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3.
JAMA ; 322(10): 957-973, 2019 09 10.
Artigo em Inglês | MEDLINE | ID: mdl-31503308

RESUMO

Importance: For-profit (vs nonprofit) dialysis facilities have historically had lower kidney transplantation rates, but it is unknown if the pattern holds for living donor and deceased donor kidney transplantation, varies by facility ownership, or has persisted over time in a nationally representative population. Objective: To determine the association between dialysis facility ownership and placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. Design, Setting, and Participants: Retrospective cohort study that included 1 478 564 patients treated at 6511 US dialysis facilities. Adult patients with incident end-stage kidney disease from the US Renal Data System (2000-2016) were linked with facility ownership (Dialysis Facility Compare) and characteristics (Dialysis Facility Report). Exposures: The primary exposure was dialysis facility ownership, which was categorized as nonprofit small chains, nonprofit independent facilities, for-profit large chains (>1000 facilities), for-profit small chains (<1000 facilities), and for-profit independent facilities. Main Outcomes and Measures: Access to kidney transplantation was defined as time from initiation of dialysis to placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. Cumulative incidence differences and multivariable Cox models assessed the association between dialysis facility ownership and each outcome. Results: Among 1 478 564 patients, the median age was 66 years (interquartile range, 55-76 years), with 55.3% male, and 28.1% non-Hispanic black patients. Eighty-seven percent of patients received care at a for-profit dialysis facility. A total of 109 030 patients (7.4%) received care at 435 nonprofit small chain facilities; 78 287 (5.3%) at 324 nonprofit independent facilities; 483 988 (32.7%) at 2239 facilities of large for-profit chain 1; 482 689 (32.6%) at 2082 facilities of large for-profit chain 2; 225 890 (15.3%) at 997 for-profit small chain facilities; and 98 680 (6.7%) at 434 for-profit independent facilities. During the study period, 121 680 patients (8.2%) were placed on the deceased donor waiting list, 23 762 (1.6%) received a living donor kidney transplant, and 49 290 (3.3%) received a deceased donor kidney transplant. For-profit facilities had lower 5-year cumulative incidence differences for each outcome vs nonprofit facilities (deceased donor waiting list: -13.2% [95% CI, -13.4% to -13.0%]; receipt of a living donor kidney transplant: -2.3% [95% CI, -2.4% to -2.3%]; and receipt of a deceased donor kidney transplant: -4.3% [95% CI, -4.4% to -4.2%]). Adjusted Cox analyses showed lower relative rates for each outcome among patients treated at all for-profit vs all nonprofit dialysis facilities: deceased donor waiting list (hazard ratio [HR], 0.36 [95% CI, 0.35 to 0.36]); receipt of a living donor kidney transplant (HR, 0.52 [95% CI, 0.51 to 0.54]); and receipt of a deceased donor kidney transplant (HR, 0.44 [95% CI, 0.44 to 0.45]). Conclusions and Relevance: Among US patients with end-stage kidney disease, receiving dialysis at for-profit facilities compared with nonprofit facilities was associated with a lower likelihood of accessing kidney transplantation. Further research is needed to understand the mechanisms behind this association.


Assuntos
Instituições Privadas de Saúde , Acesso aos Serviços de Saúde , Falência Renal Crônica/terapia , Transplante de Rim , Propriedade , Diálise Renal , Humanos , Doadores Vivos , Diálise Renal/economia , Estudos Retrospectivos , Estados Unidos , Listas de Espera
4.
S Afr Med J ; 109(8): 577-581, 2019 Jul 26.
Artigo em Inglês | MEDLINE | ID: mdl-31456551

