Dialysis Costs Research Articles

Budget impact analysis on the Italian healthcare system of roxadustat for the treatment of anemia due to chronic kidney disease

Objective: The aim of this study was to evaluate the economic consequences of the introduction of roxadustat on the market as treatment for chronic kidney disease (CKD)-related anaemia in Italy. Method: A budget impact model was developed to assess the economic impact of the introduction of roxadustat for the management of patient with CKD-related anaemia. The analysis was conducted considering National Health Service (NHS) perspective and three years’ time horizon. Eligible population for the treatment with roxadustat was estimated through published literature and clinicians’ support. Direct healthcare costs included drug acquisition (list prices for base case) and administration costs, monitoring costs, cost per blood transfusion, costs related to the management of adverse events and dialysis costs. Results: The model estimated a three years expenditure associated with the management of patients with CKD-related incident anaemia in Italy of about € 260 and € 44.6 million for non-dialysis dependent (NDD) and dialysis-dependent (DD) patients respectively. The introduction of roxadustat on the market could generate a reduction in the expenditure related to the iron supplementation both for NDD and for DD patients (−€ 397,305 and −€ 50,135 over three years of the analysis, respectively) and a reduction in the pharmaceutical expenditure for NDD patients (−€ 2.3 million, −€ 7.5 million and −€ 13 million at first, second and third year of the analysis). Overall, the introduction of roxadustat could generate a saving for NHS approximately equal to € 2.3, € 7.5 and € 13 million at first, second and third year of the analysis. Conclusion: The introduction of roxadustat could generate a reduction in the expenditure for the management of patients with CKD anaemia. A scenario analysis which used tender prices for ESAs and hypothesis of confidential discount for roxadustat showed that the saving for NHS will be kept if roxadustat’s discount is greater than 60.3%.

Challenges and Outcomes of Chronic Dialysis in Children: A Narrative Review

Chronic dialysis is a life-saving treatment for children with end-stage renal disease (ESRD). However, it comes with difficult challenges, cardiovascular ones being the most significant and fatal. Chronic kidney disease-mineral bone disorder (CKD-MBD) is also a common complication of chronic dialysis, as it has significant effects on growth and cardiovascular health. Infections are also a significant problem for those on chronic dialysis. The cost of dialysis and the lifestyle of Children with CKD are also not optimal, as they have a significantly lower Health-related quality of life (HRQoL) than children with other chronic illnesses. Children on chronic dialysis face several difficult challenges, which differ between peritoneal dialysis (PD) and hemodialysis (HD). Most of these challenges are manageable or preventable. This review article will discuss some of the challenges that children and their families encounter during chronic dialysis strategies to manage these challenges and the outcomes of long-term kidney dialysis.

Cost-effectiveness analysis of dapagliflozin for people with chronic kidney disease in Malaysia.

Chronic kidney disease (CKD) is a global health concern which results in significant economic burden. Despite this, treatment options are limited. Recently, dapagliflozin has been reported have benefits in people with CKD. This study aimed to evaluate the cost-effectiveness of dapagliflozin as an add-on to standard of care (SoC) in people with CKD in Malaysia. A Markov model was adapted to estimate the economic and clinical benefits of dapagliflozin in people with Stage 2 to 5 CKD. The cost-effectiveness was performed based upon data from the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) trial supplemented with local costs and utility data whenever possible. In Malaysia, dapagliflozin in combination with SoC was the dominant intervention compared to SoC alone (RM 81,814 versus RM 85,464; USD19,762 vs USD20,644). Adding dapagliflozin to SoC in people with CKD increased life expectancy by 0.46 years and increased quality-adjusted life years (QALY) by 0.41 in comparison with SoC alone (10.01 vs. 9.55 years, 8.76 vs. 8.35 QALYs). This translates to a saving of RM8,894 (USD2,148) with every QALY gained. The benefits were due to the delay in CKD progression, resulting in lower costs of dialysis and renal transplantation. Results were robust to variations in assumptions over disease management costs as well as subgroup of population that would be treated and below the accepted willingness-to-pay thresholds of RM 46,000/QALY. The use of dapagliflozin was projected to improved life expectancy and quality of life among people with CKD, with a saving RM8,894 (USD2,148) for every quality-adjusted life-year gained and RM7,898 (USD1,908) saving for every life year gained.

Effect of Remote and Virtual Technology on Home Dialysis.

