Dialysis Costs Research Articles

A Cost-Utility Analysis of Cinacalcet in Secondary Hyperparathyroidism in Five European Countries

A probabilistic patient-level Markov model was previously developed to simulate lifetime clinical and economic outcomes of cinacalcet treatment in secondary hyperparathyroidism (SHPT) patients using local data from Italy. The present study extends the application of the model to four other European countries - Spain, Portugal, Switzerland and the Czech Republic - in order to assess the consistency of results. Cinacalcet influences the levels of parathyroid hormone, serum calcium and phosphorous. Our simulation was based on data from the OPTIMA (Open-Label, Randomized Study Using Cinacalcet to Improve Achievement of KDOQI Targets in Patients with End-Stage Renal Disease) randomized controlled trial and from published correlations between bone-metabolism parameters, mortality and morbidity (cardiovascular [CV] events, fractures and parathyroidectomy). Local epidemiological and cost data for dialysis, drugs and event management were incorporated into the model. The simulation horizon was patient lifetime; standard treatment for SHPT (vitamin D sterols and phosphate binders) and cinacalcet plus standard treatment were compared. Effectiveness was measured in terms of life expectancy (LE) and quality-adjusted life expectancy (QALE). Health utility indexes derived from published literature took into account dialysis, CV events and fractures. The simulated mean LE extension in patients receiving cinacalcet was 1.20 life-years (LY) in Italy, 1.10 LY in Spain, 1.18 LY in Portugal, 1.10 LY in the Czech Republic and 1.40 LY in Switzerland. QALE increase was 0.89, 0.82, 0.89, 0.80 and 1.01 QALY in the same countries, respectively. The incremental cost-effectiveness ratio (ICER) result was €23,500/LY and €31,600/QALY in Italy, €21,800/LY and €29,300/QALY in Spain, €23,700/LY and €31,200/QALY in Portugal, €29,700/LY and €40,800/QALY in the Czech Republic and €24,700/LY and €34,200/QALY in Switzerland. Including dialysis costs as a part of the total costing doubled the ICER, from a minimum of €42,800/LY in Spain to a maximum of €82,800/LY in Switzerland and in the range from €57,500/QALY (Spain) to €114,700/QALY (Switzerland). Taking into consideration the limited clinical, epidemiological and health economics data available, cinacalcet treatment showed a relatively good cost-effectiveness profile in all the countries analysed, despite the differences in their healthcare systems and economic wealth.

The Growing Burden of End-Stage Renal Disease in Egypt

Background: End-stage renal disease (ESRD) has significantly increased in developing countries such as Egypt. Diabetes mellitus is still the leading cause of ESRD, while numbers of hypertensive patients among that population have significantly risen. Materials and Methods: The data presented in this article were obtained from various nephrology centers in response to the specific questionnaires distributed by the researchers. Results: Hemodialysis is available in most parts of the country. Continuous ambulatory peritoneal dialysis and renal transplantation programs have been performed in few nephrology centers. Costs for dialysis and renal transplantation are still unaffordable for most patients with ESRD. Since the cost burden has significantly increased, nephrology services should be changed from curative medicine to preventive medicine. Currently, the Egyptian Ministry of Health plans to have a detection and prevention program for chronic kidney disease. Conclusion: These data give the impression that both incidence and prevalence rates of ESRD in various areas of Egypt are increasing over time, although the rates presented here are far lower than expected.

Monthly cost of three exchanges a day peritoneal dialysis is same as of thrice a week hemodialysis in self-paying Indian patients

