privada (SP), 20%. Objetivos: Avaliar custos de diálise peritoneal (DP) e hemodiálise (HD) na perspectiva do prestador de serviços, comparando com repasses do SUS e saúde suplementar. Métodos: O método de custeio por absorção foi aplicado em clínica privada. Horizonte de estudo: Janeiro 2013 - Dezembro 2016. Variáveis analisadas: pessoal, suprimentos médicos, despesas tributárias, ativos permanentes, benefícios trabalhistas. Utilizou-se para análise o método da matriz de input-output. Resultados: Realizou-se um total de 27.666 sessões de HD em 2013, 26.601 em 2014, 27.829 em 2015, e 28.525 em 2016. Havia 264 pacientes em DP em 2013, 348 em 2014, 372 em 2015, e 300 em 2016. O custo médio mensal do prestador de serviços foi R$ 981,10 por sessão de HD para pacientes com hepatite B; R$ 238,30 para hepatite C; R$ 197,99 para pacientes soronegativos; R$ 3.260,93 para DP. Em comparação com repasses do SUS, o custeio por absorção mostrou uma diferença de -269,7% para hepatite B, +10,2% para hepatite C, -2,0% para pacientes soronegativos, e -29,8% para DP. Para repasses da SP, o custeio por absorção para hepatite B mostrou uma diferença de -50,2%, +64,24% para hepatite C, +56,27% para pacientes soronegativos, e +48,26 para DP. Conclusão: A comparação de custos da terapia dialítica da perspectiva do prestador de serviços com os repasses do SUS indicou que existem restrições de custos em HD e DP.

Incident elderly patients on peritoneal dialysis: Epidemiological characteristics and modality impact on survival time.

Aging of the population and the increased prevalence of diseases such as diabetes and arterial hypertension result in an increasing need of dialysis treatment. Herein we describe a cohort of elderly patients on peritoneal dialysis (PD) and assess the influence of the modality on the long-term survival. Out of a multicenter prospective cohort of 2,144 BRAZPD PD incident patients during a period from December 2004 to October 2007, 762 elderly adults, defined as patients ≥65-year-old, were eligible for the study, 413 started on automated PD (APD) and 349 on continuous ambulatory PD (CAPD). Patients were followed until death, transfer to hemodialysis, recovery of renal function, loss to follow-up, or transplantation. Demographics and clinical data were evaluated at baseline and described as mean ± standard deviation, median, or percentage. Competing risk and time-dependent Cox analysis were performed, having dialysis modality APD] vs. CAPD as a dependent variable, as hazard ratio (HR) is not proportional throughout the therapy time. Mean age was 74.5 ± 6.8 years in APD, 74.6 ± 6.7 in CAPD, 50.8% females in APD, 54.4% in CAPD. The frequently observed comorbidities were diabetes (52.3% in APD and 47% in CAPD) and left ventricular hypertrophy (36.3% in APD and 46.1% in CAPD) whereas 93.6% presented Davies score ≥2. In Cox time-dependent analysis, HR did not show difference up to 18 months HR = 1.11, confidence interval (CI) = 0.85-1.46], but thereafter, APD modality revealed lower risk of mortality (HR = 0.25, CI = 0.0073-0.86), when compared with CAPD. After adjustment for the confounding factors, CAPD presented a higher risk of mortality (HR = 4.50, CI = 1.29-15.64). No differences in survival were observed up to 18 months of therapy; however, beyond 18 months, APD modality was a protection factor.

Assessment of knowledge on renal replacement therapy in health care workers of the regions: Juiz de Fora, São João Nepomuceno e Santos Dumont.

UNLABELLED: In line with the Editorial "How to explain the low penetration of peritoneal dialysis in Brazil," published in 2014 in the Brazilian Journal of Nephrology written by Professor Hugo Abensur, we show the results of a study "Assessment of knowledge on renal replacement therapy in the health workers of the regions: Juiz de Fora, São João Nepomuceno e Santos Dumont "(Approved by the Ethics Committee of UFJF CAAE: 23659213.8.0000.5147 and funded by FAPEMIG under APQ number 03626-12). We conducted a study with theObjective:to evaluate the knowledge of RRT for the health professionals of Juiz de Fora, São João Nepomuceno e Santos Dumont. METHODS: A Cross-sectional study from April 2014 to April 2015 with the population of health professionals (doctors, nurses and nursing assistance) who worked in the emergency units (EU) and primary health care (PHC) . Health professionals were interviewed using a semi-structured questionnaire, based on a clinical case of a patient diagnosed with Diabetes Mellitus, Hypertension and Chronic Kidney Disease who developed worsening renal function; initially presented creatinine 1.8 mg/dL and evaluated to 12 mg/dL. Different questions did made for professional category. RESULTS: We interviewed 75 professionals from 8 municipalities, 26.7% physicians, 32% nurses and 41.3% of nurse assistance. A mean age was 38 years. Of these 70.7% were working in PHC and 29.3% in EU. Both the EU as in PHC, the frequency of cases care was similar between once a month, once every three months. Most would forward the patient to hospital and indicate RRT. The RRT is most suitable for physicians was HD (> 90% of cases) and less than 10% as first choice indicate was PD. The association of "creatinine" and "renal function" is appropriate in over 90% of respondents, despite no association with the same level of glomerular filtration when this question is asked. More than 90% of non-medical professionals wish to conduct education/training in nephrology/RRT. CONCLUSION: We observed that most professionals do not indicate peritoneal dialysis, especially medical professionals from EU or PHC; 90% of them indicated HD. On nurses from PHC 52.1% indicated HD and 9.4% DP. Those EU, 41.6% indicated HD and 26.6% PD. We conclude that minority health professionals indicate PD as first choice and the qualitative question often refer deficit "knowledge in the area" and are interested in conducting training/capacity building.