In the United States, regulatory changes dictate telehealth activities. Telehealth was available to patients on home dialysis as early as 2019, allowing patients to opt for telehealth with home as the originating site and without geographic restriction. In 2020, coronavirus disease 2019 was an unexpected accelerant for telehealth use in the United States. Within nephrology, remote patient monitoring has most often been applied to the care of patients on home dialysis modalities. The effect that remote and virtual technologies have on home dialysis patients, telehealth and health care disparities, and health care providers' workflow changes are discussed here. Moreover, the future use of remote and virtual technologies to include artificial intelligence and artificial neural network model to optimize and personalize treatments will be highlighted. Despite these advances in technology challenges continue to exist, leaving room for future innovation to improve patient health outcome and equity. Prospective studies are needed to further understand the effect of using virtual technologies and remote monitoring on home dialysis outcomes, cost, and patient engagement.

Abstract 18632: Mechanical Circulatory Support in Patients Without Cardiogenic Shock Undergoing Percutaneous Coronary Intervention

Background: The use of mechanical circulatory support (MCS) devices for high-risk percutaneous coronary intervention (PCI) has increased over the last decade. However, data on outcomes between MCS device type have been mixed and long-term outcomes are limited. Our aim was to examine the association between intravascular microaxial left ventricular assist device (LVAD) or intra-aortic balloon pump (IABP) use in patients without cardiogenic shock undergoing PCI. Methods: This retrospective study analyzed administrative claims data from a large, insured population across the United States. Patients who underwent PCI without cardiogenic shock from 4/1/2016 to 7/31/2022 were included. Using inverse probability treatment weighting (IPTW), we assessed for the association between device type and all-cause mortality during the index admission, 30-days, and up to 1-year. Secondary outcomes included stroke, bleeding, incident dialysis, repeat revascularization, and total healthcare costs. Results: We identified 2,879 patients undergoing PCI without cardiogenic shock, the mean (SD) age was 68.2 (12.5) years, 27% (n=764) were women, and 61% (n=1,757) had a primary diagnosis of acute myocardial infarction (AMI). After IPTW, intravascular LVAD use was not associated with a statistically significant difference in in-hospital (Odds ratio [OR] 1.30; 95% Confidence interval [CI]: 0.88-1.91, P =0.19) or 30-day (OR 1.19; 95% CI:0.84-1.69, P =0.33) mortality compared to IABP use. At 1-year, intravascular LVAD use was associated with a significant increase in mortality (Hazard ratio 1.23; 95% CI:1.04-1.46, P =0.01). Compared to those receiving an IABP, index admission mean total costs ($81,970 vs. $65,298; P <0.001) and mean monthly costs ($11,030 vs. $14,133; P <0.001) up to 1-year were significantly higher in those receiving an intravascular LVAD. There was no significant association between device type and stroke, bleeding, incident dialysis, and repeat revascularization at any timepoint (all, P >0.05). Conclusions: In patients without cardiogenic shock undergoing PCI, intravascular LVAD use was associated with higher costs but not associated with lower mortality. Randomized data is needed to improve device selection for these patients.

Fifty years of hemodialysis in Ghana—current status, utilization and cost of dialysis services

BackgroundKidney failure is common in Ghana. Haemodialysis (HD) is the most common treatment modality for survival. Although, HD has been available in Ghana for 50 years, the majority of patients who develop kidney failure cannot access it. We describe the state of HD, dialysis prevalence, its utilization and cost of HD after fifty years of dialysis initiation in Ghana.MethodsA situational assessment of HDs centres in Ghana was conducted by surveying nephrologists, doctors, nurses and other health care professionals in HD centres from August to October 2022. We assessed the density of HD centres, number of HD machines, prevalence of nephrologists, number of patients receiving HD treatment and the cost of dialysis in private and government facilities in Ghana.ResultsThere are 51 HD centres located in 9 of the 16 regions of Ghana. Of these, only 40 centres are functioning, as 11 had shut down or are yet to operate. Of the functioning centres most (n = 26, 65%) are in the Greater Accra region serving 17.7% of the population and 7(17.5%) in the Ashanti region serving 17.5% of the population in Ghana. The rest of the seven regions have one centre each. The private sector has twice as many HD centers (n = 27, 67.5%) as the public sector (n = 13,32.5%). There are 299 HD machines yielding 9.7 HD machines per million population (pmp) with a median of 6 (IQR 4–10) machines per centre. Ghana has 0.44 nephrologists pmp. Currently, 1195 patients receive HD, giving a prevalence of 38.8 patients pmp with 609(50.9%) in the private sector. The mean cost of HD session is US $53.9 ± 8.8 in Ghana.ConclusionThere are gross inequities in the regional distribution of HD centres in Ghana, with a low HD prevalence and nephrology workforce despite a high burden of CKD. The cost of haemodialysis remains prohibitive and mainly paid out-of-pocket limiting its utilization.