In India, majority of patients on dialysis are ‘self paying’ because of limited health insurance coverage available from government as well as private insurance providers. Hence, cost of treatment becomes one deciding factor to choose between the two modalities of dialysis – hemodialysis (HD) and peritoneal dialysis (PD). Aim is to compare the monthly cost of maintenance hemodialysis and peritoneal dialysis at our center. Majority of patients at our center are on thrice a week hemodialysis and three times a day peritoneal dialysis. These patients were asked to submit their total direct cost of treatment of last three months. It included cost of dialysis, erythropoietin, other medicines, monthly laboratory tests, hospitalization cost, travel cost, and any other directly involved in the treatment. Monthly cost (Indian Rupees, ) was then calculated by averaging the three month cost for each patient. The monthly cost of hemodialysis and peritoneal dialysis was then compared using ‘independent sample t-test’. Thirty five patients were finally included in the analysis (21 on HD and 14 on PD). Demographic profile between the two groups was similar in terms of age, sex ratio, period on dialysis, hemoglobin, blood urea nitrogen, and creatinine. Total monthly cost of dialysis was similar in both the groups ( 29,252 ± 6859 vs. 28,763 ± 5486, P = 0.85). The lower cost of hemodialysis procedure per se as compared to peritoneal dialysis procedure cost ( 14,669 ± 1376 vs. 19,528 ± 4072, P = 0.000) was compensated by higher cost of erythropoietin ( 7160 ± 3353 vs. 3093 ± 1889, P = 0.002) and travel cost ( 1654 ± 1085 vs. 76 ± 66, P < 0.0001) to equalize the monthly cost between the two groups. Our analysis showed no difference in the monthly cost of hemodialysis and peritoneal dialysis and hence, for self-paying patient in India, cost of treatment should not be a deciding factor while choosing between the two modalities.

Kidney Disease in Disadvantaged Populations

Kidney Disease in Disadvantaged Populations

Economic evaluation of end stage renal disease patients undergoing hemodialysis

Background:In India the incidence of end stage renal disease (ESRD) is increasing day by day and the option for the treatment of ESRD is dialysis or transplantation. In the present scenario, due to the cost of treatment normal people can afford only hemodialysis rather than transplantation. Since the cost of hemodialysis differs across the country, research is needed to evaluate its exact cost.Aim:This study is to analyze the healthcare cost of hemodialysis in a private hospital of South India.Materials and Methods:This is a prospective, observational study carried out in a tertiary care hospital. Patients who are undergoing routine hemodialysis in this hospital were selected for the study. Patient data as well as cost details were collected for a period of six months. Thirty patients were selected for the study and a total of 2160 dialysis sessions were studied. Patient perspective was taken for the analysis of cost. Both direct and indirect costs were analyzed. This includes cost of dialysis, investigations, erythropoietin, food, transportation, lost wages etc. Socioeconomic status of the patient was also studied.Result:The total cost per session was found to be around Rs. 4500. Fifty six percent contributes direct medical cost whereas 20% contributes direct non medical cost. Twenty four percent cost was due to indirect costs. Since the patients are paying from their own pocket, only the upper or upper middle class patient can undergo hemodialysis regularly.Conclusion:These findings are important to find out the impact of cost of hemodialysis on patients suffering from ESRD. Further studies related to costs and outcome, otherwise known as pharmacoeconomic studies, are needed to analyze the pros and cons of renal replacement therapy and to improve the quality of life of ESRD patients. Thus pharmacoeconomical studies are needed to realize that government has to take initiative to provide insurance or reimbursement for the common people.

Cost analysis of renal replacement therapy by transplant in a system of bundled payment of dialysis

Renal replacement therapies (RRT) for patients with end-stage renal failure represent a high burden on European countries' healthcare budget. Our purpose was to report and compare the costs of RRT by hemodialysis (HD) or peritoneal dialysis (PD) and renal transplantation (RT) after introduction of a bundled payment system of dialysis. We analyzed average annual cost of RT in a public national health system hospital - surgical/anesthesiologist team and material, induction and maintenance immunosuppression therapy, hospital stay, diagnostic examinations (DE), and post-transplant office visits (including DE). Incentives paid to hospitals performing RT were included. Annual cost of HD or PD was estimated by bundled payment established in a recently revised law - 537.25 €/wk. Total first year cost or RT is 61 658.14 € and from the second year forth 543.86 €/month. Dialysis costs 28 033.71 €/yr. Break-even point for cost is at 32 months, and from there on, RT is less expensive. Strategies aimed at increasing RT are needed as it confers better survival than RRT by dialysis with lower costs to Portuguese health system.