RESUMO

BACKGROUND: Chronic kidney disease (CKD) is increasingly recognised as an important cause of morbidity and mortality in South Africa (SA). Although the cost of dialysis is well documented in developed countries, little is known about this cost in sub-Saharan Africa. OBJECTIVES: To review the costs of providing peritoneal dialysis (PD) and haemodialysis (HD) at the Pietersburg renal dialysis public-private partnership (PPP) unit in Limpopo Province, SA. METHODS: A retrospective review of the cost of inputs required for HD and PD was conducted from a provider's perspective, covering the period 2007 - 2012. A top-down approach was used to estimate the average annual cost per patient on HD and PD. RESULTS: During the 6-year period under review, the number of patients on dialysis increased from 77 in 2007 to 182 in 2012. More than 60% of the patients were on HD. The average annual cost per patient was estimated to be ZAR212 286 (USD25 888) and ZAR255 076 (USD31 106) for HD and PD, respectively, in 2012. Personnel cost, PD supplies, HD supplies, the outsourcing fee and pharmaceutical supplies were the main cost drivers. PD proved to be more expensive than HD, despite the use of locally manufactured fluids. CONCLUSIONS: The study highlights the exceptionally high cost of dialysis treatment. Dialysis should be made more accessible by implementing measures to address the main cost drivers. Moreover, a comprehensive approach that includes prevention of CKD at primary healthcare level, an organ donation programme and an effective kidney transplant programme is urgently required in Limpopo. Further research is required to evaluate the cost-effectiveness of the PPP approach.


Assuntos
Diálise Peritoneal/economia , Diálise Peritoneal/estatística & dados numéricos , Diálise Renal/economia , Diálise Renal/estatística & dados numéricos , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/terapia , Parcerias Público-Privadas , Estudos Retrospectivos , África do Sul/epidemiologia , Centros de Atenção Terciária
5.
Medicine (Baltimore) ; 98(33): e16808, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31415394

RESUMO

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.


Assuntos
Assistência à Saúde/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Nefrologia/economia , Diálise Renal/economia , Insuficiência Renal Crônica/economia , Idoso , Assistência à Saúde/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Nefrologia/métodos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Equipe de Assistência ao Paciente/economia , Encaminhamento e Consulta/economia , Estudos Retrospectivos
6.
Med Care ; 57(8): 584-591, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31295188

RESUMO

BACKGROUND: The effects of Medicare payment reforms aiming to improve the efficiency and quality of care by establishing greater financial accountability for providers may vary based on the extent and types of other coverage for their patient populations. Providers who are more resource constrained due to a less favorable payer mix face greater financial risks under such reforms. The impact of the expanded Medicare dialysis prospective payment system (PPS) on quality of care in independent dialysis facilities may vary based on the extent of higher payments from private insurers available for managing increased risks. OBJECTIVES: To evaluate whether anemia outcomes for dialysis patients in independent facilities differ under the Medicare PPS based on facility payer mix. DESIGN: We examined changes in anemia outcomes for 122,641 Medicare dialysis patients in 921 independent facilities during 2009-2014 among facilities with differing levels of employer insurance (EI). We performed similar analyses of facilities affiliated with large dialysis organizations, whose practices were not expected to change based on facility-specific payer mix. RESULTS: Among independent facilities, similar modeled trends in low hemoglobin for all 3 facility EI groups in 2009-2010 were followed by increased low hemoglobin during 2012-2014 for facilities with lower EI (P<0.01). Post-PPS standardized blood transfusion ratios were 9% higher for lower EI versus higher EI independent facilities (P<0.01). Among large dialysis organizations facilities, there was no divergence in low hemoglobin by payer mix under the PPS. CONCLUSIONS: There is evidence of poorer quality of care for anemia under the PPS in independent facilities with lower versus higher EI. Provider responses to payment reform may vary based on attributes such as payer mix that could have implications for health disparities.