Estudos de custo sobre terapia dialítica no mundo: uma revisão sistemática e uma abordagem histórica / Cost studies on dialysis therapy in the world: a systematic review and a historical approach

Introdução: A doença renal afeta 850 milhões de pessoas no mundo e é uma das principais contribuintes para a carga global de doenças não transmissíveis (DNT). Projeta-se que até 2040 seja a quinta causa de anos de vida perdidos. Objetivo: Avaliar onde (geograficamente) e como estão sendo feitos os estudos de custo em terapia dialítica no mundo. Material e métodos: Foi realizada nos dias 26/06/2017, 10/07/2017 e 30/09/2018 uma busca com os unitermos "cost and cost analysis", "health expenditures" and "peritoneal dialysis", os mesmos unitermos e "renal dialysis" nas bases Pubmed, Scielo e EmBase e foram encontrados 1796 artigos, destes foram selecionados 124. Acrescentou-se análise no Google Acadêmico. Ao final, analisou-se 125 artigos. Os critérios de inclusão dos artigos foram terem como escopo do estudo o custo, utilizando metodologias diversas como custo, custo total, custo efetividade, custo utilidade, custo benefício, custo minimização, gasto, impacto econômico. A perspectiva poderia ser do pagador e do prestador de serviço. Resultados: Observou-se um maior número de publicações a partir do ano 2000. Com relação ao desenho dos estudos, a maioria apresentou metodologia de difícil reprodutibilidade, utilizando conceitos variados e métodos diversos. Há uma grande variabilidade do custo entre os países e até mesmo entre os centros de diálise. Em linhas gerais, em países de alta renda, a DPAC (diálise peritoneal ambulatorial contínua) e a DPA (diálise peritoneal automatizada) apresentam menor custo quando comparadas à HD (hemodiálise). No Brasil a maioria dos estudos mostra HD apresentando menor custo que DPAC e DPA. Os desenhos são diversos e mostram, em geral, a perspectiva do pagador. Conclusão: Estudos de custos são recentes na literatura, incluem métodos diversos e a descrição dos resultados não é padronizada. Esperamos progredir para uma discussão da saúde baseada em valor.

Introduction: Kidney disease affects 850 million people worldwide and is a major contributor to the global burden of noncommunicable diseases (NCDs). By 2040 it is projected to be the fifth cause of lost years of life. Objective:The aim of this review is to evaluate where (geographically) and how cost studies on dialysis therapy are being done in the world. Material and methods: A search was carried out on 06/26/2017, 07/10/2017 and 09/30/2018 with the keywords "cost and cost analysis", "health expenditures" and "peritoneal dialysis". The same keywords and "renal dialysis" in Pubmed, Scielo and EmBase databases and 1796 articles were found, of which 124 were selected. We added analysis in academic google. At the end we analyzed 125 articles. The inclusion criteria of the articles were the scope of the study cost, using various methodologies such as cost, total cost, cost effectiveness, cost utility, cost benefit, cost minimization, expense, economic impact. The perspective could be from the payer and the service provider. Results:We observed a greater number of publications from the year 2000. Regarding the design of the studies, most presented a difficult to reproduce methodology with different concepts and different method. There were great variability across countries and even between dialysis centers. Overall, in high-income countries, continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) are less expensive than HD (hemodialysis). In Brazil most studies show HD presenting lower cost than CAPD and APD. Conclusion: Cost studies are recent in the literature, include several methods and the description of the results is not standardized. The designs are diverse and generally show the perspective of the payer. We hope to progress to a value-based health discussion.