Economic Considerations in Frequent Home Hemodialysis

Hemodialysis (HD) is often used as an example of the most expensive chronic medical intervention that society will pay for on an ongoing basis. More intensive forms of HD have been associated with improved clinical outcomes, but concerns have been raised regarding the possibility of increased costs. We review recent Canadian studies examining the costs and cost utility of intensive HD, with a focus on comparisons with conventional in-center hemodialysis (IHD). The costs of starting a new home nocturnal hemodialysis (HNHD) program in British Columbia was estimated to be about $510,000 for the first year of the program, including the training of the first 53 patients, or about $18,830 per patient. A study by Lee et al. found the costs of home HD to be substantially less than IHD ($93,976 vs. $54,936, p < 0.001). A study by Kroeker et al. found that the lowest costs were seen with home short daily HD ($82,522), compared with $89,154 for IHD, and $91,218 for HNHD. Two studies by McFarlane et al. found that total costs were lower for those receiving HNHD (IHD $87,172 vs. HNHD $71,313), and that HNHD was associated with a superior cost-utility ratio (CAN$ 2011, HNHD $84,430/quality-adjusted life year [QALY] vs. IHD $148,722/QALY, incremental cost-effectiveness ratio: -$54,281, p < 0.05). While consistent findings of lower staffing and overhead costs for home HD, and higher consumable costs for frequent dialysis are probably reliable, findings of lower medication and hospital admission costs seen with intensive HD will need confirmation in randomized studies. Modifications to conventional dialysis funding are needed to accommodate for the additional costs of supplies and technology needed to support intensive modalities.

Haemodialysis in an emerging centre in a developing country: a two year review and predictors of mortality

BackgroundHaemodialysis is the most common form of renal replacement therapy in Nigeria. The high cost of haemodialysis has made optimal therapy of end-stage renal disease difficult in Nigeria. This paper is a review of data collected over two years of provision of dialysis services in a new tertiary hospital in Southern Nigeria.MethodsThis retrospective analysis is done on data obtained from the patient case files and dialysis records in the first two years of provision of dialysis services in our centre. A gender comparison of the patients' baseline sociodemographic, clinical and biochemical was performed and a logistic regression model used to assess the predictors of mortality.ResultsA total of 98 patients had 471 sessions in the two years under review. Males and females had similar characteristics at baseline except for a higher median serum urea in the males. The commonest causes of end-stage renal disease were chronic glomerulonephritis (34.5%), hypertension (32.1%) and diabetes mellitus (17.9%). The main predictor of mortality was under treatment with haemodialysis due to inability to pay for more than a few dialysis sessions.ConclusionsThis study has highlighted the unchanging demographics of our advanced kidney failure patients. Efforts should be aimed at subsidizing the cost of dialysis for our teeming population of dialysis dependent chronic kidney disease patients.

Systematic Barriers to the Effective Delivery of Home Dialysis in the United States: A Report From the Public Policy/Advocacy Committee of the North American Chapter of the International Society for Peritoneal Dialysis

Home dialysis, currently underused in the United States compared with other industrialized countries, likely will benefit from the newly implemented US prospective payment system. Not only is home dialysis less expensive from the standpoint of pure dialysis costs, but overall health system costs may be decreased by more subtle benefits, such as reduced transportation. However, many systematic barriers exist to the successful delivery of home dialysis. We organized these barriers into the categories of educational barriers (patient and providers), governmental/regulatory barriers (state and federal), and barriers specifically related to the philosophies and business practices of dialysis providers (eg, staffing, pharmacies, supplies, space, continuous quality improvement practices, and independence). All stakeholders share the goal of delivering home dialysis therapies in the most cost- and clinically effective and least problematic manner. Identification and recognition of such barriers is the first step. In addition, we have suggested action plans to stimulate the kidney community to find even better solutions so that collectively we may overcome these barriers.