Assuntos
Anemia/terapia , Reforma dos Serviços de Saúde/organização & administração , Medicare/organização & administração , Sistema de Pagamento Prospectivo/organização & administração , Diálise Renal/economia , Adolescente , Adulto , Idoso , Anemia/economia , Anemia/etiologia , Eritropoetina/uso terapêutico , Feminino , Custos de Cuidados de Saúde , Reforma dos Serviços de Saúde/economia , Hemoglobinas/análise , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/economia , Falência Renal Crônica/terapia , Masculino , Medicare/economia , Pessoa de Meia-Idade , Sistema de Pagamento Prospectivo/economia , Qualidade da Assistência à Saúde/economia , Qualidade da Assistência à Saúde/organização & administração , Diálise Renal/normas , Estados Unidos , Adulto Jovem
7.
J Pharm Pract ; 32(3): 292-302, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31291842

RESUMO

Acute kidney injury (AKI) develops in 8% to 16% of hospital admissions. These patients exhibit a 4- to 10-fold increase in mortality and prolonged hospital stays. There is a dearth of information on the economics of AKI, especially in critically ill patients whose health-care costs are already high. It is important that pharmacists understand the economic impact of AKI to optimally prevent and treat AKI occurrence, thus reducing total hospital costs. Authors used MEDLINE, PubMed, and Google Scholar searches up to April 2019. Inpatient AKI affects an estimated 498 000 patients in the United States with its annual cost from $4.7 to $24.0 billion. Average patient costs of AKI in the intensive care unit are generally double than those of non-AKI patients. High AKI severity portends a higher cost. Total hospital costs in patients with AKI ranged from $29 700 in cardiac surgery patients to $80 400 in cardiogenic shock. Incremental increases of cost range from $9400 in major surgery patients and up to $81 000 in nonsurviving dialysis patients. The enormity of the clinical and economic impact of AKI should be a call to action by pharmacists to expeditiously select patient-specific therapies to prevent and treat AKI, and thus reduce its economic burden on an already fragile health-care system.


Assuntos
Lesão Renal Aguda/economia , Custos Hospitalares , Hospitalização/economia , Humanos , Diálise Renal/economia
8.
Ann Transplant ; 24: 393-400, 2019 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-31263093

RESUMO

BACKGROUND Kidney transplantation is reported to save costs compared to maintenance dialysis. We analyzed the current actual costs of kidney transplantation compared to dialysis, and analyzed risk factors for higher costs after transplantation. MATERIAL AND METHODS Altogether, 338 kidney transplant recipients between 2009 and 2014 were included in this study. All individual-level cost data from specialized health care and data from all reimbursed medication and travel costs were acquired from official records. Cost data were compared before and after transplantation within the same patients starting from dialysis initiation and continued until the end of follow-up at the end of 2015. RESULTS Total annual costs were median 53 275 EUR per patient in dialysis, 59 583 EUR for the first post-transplantation year (P<0.001), and 12 045 EUR for the subsequent years (P<0.001 compared to dialysis). Median costs for specialized health care were 36 103 EUR/year per patient during dialysis, compared to median 51 640 EUR for the first post-transplantation year (P<0.001 compared to dialysis), whereas the median costs for the subsequent years declined to median 4895 EUR/year (P<0.001 compared to dialysis). The median annual costs for drug treatments and travel reimbursements during dialysis were higher compared to after transplantation (P<0.001). Delayed graft function and highly sensitized status were independent risk factor for higher costs during the first the post-transplantation year. CONCLUSIONS After the first posttransplant year the costs of a kidney transplant patient for the health care system are <1/3 of the costs seen during dialysis treatment. Delayed graft function and previous sensitization were associated with increased costs post-transplantation.


Assuntos
Falência Renal Crônica/terapia , Transplante de Rim/economia , Diálise Renal/economia , Adulto , Idoso , Feminino , Custos de Cuidados de Saúde , Humanos , Falência Renal Crônica/economia , Falência Renal Crônica/cirurgia , Masculino , Pessoa de Meia-Idade
9.
Ann Vasc Surg ; 60: 203-210, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31200049

