Cost of dialysis therapies in rural and remote Australia - a micro-costing analysis.

BACKGROUND: Maintenance dialysis is a costly and resource intense activity. In Australia, inadequate health infrastructure and poor access to technically skilled staff can limit service provision in remote areas where many Aboriginal dialysis patients live. With most studies based on urban service provision, there is little evidence to guide service development. However permanent relocation to an urban area for treatment can have significant social and financial impacts that are poorly quantified. This study is part of a broader project to quantify the costs and benefits of dialysis service models in urban and remote locations in Australia's Northern Territory (NT). METHODS: We undertook a micro-costing analysis of dialysis service delivery costs in urban, rural and remote areas in the NT from the payer perspective. Recurrent maintenance costs (salaries, consumables, facility management and transportation) as well as capital costs were included. Missing and centralised costs were standardised; results were inflated to 2017 values and reported in Australian dollars. RESULTS: There was little difference between the average annual cost for urban and rural services with respective median costs of $85,919 versus $84,629. However remote service costs were higher ($120,172 - $124,492), driven by higher staff costs. The inclusion of capital costs did not add substantially to annual costs. Annual home haemodialysis costs ($42,927) were similar to other jurisdictions despite the significant differences in program delivery and payment of expenses not traditionally borne by governments. Annual peritoneal dialysis costs ($58,489) were both higher than home and in-centre haemodialysis by recent national dialysis cost studies. CONCLUSION: The cost drivers for staffed services were staffing models and patient attendance rates. Staff salaries and transport costs were significantly higher in remote models of care. Opportunities to reduce expenditure exist by encouraging community supported services and employing local staff. Despite the delivery challenges of home haemodialysis including high patient attrition, the program still provides a cost benefit compared to urban staffed services. The next component of this study will examine patient health service utilisation and costs by model of care to provide a more comprehensive analysis of the overall cost of providing services in each location.

Organizational and operational redesign: if we should, then how?

Health care leaders and clinical professionals are reconfiguring their environments. However, restructuring of management, reengineering of work, and redesigning process work flows and care delivery modalities contribute to demands that are inherent in an industry that deals with multiple variables of the human condition. After approximately 7 years of health care reengineering and redesign, fundamental tenets are being validated regarding leadership attributes, employee preparation and involvement, and commitment to the process of ongoing redesign and improvement.

Why empowerment does not empower: the bankruptcy of current paradigms.

As a result of the rapid changes taking place in health care, nurse leaders are more challenged than ever to assume a new and different kind of leadership. Under the current paradigm, leaders are responsible for the performance of their people. Leaders do things TO the organization and the people in it. That paradigm of leader responsibility for other people's performance, given today's circumstances, guarantees organizational failure. A radical transformation in leadership thinking must take place. The leader's job is to get the people to be responsible for their own performance.

Learned heart-rate control by a patient with a ventricular parasystolic rhythm.

A 31-year-old woman with a ventricular parasystolic rhythm is described. The arrhythmia was always absent below a rate of 72 per minute, and always present over a rate of 106 per minute. Voluntary heart-rate control was learned using a biofeedback techinque, as a result of which she could increase her rate by 25 per minute and decrease it by 1-2 per minute. Both voluntary speeding and exercise brought on the arrhythmia, but later in the training she could reach a higher heart-rate before the arrhythmia appeared. Propranolol inhibited the arrhythmia only to the extent that is slowed the heart.