Cinacalcet

This article provides an overview of the clinical profile of the calcimimetic agent cinacalcet (Mimpara®, Sensipar®) in the treatment of patients with secondary hyperparathyroidism (SHPT) undergoing dialysis for end-stage renal disease (ESRD), followed by a comprehensive review of pharmacoeconomic analyses with cinacalcet in this patient population. Most patients with ESRD undergoing dialysis develop SHPT, which is associated with disturbances in bone mineral metabolism and the development of fractures, cardiovascular disease and other clinical events. Standard treatment of SHPT includes phosphate binders and active vitamin D derivatives. However, standard treatment alone seldom achieves recommended target plasma or serum levels of parathyroid hormone (PTH), calcium and phosphorous. The addition of cinacalcet to standard therapy in patients with SHPT undergoing dialysis for ESRD improves the likelihood of achieving target biochemical levels compared with standard therapy alone. On the basis of association studies, improvements in these intermediate endpoints are likely to reduce the risk of clinical events, such as fractures and cardiovascular disease. Therefore, part of the acquisition cost of cinacalcet is likely to be offset by reductions in other healthcare resource use, such as reductions in costs associated with a lower likelihood of clinical events, as well as potential reductions in dosages of standard treatment. A number of pharmacoeconomic analyses across various country settings indicate that cinacalcet plus standard therapy is cost effective relative to standard therapy alone if dialysis costs are excluded, or that early initiation of cinacalcet is cost effective compared with delaying cinacalcet treatment until PTH levels become very uncontrolled. However, across analyses with cinacalcet, results were variable and not always favourable. This wide range of results stems from differences in selection of data sources used to populate the models, regional differences in healthcare resource use and costs, as well as other factors. Future cost-effectiveness analyses with cinacalcet should incorporate data on hard clinical outcomes from the EVOLVE study once this information becomes available.

Cost–Benefit Estimation of Cadaveric Kidney Transplantation: The Case of a Developing Country

BackgroundIn this paper we have estimated the cost savings for the health care system and quality-of-life improvement for patients from an increased number of kidney transplants in Chile. We compared the present value of dialysis and transplantation costs and quality of life over a 20-year horizon. MethodsWe used Markov models and introduced some degree of uncertainty in the value of some of the parameters that built the model. Using Monte Carlo simulations, we estimated the confidence intervals for our results. ResultsOur estimates suggested that a kidney transplant showed an expected savings value of US$28,000 for the health care system. If the quality-of-life improvement was also considered, the expected savings rise to US$ 102,000. These results imply that increasing donation rate by 1 donor per million population would achieve an estimated cost saving of US$827,000 per year, or near US$3 million per year considering the effect on the quality of life. ConclusionThese results demonstrated that kidney transplantation along with a better quality of life for patients are a cost-saving decision for developing countries.

Associations of Renal Function at 1-Year After Kidney Transplantation With Subsequent Return to Dialysis, Mortality, and Healthcare Costs

Improved early kidney transplant outcomes limit the contemporary utility of standard clinical endpoints. Quantifying the relationship of renal function at 1 year after transplant with subsequent clinical outcomes and healthcare costs may facilitate cost-benefit evaluations among transplant recipients. Data for Medicare-insured kidney-only transplant recipients (1995-2003) were drawn from the United States Renal Data System. Associations of estimated glomerular filtration rate (eGFR) level at the first transplant anniversary with subsequent death-censored graft failure and patient death in posttransplant years 1 to 3 and 4 to 7 were examined by parametric survival analysis. Associations of eGFR with total health care costs defined by Medicare payments were assessed with multivariate linear regression. Among 38,015 participants, first anniversary eGFR level demonstrated graded associations with subsequent outcomes. Compared with patients with 12-month eGFR more than or equal to 60 mL/min/1.73 m, the adjusted relative risk of death-censored graft failure in years 1 to 3 was 31% greater for eGFR 45 to 59 mL/min/1.73 m (P<0.0001) and 622% greater for eGFR 15 to 30 mL/min/1.73 m (P<0.0001). Associations of first anniversary eGFR level with graft failure and mortality remained significant in years 4 to 7. The proportions of recipients expected to return to dialysis or die attributable to eGFR less than 60 mL/min/1.73 m over 10 years were 23.1% and 9.4%, respectively, and were significantly higher than proportions attributable to delayed graft function or acute rejection. Reduced eGFR was associated with graded and significant increases in health care spending during years 2 and 3 after transplant (P<0.0001). eGFR is strongly associated with clinical and economic outcomes after kidney transplantation.