RESUMO

BACKGROUND: The annual cost of care associated with end-stage renal disease (ESRD) per patient on hemodialysis is approaching $100,000, with nearly $42 billion in national spend per year. Early cannulation arteriovenous grafts (ECAVGs) help decrease the use of central venous catheters (CVCs), thus potentially decreasing the cost of care. However, a formal financial analysis that also includes the cost of CVC-related complications and secondary interventions has not been completed. The purpose of this project is to evaluate the overall financial costs associated with ECAVGs on patients with ESRD during a one-year period. METHODS: Access modality, complications, secondary interventions, hospital outcomes, and cost of care were determined for 397 sequential patients who underwent access creation between July 2014 and October 2018. A detailed financial analysis was completed, including an evaluation of implant, supplies, medications, laboratories, labor, and other direct costs. All variables were measured at the time of the index procedure, 30 days, 90 days, 180 days, 270 days, and one year. RESULTS: There were 131 patients who underwent arteriovenous fistula (AVF) and 266 who underwent ECAVG for dialysis access. The average cost of care was $17,523 for AVF and $5,894 for ECAVG at one year (P < 0.01). Fewer CVC-related complications and secondary interventions associated with ECAVGs saved $11,630 per patient with ESRD, primarily in the form of supply costs. Fewer CVCs in the patients receiving ECAVGs led to an additional $1,083 decrease in cost associated with sepsis reduction at one year. A subsequent decrease in length of stay and ICU utilization led to an additional $2.0 million decrease in annual cost of care for patients with ESRD. CONCLUSIONS: The use of ECAVGs has significant cost savings over using an AVF and CVC for urgent-start dialysis in patients with ESRD. This cost savings is secondary to decreased CVC-related complications and fewer secondary interventions. Significant national savings are possible with appropriate use of ECAVGs in patients with ESRD.


Assuntos
Derivação Arteriovenosa Cirúrgica/economia , Implante de Prótese Vascular/economia , Prótese Vascular/economia , Cateterismo/economia , Custos de Cuidados de Saúde , Falência Renal Crônica/economia , Falência Renal Crônica/terapia , Indicadores de Qualidade em Assistência à Saúde/economia , Diálise Renal/economia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/instrumentação , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Cateterismo/efeitos adversos , Redução de Custos , Análise Custo-Benefício , Humanos , Desenho de Prótese , Diálise Renal/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
10.
JAMA Netw Open ; 2(5): e193987, 2019 05 03.
Artigo em Inglês | MEDLINE | ID: mdl-31099872

RESUMO

Importance: Mergers and acquisitions among health care institutions are increasingly common, and dialysis markets have undergone several decades of mergers and acquisitions. Objective: To examine the outcomes of hemodialysis facility acquisitions independent of associated changes in market competition resulting from acquisitions. Design, Setting, and Participants: Cohort study using difference-in-differences (DID) analyses to compare changes in health outcomes over time among in-center US dialysis facilities that were acquired by a hemodialysis chain with facilities located nearby but not acquired. Multivariable Cox proportional hazards regression models and negative binomial models with predicted marginal effects were developed to examine health outcomes, controlling for patient, facility, and geographic characteristics. All facility ownership types were examined together and stratified analyses were conducted of facilities that were independently owned and chain owned prior to acquisitions. The study was conducted from January 2001 to September 2015; 174 905 patients starting in-center dialysis in the 3 years before and following dialysis facility acquisitions were included. Data were analyzed from March 2017 to December 2018. Exposures: Acquisition by a hemodialysis chain. Main Outcomes and Measures: Twelve-month hazard of death and hospital days per patient-year were the primary outcomes. Results: Of the 174 905 patients included in the study, 79 705 were women (45.6%), 24 409 (14.0%) were of Hispanic ethnicity, 61 815 (35.3%) were black, 105 272 (60.2%) were white, and 1247 (0.7%) were Native American. Mean (SD) age was 65 (15) years. Before acquisitions, adjusted mortality and hospitalization rates were 10% (95% CI, -16% to -5%) and 2.9 days per patient-year (95% CI, -3.8 to -2.0) lower, respectively, at independently owned facilities that were acquired compared with those that were not acquired, while hospitalization rates were 0.7 days (95% CI, -1.2 to -2.0) lower at chain-owned facilities that were acquired compared with those that were not acquired. In stratified analyses of independently owned facilities, mortality decreases were smaller at acquired (-8.4%; 95% CI, -14% to -25%) vs nonacquired (-20.3%; 95% CI, -25.8% to -14.3%) facilities (DID P < .001). Similarly, hospitalization rates did not change at acquired facilities and decreased by 2.6 days per patient-year (95% CI, -3.6 to -1.7 days) at nonacquired facilities (DID P < .001). Acquisitions were not associated with changes in health outcomes at chain-owned facilities. Slower reductions in mortality and hospitalization rates at independently owned facilities contributed to significant differences in hospitalizations (-2.0 days; 95% CI, -2.5 to -1.6, at nonacquired vs 0.9 days; 95% CI, -1.3 to -0.5, at acquired facilities; DID, P < .001) across all ownership types but not mortality (DID, P = .28) with regard to acquisitions. Conclusions and Relevance: Acquisition of independently owned dialysis facilities by larger dialysis organizations was associated with slower decreases in mortality and hospitalization rates, as nonacquired facilities appeared to experience more rapid improvements in outcomes over time.


