KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update

The prevalence of chronic kidney disease and end-stage renal disease requiring dialysis therapy continues to increase worldwide, and despite technological advances, treatment remains resource intensive. Thus, the increasing burden of dialysis therapy on finite health-care budgets is an important consideration. The principles of allocative efficiency and the concept of 'opportunity cost' can be used to assess whether dialysis is economically justified; if dialysis is to be provided, cost-minimization and cost-utility analyses can be used to identify the most efficient dialysis modality. Existing studies have examined the cost, and where relevant the effectiveness, of the various currently available peritoneal dialysis and haemodialysis modalities. In this Review, we discuss variations in the intrinsic costs of the available dialysis modalities as well as other factors, such as variation by country, available health-care infrastructures, the timing of dialysis initiation and renal transplantation. We draw on data from robust micro-costing studies of the various dialysis modalities in Canada to highlight key issues.

Economic evaluation of dialysis therapies

The treatment of chronic kidney disease (CKD) and of end-stage renal disease (ESRD) imposes substantial societal costs. Expenditure is highest for renal replacement therapy (RRT), especially in-hospital haemodialysis. Redirection towards less expensive forms of RRT (peritoneal dialysis, home haemodialysis) or kidney transplantation should decrease financial pressure. However, costs for CKD are not limited to RRT, but also include nonrenal health-care costs, costs not related to health care, and costs for patients with CKD who are not yet receiving RRT. Even if patients with CKD or ESRD could be given the least expensive therapies, costs would decrease only marginally. We therefore propose a consistent and sustainable approach focusing on prevention. Before a preventive strategy is favoured, however, authorities should carefully analyse the cost to benefit ratio of each strategy. Primary prevention of CKD is more important than secondary prevention, as many other related chronic diseases, such as diabetes mellitus, hypertension, cardiovascular disease, liver disease, cancer, and pulmonary disorders could also be prevented. Primary prevention largely consists of lifestyle changes that will reduce global societal costs and, more importantly, result in a healthy, active, and long-lived population. Nephrologists need to collaborate closely with other sectors and governments, to reach these aims.

Reducing the costs of chronic kidney disease while delivering quality health care: a call to action

Summary Estimates suggest that one third of United States health care spending results from overuse or misuse of tests, procedures, and therapies. The American Board of Internal Medicine Foundation, in partnership with Consumer Reports , initiated the “Choosing Wisely” campaign to identify areas in patient care and resource use most open to improvement. Nine subspecialty organizations joined the campaign; each organization identified five tests, procedures, or therapies that are overused, are misused, or could potentially lead to harm or unnecessary health care spending. Each of the American Society of Nephrology’s (ASN’s) 10 advisory groups submitted recommendations for inclusion. The ASN Quality and Patient Safety Task Force selected five recommendations based on relevance and importance to individuals with kidney disease.Recommendations selected were: ( 1 ) Do not perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms; ( 2 ) do not administer erythropoiesis-stimulating agents to CKD patients with hemoglobin levels ≥10 g/dl without symptoms of anemia; ( 3 ) avoid nonsteroidal anti-inflammatory drugs in individuals with hypertension, heart failure, or CKD of all causes, including diabetes; ( 4 ) do not place peripherally inserted central catheters in stage 3–5 CKD patients without consulting nephrology; ( 5 ) do not initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.These five recommendations and supporting evidence give providers information to facilitate prudent care decisions and empower patients to actively participate in critical, honest conversations about their care, potentially reducing unnecessary health care spending and preventing harm.

Critical and honest conversations: the evidence behind the "Choosing Wisely" campaign recommendations by the American Society of Nephrology.

Aims To identify trends in the demographic and smoking characteristics of new callers to the New Zealand Quitline, a national free-phone smoking cessation service, between 2001 and 2005. Methods Demographic and smoking behaviour of Quitline callers were routinely collected by Quit Advisors over the phone. Characteristics of new callers were extracted from the client database, and compared across 5 years to determine changes over time. Results Statistically significant differences were found in all variables (except for gender) across the 5-year period. The results show an increased proportion of callers are under 25 years old (67% increase), started smoking at 15 years old or older (10% increase), and/or have smoked for less than 10 years (86% increase). There is also an increased proportion of callers smoking roll-your-own cigarettes (13% increase). In terms of ethnicity, the proportion of Pacific people using the Quitline increased by 54%, while the proportion of Māori callers fluctuated at just above 20% of all new callers. The proportion of pregnant callers also increased over time (127% increase) although the overall percent remains small. Conclusions The results indicate notable changes in the characteristics of new Quitline callers between 2001 and 2005. Such information will be of benefit to the future design of Quitline marketing and adapting service provision to best meet the needs of callers. New Zealand’s national free-phone Quitline was established in 1999. Since then, no analysis has been conducted to identify trends in characteristics of callers over time. Similar research appears to be lacking in other countries, where researchers have built profiles using accumulated statistics without addressing changes over time. This study therefore aimed to explore this aspect by analysing the demographic and smoking characteristics of new callers registering with the New Zealand Quitline during the 5 years from 2001 to 2005. In November 2000, the New Zealand Quitline became a world-first by providing heavily subsidised nicotine replacement therapy (NRT) in the form of patches and gum as an adjunct to its telephone smoking cessation service. Prior to the introduction of NRT, Quitline callers received information and practical strategies for quitting, along with proactive follow-up calls from a Quit Advisor for quit support and advice. With the new service, callers are eligible to receive NRT when certain conditions are met (such as a satisfactory medical history and a commitment to quit). The availability of heavily subsidised NRT (a 92% reduction in the over-the-counter price) was well received by the smoking population, evidenced in the sharp increase of callers that was sustained for several years. This was similar to a more recent experience in Minnesota, USA where the Quitline offering free patches and gum to callers.

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Clinical trial registration: looking back and moving ahead

https://www.ajkd.org/article/S0272-6386(11)00049-7/pdf

Cost-Effectiveness of Initiating Dialysis Early: A Randomized Controlled Trial

Pressure to fund Herceptin (trastuzumab) for use in early-stage breast cancer is a welcome development for those patients who may benefit. However such a decision would have major implications since the health gains made by trastuzumab come at a very high cost (when compared to health gains achieved by other drugs currently funded on PHARMAC's schedule). The budget for trastuzumab (estimated to be NZ30m dollars/annum but this is currently being negotiated) will be funded from district health board (DHB) budgets, which will impact other patients unless DHB budgets are appropriately increased. In comparative terms, this proposed expenditure is almost the same as what is currently being spent on all other oncology agents together, and is similar to the total cost of hospital services in New Zealand regions such as Wairarapa and Marlborough.

Martin Rosevear

Papers

Cost-Effectiveness of Initiating Dialysis Early: A Randomized Controlled Trial

PHARMAC and Herceptin for early-stage breast cancer in New Zealand: Herceptin or deception?