Cost-Effectiveness of Lanthanum Carbonate in the Treatment of Hyperphosphatemia in Chronic Kidney Disease Before and During Dialysis

ObjectivesHyperphosphatemia is a common and harmful condition in patients with chronic kidney disease (CKD). We determined the cost-effectiveness of the noncalcium-based phosphate binder lanthanum carbonate (LC) as second-line treatment of hyperphosphatemia after therapy failure with calcium-based binders (CB). MethodsTwo CKD populations were modeled: 1) predialysis CKD patients and 2) incident dialysis patients. Patients not responding to CB with a serum phosphate (SP) level >5.5 mg/dl received a trial with LC. Patients not responding to LC (SP >4.6 mg/dl) returned to CB treatment. Patient-level data were obtained from clinical trials in predialysis and dialysis. Time-dependent, life-long Markov models (discounting at 3.5% annually) were developed, using a UK National Health Service perspective. ResultsThe health gains with second-line LC treatment compared to CB treatment were 44 and 56 quality-adjusted life-years (QALYs) for the predialysis and incident dialysis populations, respectively. Second-line LC was a cost-saving strategy in the predialysis population because of the cost-savings of delayed CKD progression. Second-line LC was cost-effective at £6900 (90% probability interval: £5800–£8300) per QALY gained in the dialysis population. Results were robust to plausible variations in other model parameters; inclusion of future unrelated dialysis costs had a large influence on cost-effectiveness estimates. ConclusionsSecond-line treatment with LC is associated with considerable clinical benefits and good value for money in CKD, irrespective of dialysis status. These results support Kidney Disease Outcomes Quality Initiative guidelines to treat CKD patients with hyperphosphatemia irrespective of dialysis status.

157 Dialysis Is Not Indicated Immediately After Contrast in End Stage Renal Disease Patients on Hemodialysis

DIALYSIS IS NOT INDICATED IMMEDIATELY AFTER CONTRAST IN END STAGE RENAL DISEASE PATIENTS ON HEMODIALYSIS Sophie Kwok, Mamatha Chella, Beenu Singh, Anjali Acharya Albert Einstein College of Medicine (Jacobi Medical Center), Bronx, New York, United States. Contrast agents can cause renal injury and is associated with other complications, such as intravascular volume expansion and pulmonary edema. Contrast is removed efficiently by hemodialysis. Many radiologists encourage immediate dialysis after a procedure with contrast media because it may precipitate fluid overload, but when this risk becomes clinically significant is poorly understood. We undertook a retrospective chart review to determine if dialysis was required for pulmonary edema in patients with end stage renal disease on maintenance dialysis after administration of contrast media. We studied all patients who were on dialysis three times a week and received contrast procedures from January 2008 to November 2010. Only procedures requiring at least 50 ml of contrast were included. There were 104 radiographic studies (60 unique patients) that used intravascular contrast media. Five studies used ionic contrast medium (hypaque) and the remaining studies used non-ionic contrast media (omnipaque, visipaque). The studies were: two CT head, seven CT neck, 18 CT chest, 43 CT abdomen/pelvis, seven CT chest/abdomen/pelvis, one upper extremity CT, 11 angiographies of the lower extremities, eight cardiac catheterizations, and seven fistulograms. Average volume of contrast used was 117.2 ml (range 50 to 260 ml). After seven studies (6.7%), seven different patients were dialyzed for fluid overload earlier than their next scheduled dialysis; however, these patients were already in pulmonary edema prior to contrast administration. After three studies (2.9%), three different patients were dialyzed earlier because of hyperkalemia. None of the patients had post-procedural side effect of pulmonary edema that warranted dialysis before the next routinely scheduled session. The results of this study suggest that contrast agents may be given safely to patients with end stage renal disease on maintenance hemodialysis without the additional cost or inconvenience of emergent post-procedural dialysis.