Avaliação do conhecimento sobre terapia renal substitutiva dos profissionais de saúde nas regiões de Juiz de Fora, São João Nepomuceno e Santos Dumont / Assessment of knowledge on renal replacement therapy in health care workers of the regions: Juiz de Fora, São João Nepomuceno e Santos Dumont

ResumoEm consonância com o Editorial "Como explicar a baixa penetração da diálise peritoneal no Brasil" publicado em 2014 no Jornal Brasileiro de Nefrologia, escrito pelo Professor Hugo Abensur,1 mostramos os resultados de um estudo denominado "Avaliação do conhecimento sobre terapia renal substitutiva dos profissionais de saúde nas microrregiões de Juiz de Fora, São João Nepomuceno e Santos Dumont" (Aprovado pelo Comitê de Ética da UFJF CAAE: 23659213.8.0000.5147 e financiado pela FAPEMIG sob número APQ 03626-12).Objetivo:Avaliar o conhecimento sobre TRS dos profissionais de saúde das microrregiões de Juiz de Fora, São João Nepomuceno e Santos Dumont.Métodos:Estudo transversal no período de abril de 2014 a abril de 2015. A população estudada foi de profissionais de saúde (médicos, enfermeiros e técnicos de enfermagem) que trabalhavam nas unidades de pronto atendimento (UPA) e atenção primária à saúde (UAPS). Os profissionais de saúde foram entrevistados com o uso de um questionário semiestruturado, baseado em um caso clínico de uma paciente com diagnóstico de Diabetes Mellitus, Hipertensão Arterial e Doença Renal Crônica que evoluiu com piora da função renal, de uma creatinina de 1,8 mg/dL para 12 mg/dL e com diferentes perguntas conforme trabalhasse na UAPS ou UPA e categoria profissional e nele continha uma questão qualitativa.Resultados:Foram entrevistados 75 profissionais de 8 municípios, sendo 26,7% médicos, 32% enfermeiros e 41,3% técnicos de enfermagem. A idade média foi de 38 anos. Destes, 70,7% trabalhavam em UAPS e 29,3% em UPA. Tanto na UPA quanto na UAPS a frequência referida de atendimento de casos semelhantes ficou entre uma vez por mês e uma vez a cada três meses. A maioria encaminharia o paciente para unidade hospitalar e indicaria TRS. A TRS mais indicada pelos médicos é a HD (> 90% dos casos) e menos de 10% indicariam DP como primeira escolha. A associação de "creatinina" e função renal" é adequada em mais de 90% das respostas, a despeito de não haver associação da mesma com nível de filtração glomerular, quando esta pergunta é feita. Mais de 90% dos profissionais não médicos desejam realizar treinamento/capacitação em nefrologia/TRS.Conclusão:Observamos que a maioria dos profissionais não indicam diálise peritoneal, principalmente profissionais médicos, tanto das UAPS quanto das UPAs; 90% destes indicaram HD. Sobre enfermeiros e técnicos de enfermagem das UAPS, 52,1% indicaram HD e 9,4% DP. Aqueles da UPA 41,6% indicaram HD e 26,6% DP. Concluímos que uma minoria dos profissionais de saúde indicaria DP como primeira escolha e, na questão qualitativa referem frequente déficit de "conhecimento na área", estão interessados em realizar treinamento/capacitação.

AbstractIn line with the Editorial "How to explain the low penetration of peritoneal dialysis in Brazil," published in 2014 in the Brazilian Journal of Nephrology written by Professor Hugo Abensur, we show the results of a study "Assessment of knowledge on renal replacement therapy in the health workers of the regions: Juiz de Fora, São João Nepomuceno e Santos Dumont "(Approved by the Ethics Committee of UFJF CAAE: 23659213.8.0000.5147 and funded by FAPEMIG under APQ number 03626-12). We conducted a study with theObjective:to evaluate the knowledge of RRT for the health professionals of Juiz de Fora, São João Nepomuceno e Santos Dumont.Methods:A Cross-sectional study from April 2014 to April 2015 with the population of health professionals (doctors, nurses and nursing assistance) who worked in the emergency units (EU) and primary health care (PHC) . Health professionals were interviewed using a semi-structured questionnaire, based on a clinical case of a patient diagnosed with Diabetes Mellitus, Hypertension and Chronic Kidney Disease who developed worsening renal function; initially presented creatinine 1.8 mg/dL and evaluated to 12 mg/dL. Different questions did made for professional category.Results:We interviewed 75 professionals from 8 municipalities, 26.7% physicians, 32% nurses and 41.3% of nurse assistance. A mean age was 38 years. Of these 70.7% were working in PHC and 29.3% in EU. Both the EU as in PHC, the frequency of cases care was similar between once a month, once every three months. Most would forward the patient to hospital and indicate RRT. The RRT is most suitable for physicians was HD (> 90% of cases) and less than 10% as first choice indicate was PD. The association of "creatinine" and "renal function" is appropriate in over 90% of respondents, despite no association with the same level of glomerular filtration when this question is asked. More than 90% of non-medical professionals wish to conduct education/training in nephrology/RRT.Conclusion:We observed that most professionals do not indicate peritoneal dialysis, especially medical professionals from EU or PHC; 90% of them indicated HD. On nurses from PHC 52.1% indicated HD and 9.4% DP. Those EU, 41.6% indicated HD and 26.6% PD. We conclude that minority health professionals indicate PD as first choice and the qualitative question often refer deficit "knowledge in the area" and are interested in conducting training/capacity building.