Epidemiology and outcome research in CKD 5D

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Introduction and Aims: The Portuguese National Health Service funds haemodialysis (HD) and peritoneal dialysis (PD) treatments using the same bundled payment system, since 2008. However, this package does not include hospitalizations, physician/emergency room visits, access-related procedures and patient transportation. The aim of our study was to evaluate the annual health care expenses of chronic kidney disease (CKD) patients initiating HD with a catheter (CVC) or an arteriovenous fistula (AVF) and PD, in Portugal. Methods: The study was performed from the Public Administration perspective. One year cost data of 152 CKD patients who consecutively initiated dialysis in our institution in the year 2008 (HD-AVF, n=65; HD-CVC, n=45; PD, n=42) were generated and analyzed, using an intention-to-treat approach. Annual health care expenses were evaluated using a mixed costing method: a) HD and PD treatment expenses were established as the bundled payment of €547.94 per patient-week; b) hospitalizations (inpatient), physician/emergency room visits (outpatient) and transportation data, related or unrelated to kidney failure as defined by the discharge diagnosis [International Classification of Diseases Ninth Revision codes], was captured from the Information Management Division of São João Hospital. Expenditure was determined in accordance with the Ministry of Health and Welfare Ordinance Legislation; c) dialysis access expenses were estimated using a micro-costing approach, using publicly available hospital suppliers' price lists. Multivariate analysis was used to assess the impact of various comorbid factors on the outcome of interest (annual health care expenses). Results are reported in 2010 Euros (€). Results: Dialysis treatment expenses for HD-AVF, HD-CVC and PD modalities were €28,270, €27,332 and €28,062 per patient-year at risk, respectively (p=0.002). Compared with HD-AVF and PD patients, HD-CVC patients were more likely to have outpatient (€2869 vs. €1794 vs. €1315 per patient-year at risk for, HD-CVC, HD-AVF and PD; p<0.001) and inpatient expenses (€10,554.1 vs. €1324.7 vs. €2052.2 per patient-year at risk, for HD-CVC, HD-AVF and PD; p<0.001). Transportation expenditure were significantly lower in PD modality (€852 vs. €2232 vs. €2099 per patient-year at risk, for PD, HD-AVF and HD-CVC; p<0.001).The costs related to dialysis access for PD, HD-AVF and HD-CVC patients were €1172, €1555 and €4208 per patient-year, respectively (p<0.001). Mean annual health care expenses for HD-AVF, HD-CVC and PD patients were €33,621, €42,855 and €32,282 per patient-year at risk, respectively (p<0.001). In multivariate analysis, PD and HD-AVF modalities were associated with approximately €7500 per patient-year cost savings, compared to HD-CVC modality (β-coefficient= -7364, 95%CI [3749 to 10979]; p<0.001). Conclusions: Patients who choose PD or HD with a functioning AVF incur significant lower annual health care expenses compared to those who initiate HD with a catheter, in the new Portuguese bundled payment plan.

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