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

Planned early initiation of dialysis therapy based on estimated kidney function does not influence mortality and major comorbid conditions, but amelioration of symptoms may improve quality of life and decrease costs. Patients with progressive chronic kidney disease and a Cockcroft-Gault estimated glomerular filtration rate of 10-15 mL/min/1.73 m(2) were randomly assigned to start dialysis therapy at a glomerular filtration rate of either 10-14 (early start) or 5-7 mL/min/1.73 m(2) (late start). Of the original 828 patients in the IDEAL (Initiation of Dialysis Early or Late) Trial in renal units in Australia and New Zealand, 642 agreed to participate in this cost-effectiveness study. STUDY PERSPECTIVE & TIMEFRAME: A societal perspective was taken for costs. Patients were enrolled between July 1, 2000, and November 14, 2008, and followed up until November 14, 2009. Planned earlier start of maintenance dialysis therapy. Difference in quality of life and costs. Median follow-up of patients (307 early start, 335 late start) was 4.15 years, with a 6-month difference in median duration of dialysis therapy. Mean direct dialysis costs were significantly higher in the early-start group ($10,777; 95% CI, $313 to $22,801). Total costs, including costs for resources used to manage adverse events, were higher in the early-start group ($18,715; 95% CI, -$3,162 to $43,021), although not statistically different. Adjusted for differences in baseline quality of life, the difference in quality-adjusted survival between groups over the time horizon of the trial was not statistically different (0.02 full health equivalent years; 95% CI, -0.09 to 0.14). Missing quality-of-life questionnaires and skewed cost data, although similar in each group, decrease the precision of results. Planned early initiation of dialysis therapy in patients with progressive chronic kidney disease has higher dialysis costs and is not associated with improved quality of life.

Cost-effectiveness analysis of renal replacement therapy in Austria

Providing renal replacement therapy (RRT) for end-stage renal disease patients is resource intensive. Despite growing financial pressure in health care systems worldwide, cost-effectiveness studies of RRT modalities are scarce. We developed a Markov model of costs, quality of life and survival to compare three different assignment strategies to chronic RRT in Europe. Mean annual treatment costs for haemodialysis were €43,600 during the first 12 months, €40,000 between 13 and 24 months and €40,600 beyond 25 months after initiation of treatment. Mean annual treatment costs for peritoneal dialysis were €25,900 during the first 12 months, €15,300 between 13 and 24 months and €20,500 beyond 25 months. Mean annual therapy costs for a kidney transplantation during the first 12 months were €50,900 from a living donor, €51,000 from a deceased donor, €17,200 between 13 and 24 months and €12,900 beyond 25 months after engraftment. Over the next 10 years in Austria with a population of 8 million people, increased assignment to peritoneal dialysis of 20% incident patients saved €26 million with a discount rate of 3% and gained 839 quality-adjusted life years (QALYs); additionally, increasing renal transplants to 10% from live donations saved €38 million discounted and gained 2242 QALYs. Live donor renal transplantation is cost effective and associated with increase in QALYs. Therefore, preemptive live kidney transplantation should be promoted from a fiscal as well as medical point of view.

Costs and added value of haemodialysis and peritoneal dialysis outsourcing agreements.

Despite the discrepancy in results from Spanish studies on the costs of dialysis, it is assumed that peritoneal dialysis (PD) is more efficient than haemodialysis (HD). To analyse the costs and added value of HD and PD outsourcing agreements in Galicia, the medical transport for HD and the relationship between the cost of the agreement and the cost of consumables used in continuous ambulatory peritoneal dialysis (CAPD) with bicarbonate. The cost of the outsourcing agreements and the staff was obtained from official publications. The cost of PD and medical transport were calculated using health service data for one month and extrapolating it to one year. The cost of CAPD consumables was provided by the suppliers. The added value was calculated from the investments generated for each agreement treating 40 patients. Expressed as patient/year, the mean costs for treatment were €21595 and €25664 in HD and PD, respectively. Medical transport varied between €3323 and €6338, while those of the CAPD agreement and consumables were €19268 and €12057, respectively. The added value was greater with the HD agreement, especially considering the jobs created. One cannot generalise that the cost of PD, which is significantly influenced by prescriptions, is lower than that of HD. It would be appropriate to review the additional cost to consumables in the CAPD agreement. The added value generated by dialysis agreements should be considered in future studies and in health planning. More controlled studies are needed to better understand this issue.