Assuntos
Instituições Associadas de Saúde/estatística & dados numéricos , Diálise Renal/mortalidade , Adulto , Idoso , Estudos de Coortes , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Propriedade/estatística & dados numéricos , Sistema de Registros , Diálise Renal/economia , Adulto Jovem
11.
PLoS One ; 14(5): e0216432, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31100069

RESUMO

To investigate how changes in eGFR can affect medical costs, a regional cohort of national health insurance beneficiaries in Japan was developed from a nationwide database system (Kokuho database, KDB), and non-individualized data were obtained. From 105,661 people, subjects on chronic dialysis and subjects without consecutive medical checkups were excluded. Finally, medical costs in the follow-up year categorized by annual changes in eGFR between baseline and the next year were longitudinally examined in 70,627 people ranging in age from 40 to 74 years. Global mean costs for subjects with a rapid decrease in eGFR (≤-30%/year) were the highest among all ΔeGFR categories. In men, the cost was 1.42 times that for a stable eGFR. A total of 6,268 (19.4%) men and 5,381 (14.0%) women with eGFR <60 ml/min/1.73 m2 were identified in the baseline year. The mean cost was higher with a low eGFR than without a low eGFR, and there were also higher proportions newly initiating dialysis in 2014 (low eGFR with rapid decrease in eGFR vs. with stable eGFR: 9.61% vs. 0.02% in women, P<0.001). Moreover, the costs for low eGFR subjects with a rapid decrease in eGFR were more than twice those of non-low eGFR subjects with a rapid decrease in eGFR and also compared to low eGFR subjects with a stable eGFR. Moreover, initiating chronic dialysis was considered one of the major causes of high medical costs in women with rapid eGFR decline. To the best of our knowledge, this is the first study of renal disease using a cohort developed from the KDB system recently established in Japan.


Assuntos
Taxa de Filtração Glomerular , Diálise Renal/economia , Insuficiência Renal Crônica , Adulto , Idoso , Grupo com Ancestrais do Continente Asiático , Estudos de Coortes , Custos e Análise de Custo , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/economia , Insuficiência Renal Crônica/fisiopatologia , Insuficiência Renal Crônica/terapia
12.
J Vasc Access ; 20(1_suppl): 38-44, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31032732

RESUMO

At the second Dialysis Access Symposium held in Nagoya, Japan, a proposal was made to investigate the differences in vascular access methods used in different countries. In this article, we describe the management of vascular access in Japan. The Japanese population is rapidly aging, and the proportion of elderly patients on dialysis is also increasing. There were 325,000 dialysis patients in Japan at the end of 2015, of whom 65.1% were aged 65 years or above. The number of patients with diabetic nephropathy or nephrosclerosis as the underlying condition is also increasing, whereas the number with chronic glomerulonephritis is steadily decreasing. The Japanese health insurance system enables patients to undergo medical treatment at almost no out-of-pocket cost. Percutaneous transluminal angioplasty suffers from a severe device lag compared with other countries, but although there are limitations on permitted devices, the use of those that have been authorized is covered by medical insurance. One important point that is unique to Japan is that vascular access is performed and managed by doctors involved in dialysis across a wide range of disciplines, including nephrologists, surgeons, and urologists. This may be one factor contributing to the good survival prognosis of Japanese dialysis patients.