Estimated indirect costs of haemodialysis versus peritoneal dialysis from a patients’ perspective at an Academic Hospital in Pretoria, South Africa

In South Africa (SA), patients with kidney failure can be on either haemodialysis (HD), which is performed by a healthcare professional in a hospital thrice weekly; or peritoneal dialysis (PD), which can performed daily at home. There needs to be more studies within the South African healthcare sector on the cost of kidney failure and especially the indirect costs associated with patients being on dialysis to provide future guidance. This study aimed to determine and compare the indirect costs associated with HD and PD from the patients’ perspective at an Academic Hospital in Pretoria. The study used a cross-sectional prospective quantitative study design. The researcher used face-to-face interviews to collect data and the human capital approach to calculate productivity losses. The study population included all patients over 18 receiving HD or PD for over three months; 54 patients participated (28 on HD and 26 on PD). The study lasted seven months, from September 2020 to March 2021. Haemodialysis patients incurred greater productivity losses per annum ($8127.55) compared to PD (R$3365.34); the difference was statistically significant with a P-value of p < 0.001. More HD (96.4%) patients were unemployed than (76.9%) PD patients.

Perbandingan biaya terapi hemodialisis dengan peritoneal dialisis di Asia: Narrative review

The high prevalence of Chronic Kidney Disease (CKD) patients increases the demand for dialysis therapy. Studies comparing dialysis modality therapies undergone by CKD patients in the Asian region are still limited. The research objective is to compare the costs of Hemodialysis (HD) and Peritoneal Dialysis (PD) therapies in Asian countries. The review of 4 Asian regions indicates that patients undergoing HD therapy have a higher financial burden than PD therapy. The main costs affecting the high expenses of HD therapy come from the remuneration of healthcare professionals specialized in assisting patients, including doctors, nurses, and technicians. Productivity loss and transportation costs also contribute to HD therapy's higher costs than PD therapy. However, in the Western Asian region, PD therapy costs more than Hemodialysis therapy. PD therapy costs more due to additional direct medical expenses such as filters, bicarbonate cartridges, tubes, acid dialysate, and pyrogen filters.

Dialysis capacity and nutrition care across Bangladesh: A situational assessment.

Hemodialysis (HD) is a treatment for ensuring the survival of end-stage kidney disease (ESKD) patients, and nutrition care is integral to their management. We sent questionnaires to evaluate the total dialysis service capacity and nutrition services across all dialysis facilities (DF) in Bangladesh, with responses from 149 out of 166 active DFs. Survey results revealed that 49.7% of DFs operated two shifts, and 42.3% operated three shifts daily, with 74.5% holding between one and ten dialysis machines. Sixty-three percent of DFs served between one and 25 patients per week, and 77% of patients received twice-weekly dialysis. The average cost for first-time dialysis was 2800 BDT per session (range: 2500-3000 BDT), but it was lower if reused dialyzers were used (2100 BDT, range: 1700-2800 BDT). Nutritionists were available in only 21% of the DFs. Parameters related to nutritional health screening (serum albumin, BMI, MIS-malnutrition inflammation assessment, and dietary intakes) were carried out in 37.6%, 23.5%, 2%, and 2% of the DFs, respectively, only if recommended by physicians. Nutrition education, if recommended, was provided in 68.5% of DFs, but only in 17.6% of them were these delivered by nutritionists. The recommendation for using renal-specific oral nutrition supplements (ONS) is not a familiar practice in Bangladeshi DFs and, therefore, was scarcely recommended. Dialysis capacity across Bangladesh is inadequate to meet current or projected needs and nutrition education and support across the DFs to benefit improving patients' quality of life is also inadequate.

Dialysis costs for a health system participating in value-based care.