Nephrology around Europe: organization models and management strategies: Spain

The main aim of this report is to present a picture of the current organization of nephrology in Spain. The Spanish health system offers almost universal coverage, a wide variety of services and a high-quality network of hospitals and primary care centers. Spain has a specialized health care training system that is highly developed, highly regulated, with the capacity to provide high-quality training in 54 different specialties. Nephrology is basically a hospital-based specialty. There are no private dialysis patients in Spain. Hemodialysis centers are 40% public, 15% private and 45% run by companies. The National Health System covers 95% of the population, and there is no cost to patients for treatment of renal disease (dialysis and transplant). We observed a clear decrease of nephrology in residents' election rankings, with position 29 out of 47 specialties in 2007. Some of the reasons for this are the complexity of the subject, no clear information at the university, reduction of professional posts and a very good public service with minimal private practice. In Spain, a model of organization for transplantation was adopted based on a decentralized transplant coordinating network. For cadaveric donors, it compares favorably with rates in other Western countries. Living donor transplantation is very low in Spain--just 10% of total renal transplantation activity. New programs due to financial constraints need to include reduced dialysis costs, greater cost-effectiveness of prescriptions, better handling of ethical issues related to the need for using a clinical score of chronic kidney disease patients to make decisions about conservative or renal replacement therapy and an action plan for improvement of organ donation and transplantation. Recovery of skills (acute kidney injury, biopsies, vascular access, etc.), research and advances in autonomous activities (imaging, surgical and medical vascular training, etc.) are some of the future educational paths needed in nephrology. Adequate decisions in the context of economic restrictions need to be discussed for the sustainability of nephrological care.

Economic Evaluation of Cinacalcet in the Treatment of Secondary Hyperparathyroidism in Italy

Imbalanced levels of parathyroid hormone (PTH), serum calcium (Ca) and phosphorous (P) are associated with an increased risk of cardiovascular (CV) death and fracture in dialysis patients with secondary hyperparathyroidism (SHPT). The calcimimetic agent cinacalcet can attenuate the mineral and hormonal imbalances characteristic of SHPT and may improve outcomes in such patients. Here we describe a cost-utility analysis of cinacalcet for SHPT in dialysis patients in Italy. We developed a probabilistic Markov model to simulate the effect of cinacalcet on Ca, P and PTH levels in dialysis patients with SHPT, based on data from a European, multicentre, open-label study. The model then correlated these levels with mortality and morbidity (CV events, fractures and parathyroidectomies) using data from the literature, and incorporated Italian data for dialysis, drugs and management of events according to the national cost structure. The simulation horizon was patient lifetime; simulated treatment alternatives were standard treatment (mainly vitamin D sterols and phosphate binders) and cinacalcet + standard treatment. A 3.5% discount rate was applied to life expectancy (LE), quality-adjusted life-expectancy (QALE), costs and times below the upper ranges (time in range [TiR]) recommended by the National Kidney Foundation - Kidney Disease Outcomes Quality initiative for PTH, Ca, P and Ca × P. Utilities were derived from the published literature and took into account dialysis and the impairment of quality of life due to the occurrence of CV events and fractures. Costs were evaluated in year 2009 values from the perspective of the Italian National Healthcare System. Baseline results were calculated with 10,000 iterations. Compared with standard treatment alone, addition of cinacalcet was associated with a mean (SD) increase in TiR of 5.26 (6.59), 3.63 (6.87), 1.70 (6.66) and 2.68 (5.55) discounted patient-years for PTH, Ca and P, respectively, and combined PTH, Ca, P and Ca × P. Cinacalcet increased LE by 1.20 (3.75) life-years (LYs) and QALE by 0.89 (2.59) QALYs. When including the cost for dialysis, the incremental cost-effectiveness ratio (ICER) was €50,012 per LY and €67,361 per QALY, while, if dialysis costs were not included, the ICER was €23,473 per LY and €31,616 per QALY. The results suggest that cinacalcet treatment could be considered cost effective for treatment of SHPT in the Italian healthcare setting, but further investigations are needed to confirm these findings.

Race Predicts Dialysis Costs, but Unclear Why

Race Predicts Dialysis Costs, but Unclear Why