Assuntos
Derivação Arteriovenosa Cirúrgica , Implante de Prótese Vascular , Nefropatias/terapia , Diálise Renal , Idoso , Angioplastia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/economia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/cirurgia , Custos de Cuidados de Saúde , Humanos , Japão/epidemiologia , Nefropatias/diagnóstico , Nefropatias/economia , Nefropatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Diálise Renal/efeitos adversos , Diálise Renal/economia , Fatores de Risco , Resultado do Tratamento , Grau de Desobstrução Vascular
13.
Contrib Nephrol ; 198: 87-93, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30991413

RESUMO

BACKGROUND: With the growth in the global economy, the number of patients worldwide undergoing renal replacement therapy such as hemodialysis is increasing by 6-7% annually. Accordingly, medical costs for the treatment of chronic kidney disease (CKD) progressing to end-stage renal disease (ESRD) as well as for renal replacement therapy have become a major issue. SUMMARY: It has been reported that in the United States, the annual medical cost for a patient with CKD is approximately USD 20,000, and that the total medical cost for a CKD patient is higher than that of an ESRD patient [1]. In the present study, we found that the medical costs for renal replacement therapy (RRT) in Japan are reasonable compared to those in the United States and Europe. Key Messages: The medical costs for RRT in Japan are reasonable and are not a major issue in Japan.


Assuntos
Insuficiência Renal Crônica/economia , Progressão da Doença , Europa (Continente) , Custos de Cuidados de Saúde , Humanos , Japão , Diálise Renal/economia , Insuficiência Renal Crônica/terapia , Terapia de Substituição Renal/economia , Estados Unidos
14.
Ann Vasc Surg ; 59: 158-166, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31009720

RESUMO

BACKGROUND: Almost 80% of patients with end-stage renal disease (ESRD) initiate dialysis via a central venous catheter (CVC). CVCs are associated with multiple complications and a high cost of care. The purpose of our project is to determine the impact of early cannulation arteriovenous grafts (ECAVGs) on quality of care and costs. METHODS: The dialysis access modality, complications, secondary interventions, hospital outcomes, and detailed costs were tracked for 397 sequential patients who underwent access creation between July 2014 and October 2018. Complications were grouped into deep vein thrombosis, line infections, sepsis, pneumothorax, and other. Secondary interventions included angioplasty, angioplasty and stent grafting, thrombectomy, surgical revision, and explantation. Hospital outcomes included length of stay, inpatient mortality, 30-day readmission, and discharge disposition. Costs included supplies, medications, laboratory tests, labor, and other direct costs. All variables were measured at the time of the index procedure, 30 days, 90 days, 180 days, 270 days, 1 year, 18 months, and 2 years. RESULTS: There were 131 patients who underwent arteriovenous fistula (AVF) and 266 who received ECAVG for dialysis access. The total cost of care per patient was $17,523 for AVF and $5,894 for ECAVG at 1 year (P < 0.01). Primary-assisted patency for AVF was 49.3% versus 81.4% for ECAVG (P = 0.027), and secondary-assisted patency for AVF was 63.8% versus 85.4% for ECAVG at 1 year (P = 0.011). There was a survival advantage for ECAVGs at 1 year (78.6% for AVF vs 85.0% for ECAVG, P = 0.034). Patients who received ECAVG had fewer CVC days (2.3% vs 19.1% for AVF, P < 0.001), fewer complications (1.6% vs. 21.5% for AVF, P < 0.001), and fewer secondary interventions (17.0% vs 52.5% for AVF, P < 0.001). CONCLUSIONS: This is the first study on patients with ESRD to report detailed outcomes and cost analysis as it relates to AVF versus ECAVG. ECAVGs have an advantage over AVFs due to lower overall cost and better clinical outcomes at 1 year. Implementation of an urgent start dialysis access program centered around ECAVGs may help achieve the national goal of better health care at a lower cost for patients with ESRD.