Unplanned "crash" dialysis starts are associated with worse outcomes and higher costs, a challenging problem for health systems participating in value-based care (VBC). We examined expenditures and utilization associated with these events in a large health system. Retrospective, single-center study at Cleveland Clinic, a large, integrated health system participating in VBC contracts, including a Medicare accountable care organization. We analyzed beneficiaries who transitioned to dialysis between 2017 and 2020. Crash starts involved initiating inpatient hemodialysis (HD) with a central venous catheter (CVC). Optimal starts were initiated with either home dialysis or outpatient HD without a CVC. Suboptimal starts were initiated with outpatient HD with a CVC or inpatient HD without a CVC. A total of 495 patients initiated chronic dialysis: 260 crash starts, 130 optimal starts, and 105 suboptimal starts. Median predialysis 12-month cost was $67,059 for crash starts, $17,891 for optimal starts, and $7633 for suboptimal starts (P < .001). Median postdialysis 12-month cost was $71,992 for crash starts, $55,427 for optimal starts, and $72,032 for suboptimal starts (P = .001). Predialysis inpatient admission per 1000 beneficiaries was 1236 per 1000 for crash starts vs 273 per 1000 for optimal starts and 170 per 1000 for suboptimal starts (P < .001). Postdialysis inpatient admission for crash starts was 853 per 1000 vs 291 per 1000 for optimal starts and 184 per 1000 for suboptimal starts (P < .001). In a major health system, crash starts demonstrated the highest cost and hospital utilization, a pattern that persisted after dialysis initiation. Developing strategies to promote optimal starts will improve VBC contract performance.

OUT OF POCKET AND HEALTH FACILITY CHARGES AMONG PATIENTS UNDERGOING DIALYSIS AT SERVICES HOSPITAL, LAHORE

ABSTRAC&#x0D; Background:- Dialysis is the process of removing waste products and excess fluid from the body. Dialysis allows the patient with kidney failure a chance to live a productive life. Government Hospitals in Punjab providing free treatment to all Hemodialysis patients, Government introduced Sehat Sahoolat card for citizen of Pakistan for their family by providing 1 million rupees per year for every family. Most of the patients spending out of pocket expenditures to meet their medical demand and due to this burden some time they can’t continue their routine visit for Hemodialysis to sustain their daily life, the impact of this out pocket expenditure disturb the home budget as well as their treatment continuity. The purpose of this study to find out different categories of expenses and its impact on their treatment, &#x0D; Of patients being treated with dialysis about 10% receive peritoneal dialysis and the remainders receive Hemodialysis. Pakistan is among the lower middle income countries. It is reported that the cost of dialysis per patient is approximately international $4,003.03 per year. Dialysis is exhausting for patients and fraught with morbidity and eventual mortality. While out-of-pocket expenditure remains the major source of health care financing in Pakistan (two-thirds of the total health spending), the financial burden varies enormously across diseases and by the economic wellbeing of the households.1&#x0D; Objectives: To assess out of pocket expenditures and health facility charges among patients undergoing dialysis at Services Hospital, Lahore.&#x0D; Study design: It was a descriptive Cross section study.&#x0D; Study setting: Dialysis unit of Services Hospital, Lahore.&#x0D; Sample size: The sample size was estimated by using WHO SS (Sample Size) software by using formula of estimating a population proportion with specific relative precision at confidence level of 75%, anticipated population proportion of 75% and relative precision of 10%. The maximum sample size is 130.&#x0D; Result: We audited records Mean out of pocket incurred both medical and non medical 4950/week while mean out of pocket charges on lab investigation were 10300/ during one year of dialysis, Study shows that those with co-morbidity but they lost the regularity treatment were 69.2% and having only renal dialysis 8.4% and lost the regular treatment due to out of pocket expenditures either expending from their own pocket or support from family. Highly significant with df=1 Chi squire=14.0793 P value=0.0001. &#x0D; Reason to lost continuity of treatment from 33 cases 90.9% due to out of pocket expenditures while 9.09% says due to other reason ,their source of income was personal and from family support respectively. df=1 Chi squire= 0.0143478 P value=0.90&#x0D; Conclusion: Our research concluded that health facilities provided by the dialysis unit of Services hospital to the patients were considered to be average. Majority of patients who spent money on medicines and transport, were financially supported by their families. Government hospitals were preferred because medical facilities were affordable.&#x0D; Key words: Out of Pocket. Hemodialysis,Financial burden ,Co-Morbidity

High Hospital-related Costs at the End-of-life in Patients With Multiple Myeloma: A Single-center Study.