Assuntos
Derivação Arteriovenosa Cirúrgica , Cateterismo , Falência Renal Crônica/terapia , Diálise Renal , Enxerto Vascular , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/economia , Derivação Arteriovenosa Cirúrgica/mortalidade , Derivação Arteriovenosa Cirúrgica/normas , Cateterismo/efeitos adversos , Cateterismo/economia , Cateterismo/mortalidade , Cateterismo/normas , Redução de Custos , Análise Custo-Benefício , Feminino , Oclusão de Enxerto Vascular/economia , Oclusão de Enxerto Vascular/terapia , Custos de Cuidados de Saúde , Mortalidade Hospitalar , Hospitalização , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/economia , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , /normas , Indicadores de Qualidade em Assistência à Saúde , Diálise Renal/efeitos adversos , Diálise Renal/economia , Diálise Renal/mortalidade , Diálise Renal/normas , Retratamento , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/economia , Enxerto Vascular/mortalidade , Enxerto Vascular/normas
16.
East Mediterr Health J ; 25(2): 134-141, 2019 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-30942478

RESUMO

Globally the nephrology community is witnessing an increased use of high-flux membranes and ultrapure water in haemodialysis (HD) units, and in low-and middle-income countries, data are lacking regarding HD water quality. In Lebanon the Ministry of Public Health released a decree calling for a progressive change in the HD water treatment system in order to implement ultrapure water in all dialysis facilities. This article reports on the problems previously encountered regarding water quality in Lebanon. It exposes the recent changes in standards as recommended by the government, especially the mandatory three sessions per week and ultrapure water. In addition, it analyses the cost-effectiveness of ultrapure water implementation in a low/middle-income country and demonstrates that the cost is lower than in high-income countries. Finally, this article summarizes the obstacles met and suggests a practical approach to maintain this high level of water treatment quality.


Assuntos
Qualidade da Assistência à Saúde , Diálise Renal/normas , Purificação da Água , Análise Custo-Benefício , Política de Saúde , Humanos , Líbano , Melhoria de Qualidade/normas , Diálise Renal/economia , Microbiologia da Água , Purificação da Água/economia , Purificação da Água/normas
18.
Artigo em Inglês | MEDLINE | ID: mdl-30836681

RESUMO

Chronic kidney disease (CKD) has been redefined in the new millennium as any alteration of kidney morphology, function, blood, or urine composition lasting for at least 3 months. This broad definition also encompasses diseases or conditions that are associated with normal kidney function, such as a kidney scarring from an acute pyelonephritis episode or a single kidney, as a result of kidney donation. CKD is a relevant public health problem. According to the 2015 Global Burden of Disease Study, it was the 12th leading cause of death, leading to 1.1 million deaths, worldwide, each year. The role of CKD as a cause of death is evident where renal replacement therapy (RRT) is not available, however, its role in increasing death risk is not easily calculated. RRT consumes about 3⁻5% of the global healthcare budget where dialysis is available without restrictions. While the prevalence of CKD is increasing overall as lifespans extend, being linked to diabetes, hypertension, obesity, and atherosclerosis, CKD is at least partly preventable and its effects may be at least partly counterbalanced by early and appropriate care. We will welcome papers on all aspects of CKD, including organization, cost, and models of care. Papers from developing countries will be particularly welcomed.


Assuntos
Bioética , Organizações de Planejamento em Saúde/normas , Assistência de Longa Duração/organização & administração , Insuficiência Renal Crônica/terapia , Organizações de Planejamento em Saúde/tendências , Humanos , Masculino , Diálise Renal/economia , Diálise Renal/ética , Insuficiência Renal Crônica/economia , Insuficiência Renal Crônica/epidemiologia , Terapia de Substituição Renal/economia , Terapia de Substituição Renal/ética
19.
J Vasc Interv Radiol ; 30(2): 203-211.e4, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30717951