High Hospital-related Costs at the End-of-life in Patients With Multiple Myeloma: A Single-center Study.

Manual single lumen alternating micro-batch dialysis achieves reliable clearance via diffusion.

Acute kidney injury is a cause of preventable deaths in low resource settings due to lack of dialysis access and cost. A manual single lumen alternating micro-batch (mSLAMB) dialysis technique performs kidney replacement therapy using single lumen access, low-cost bags/tubing, intravenous fluids, anda filter without electricity, a battery, or a pump. We propose a protocol whereby mSLAMB can perform diffusive clearance simply and efficiently to bring dialysis to underserved populations. Expired packed red blood cells mixed with crystalloid solution were spiked with urea and anticoagulated with heparin. A Static diffusion Technique (with short flushes of fluid before each filter pass) was compared to a Dynamic diffusion Technique (with fluid running through the filter during the forward pass) to assess urea and potassium clearance. Passive ultrafiltration was the difference between the 200 mL batch volume and volume returned to the blood bag per cycle. Five cycles achieved urea reduction ratios (URR) between 17-67% and potassium clearance of 18-60%, with higher percentagesachieved from higher proportions of batch volume dialyzed to patient volume. Dynamic Technique increased clearance over the Static Technique. Passive ultrafiltration volumes were 2.5-10% of batch volume. mSLAMB dialysis performs diffusive clearance and passive ultrafiltration efficiently, while preserving resources and available manpower. mSLAMB is a dialysis technique that can perform efficient diffusive clearance and passive ultrafiltration without electricity, batteries, or a pump. With basic medical supplies and limited manpower, mSLAMB is a cost-effective means of providing emergency dialysis in low resource areas. We propose a basic algorithm for safe and cost-effective dialysis for people of different ages and sizes.

Value of an Integrated Home Dialysis Model in the United Kingdom: A Cost-Effectiveness Analysis

ObjectivesThis study aimed to determine the lifetime cost-effectiveness of increasing home hemodialysis as a treatment option for patients experiencing peritoneal dialysis technique failure compared with the current standard of care. MethodsA Markov model was developed to assess the lifetime costs, quality-adjusted life-years, and cost-effectiveness of increasing the usage an integrated home dialysis model compared with the current patient pathways in the United Kingdom. A secondary analysis was conducted including only the cost difference in treatments, minimizing the impact of the high cost of dialysis during life-years gained. Sensitivity and scenario analyses were performed, including analyses from a societal rather than a National Health Service perspective. ResultsThe base-case probabilistic analysis was associated with incremental costs of £3413 and a quality-adjusted life-year of 0.09, resulting in an incremental cost-effectiveness ratio of £36 341. The secondary analysis found the integrated home dialysis model to be dominant. Conclusions on cost-effectiveness did not change under the societal perspective in either analysis. ConclusionsThe base-case analysis found that an integrated home dialysis model compared with current patient pathways is likely not cost-effective. These results were primarily driven by the high baseline costs of dialysis during life-years gained by patients receiving home hemodialysis. When excluding baseline dialysis-related treatment costs, the integrated home dialysis model was dominant. New strategies in kidney care patient pathway management should be explored because, under the assumption that dialysis should be funded, the results provide cost-effectiveness evidence for an integrated home dialysis model.

Process control: simply a matter of efficiency or of survival and costs? A single-centre quality improvement project in living donor renal transplant

BackgroundRising incidence and prevalence of end-stage renal disease is a worldwide concern for sustainability of healthcare systems and societies. Living donor renal transplant [LDRT] provides highest health achievements and cost containment than any alternative form of renal replacement therapy. Nonetheless, about 25% of potential LDRTs are missed for causes directly related with inadequate timing in donor assessment. Our quality improvement (QI) project implement process control tools and strategy aiming at reducing total evaluation time for donor candidates and minimizing dialysis exposure for intended recipients, which are the two main determinants of clinical outcomes and costs.MethodsThe study includes patients who underwent donor nephrectomy between January 1, 2017 and December 31, 2021. Six Sigma DMAIC approach was adopted to assess Base Case performance (Jan2017-Jun2019) and to design and implement our QI project. Study of current state analysis focused on distribution of time intervals within the assessment process, analysis of roles and impacts of involved healthcare providers and identification of targets of improvement. Improved Scenario (Jul2019-Dec2021) was assessed in terms of total lead time reduction, total pre-transplantation dialysis exposure and costs reduction, and increase in pre-emptive transplantations. The study was reported following SQUIRE 2.0 Guidelines for QI projects.ResultsStudy population includes 63 patients, 37 in Base Case and 26 in Improved Scenario. Total lead time reduced from a median of 293 to 166 days and this in turn reduced pre-transplantation dialysis exposure and costs by 45%. Rate of potential pre-emptive donors’ loss changes from 44% to 27%.ConclusionsLean methodology is an effective tool to improve quality and efficiency of healthcare processes, in the interest of patients, healthcare professionals and payers.

The US Supreme Court and Future of Financing Dialysis Care.

The US Supreme Court and Future of Financing Dialysis Care.

Financial toxicity and dialysis: Autonomy and truth-telling in resource-limited settings.

From an ethical perspective, resource limitations provide a challenge for healthcare providers. Handling disclosure of the financial details of treatment options in a way that empowers patients, even in the face of extreme poverty, requires careful consideration of the personal preferences and motivations of each patient. This article will consider the high costs of dialysis for patients experiencing extreme poverty in light of various ethical principles, including informed consent and truth-telling. It will conclude that a graduated method of disclosing the physical and financial burdens of each treatment option is the best way forward, particularly for healthcare workers engaged in resource-limited settings.

PS-C18-12: STRESS AND COPING STRATEGY AMONG CAREGIVERS OF HYPERTENSIVE PATIENTS UNDERGOING HEMODIALYSIS- A PROSPECTIVE STUDY

Objective: To find out the level of burden/stress, and quality of life (QoL) among caregivers of hypertensive patients undergoing hemodialysis. And, to access the coping strategies used by caregivers. Design and Methods: This was a prospective observational study of caregivers of hypertensive patients undergoing hemodialysis having a history of caring for hemodialysis patient for at least 3 months and who had more than or equal to 18 years of age. A scheduled interview was arranged for each participant to complete the validated inventory questionnaire; Caregivers burden (CGB) Scale, WHO-QOL-BREF scale, and COPE inventory questionnaire to measure the level of stress, QoL and coping strategies used by the caregivers. Results: A total of 100 caregivers of hypertensive patients undergoing hemodialysis were enrolled in the study. Age varied from 20 to 76 years (mean 39.66 ± 12.74 years). The majority of the participants were male (62.9%) married (83.5%), employed (68%), and literate (95.8%). Around half (50.5%) of the patients had reimbursed the cost of dialysis from the Government schemes. Around half of the caregivers reported medium to high (medium, high; 40.21%, 10.31% respectively) levels of stress on utilizing the CGB scale. Using the WHOQOL-BREF questionnaire, it was found that participants had an overall good QoL (Table 1). Most of the caregivers adopted turning to religion, seeking social support, positive reinterpretation, planning, and acceptance as a coping strategy (Table 1). Conclusion: In view of moderate to high levels of stress among caregivers of hypertensive patients undergoing hemodialysis, there may be recommendations for developing a practicing guideline to address the caregiver assessment, education, and provision of referral to support services.

Reining in Costs of Kidney Dialysis: US Supreme Court Offers Hope to End Predatory Pricing

PurposeTwo for-profit dialysis providers control >70% of the US kidney dialysis market. They use their excessive market power to force private insurers to pay nearly 4 times the Medicare rate, earning exorbitant profits for themselves at the expense of the health care system. Both the legislative and judicial systems have been called on to address this inequity, so far without success. MethodsWe examined the history of this issue as set forth in official Centers for Medicare & Medicaid Services, US Department of Health and Human Services, Federal Trade Commission, and other regulatory documents as well as court filings and opinions. We analyzed the legislative efforts to address the problem and the judicial response. FindingsWe found that most efforts, to date, have failed. However, a 2022 US Supreme Court decision helps illuminate a path forward, in large part by defining the limits of judicial intervention. ImplicationsWe identify a path forward that would separate the monopolistic players using a multipronged effort involving US Department of Justice, Federal Trade Commission, Office of Inspector General, and states attorneys general. We also caution that, based on our research, the providers could challenge further efforts by deciding to withdraw services in certain areas or refuse to do business with certain insurers, resulting in patients having difficulty accessing dialysis.

Community Houses to Increase Access to Home Dialysis.

Community Houses to Increase Access to Home Dialysis.