RESUMO

PURPOSE: To compare reinterventions and associated costs to maintain arteriovenous graft hemodialysis access circuits after rescue with percutaneous transluminal angioplasty (PTA), with or without concurrent Viabahn stent grafts, over 24 months. MATERIALS AND METHODS: This multicenter (n = 30 sites) study evaluated reintervention number, type, and cost in 269 patients randomized to undergo placement of stent grafts or PTA alone. Outcomes were 24-month average cumulative number of reinterventions, associated costs, and total costs for all patients and in 4 groups based on index treatment and clinical presentation (thrombosed or dysfunctional). RESULTS: Over 24 months, the patients in the stent graft arm had a 27% significant reduction in the average number of reinterventions within the circuit compared to the PTA arm (3.7 stent graft vs 5.1 PTA; P = .005) and similar total costs ($27,483 vs $28,664; P = .49). In thrombosed grafts, stent grafts significantly reduced the number of reinterventions (3.7 stent graft vs 6.2 PTA; P = .022) and had significantly lower total costs compared to the PTA arm ($30,329 vs $37,206; P = .027). In dysfunctional grafts, no statistical difference was observed in the number of reinterventions or total costs (3.7 stent graft vs 4.4 PTA; P = .12, and $25,421 stent graft and $22,610 PTA; P = .14). CONCLUSIONS: Over 24 months, the use of stent grafts significantly reduced the number of reinterventions for all patients, driven by patients presenting with thrombosed grafts. Compared to PTA, stent grafts reduced overall treatment costs for patients presenting with thrombosed grafts and had similar costs for stenotic grafts.


Assuntos
Angioplastia com Balão , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Oclusão de Enxerto Vascular/cirurgia , Diálise Renal , Stents , Trombose/cirurgia , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/economia , Derivação Arteriovenosa Cirúrgica/economia , Prótese Vascular/economia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Redução de Custos , Análise Custo-Benefício , Oclusão de Enxerto Vascular/economia , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Custos de Cuidados de Saúde , Humanos , Estudos Prospectivos , Diálise Renal/economia , Reoperação , Fatores de Risco , Stents/economia , Trombose/economia , Trombose/etiologia , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
20.
J Med Econ ; 22(5): 421-429, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30724682

RESUMO

OBJECTIVES: Hepatorenal Syndrome (HRS) is characterized by renal failure in patients with advanced chronic liver disease (CLD) and is the leading cause of hospitalizations in CLD. This study examines the clinical and economic burden, outcomes, and unmet need of HRS treatment in US hospitals. METHOD: A retrospective cohort study was conducted based on a large electronic health records database (Cerner HealthFacts) with records for hospitalized HRS patients from January 2009-June 2015. Demographics, clinical characteristics, treatment patterns, and economic outcomes were analyzed. Prognostic indicators of cirrhosis, kidney injury, end-stage liver disease, and acute-on-chronic liver failure were used to determine mortality risk. RESULTS: A total of 2,542 patients hospitalized with HRS were identified (average age = 57.9 years, 61.8% males, 74.2% Caucasian), with an average total hospital charge of $91,504 per patient and a mean length of stay (LOS) of 30.5 days. The mortality rate was 36.9% with 8.9% of patients discharged to hospice. Of all patients, 1,660 patients had acute kidney injury, 859 with Stage 3 disease, and 26.7% had dialysis. The 30-day readmission rate was 33.1%, 41% of which were unplanned. Nearly one-third of study patients had commercial insurance (30.2%), followed by Medicare (29.9%); hospital charges varied by LOS, receipt of dialysis, and discharge status. Regression analysis demonstrated that HRS costs are associated with LOS, dialysis, and hospital mortality. CONCLUSION: HRS is associated with poor outcomes and high hospital costs. Analysis of HRS cost drivers demonstrated an unmet need for additional treatment options to improve outcomes in this patient population.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Síndrome Hepatorrenal/economia , Síndrome Hepatorrenal/fisiopatologia , Adolescente , Adulto , Fatores Etários , Idoso , Grupos de Populações Continentais , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , Síndrome Hepatorrenal/terapia , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Diálise Renal/economia , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos , Adulto Jovem
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