cost effectiveness analysis on chronic dialysis ...inahea.org/files/hari2/4. elsa novelia.pdf ·...

INA HEA, Jakarta 2015

COST EFFECTIVENESS ANALYSIS ON CHRONIC DIALYSIS : COMPARISON BETWEEN HAEMODIALYSIS AND CHRONIC

AMBULATORY PERITONEAL DIALYSIS

ELSA NOVELIA

BPJS Kesehatan


BACKGROUND

LITERATURE REVIEW

FRAMEWORK CONSEPTS

METHODOLOGY

RESULT

DISCUSSION

CONCLUSION

2


BACKGROUND

3

Decreased renal function up with not being able to work in maintaining the balance of

fluids/chemicals

(Sherwood 2001)

Damage of Renal > 3 months with pathology abnormalities, glomerular

filtration rate < 60 ml/min

(Chonchol 2005)


CLASSIFICATION OF CKD

Penanda Tahapan CKD Kode CKD (ICD-9-CM)eGFR ≥90 ml/min/1.73 m2, ACR ≥30 mg/g 585.1 Chronic kidney disease, Stage 1eGFR 60–89, ACR ≥30 585.2 Chronic kidney disease, Stage 2 (mild)eGFR 30–59 585.3 Chronic kidney disease, Stage 3 (moderate)eGFR 15–29 585.4 Chronic kidney disease, Stage 4 (severe)eGFR <15 585.5 Chronic kidney disease, Stage 5Keterangan: ACR adalah Albumin/Creatinin Ratio

4

Source: National Health and Nutrition Examination Survey (2002)

INA HEA, Jakarta 2015 5

Worldwide 7% or 488 million CKD

1,6 million ESRD/CKD stage 5

America 12,3 %, 36 million CKD

117 thousand ESRD

Indonesia 0,2% ESRD > 15 years old or 482 thousand inhabitant (Riskesdas 2013)


ESRD PATIENT AND VISIT TO HOSPITAL

ESRD

2010 2011 2012 2013

number Ratio /100.000 members

numberRatio/100.000

membersnumber

Ratio/100.000 members

numberRatio/ 100.000

members

Patient 26.455 159,8 23.261 141,1 24.362 148,7 25.975 160,9

Outpatient 28.546 172,4 52.614 319,2 54.512 332,7 54.092 335,2

Inpatient 12.533 75,7 23.911 145,1 26.703 162,9 28.829 178,6

6

Source: PT Askes Data (2013)


DM AND HYPERTENSION

DIAGNOSISTOTAL OF PATIENT

2010 2011 2012 2013

DM414.906 348.518 371.243 380.887

HYPERTENSION482.150 511.661 527.816 522.125

7

Sources: PT Askes Data (2013)


COST CONSEQUENCES OF ESRD TREATMENT

32 billion USD/year (Harvard Stem Cell Institute 2011)

1 trillion USD in next 10 years(World Kidney Day Organisation 2013)

8


COST OF ESRD

231,51

336,20

417,68

482,07

2010 2011 2012 2013

Cost of ESRD (Billion RP)

9



Year Cost of ESRD Cost of Health Care % cost of ESRD compare tocost of Health Care

2010 231,512,443,433.64 4,342,338,234,959 5,3%

2011 336,204,155,653.31 5,166,418,195,229 6,5%

2012 417,687,396,410.29 6,490,512,490,936 6,4%

2013 482,067,148,455.74 6,900,109,165,791 6,9%

10


COST OF ESRD


COST OF RENAL REPLACEMENT

Transplant 172 Million (Rp) +

immunosuppressant drugs per year 68

Million

HD 2 times a week, 5 hours,

54 – 72 (Rp) Million

CAPD 53-70 Million (Rp) +

Catheter 10 Million

11

Source: Karopadi (2013)


QUALITY OF LIFE

Chronic Disease (ESRD)

Poor Quality of Life Poor Mental Health

12


RENAL REPLACEMENT THERAPY

WORLDWIDE CAPD120 THOUSAND (2009)

INDONESIA CAPD800 OR 10 % OF HD (2009)

13


HD VS CAPDTREATMENT 2010 2011 2012 2013

HD 334,382 408,800 491,520 557,095

CAPD 6,571 6,464 7,497 8,645

Ratio CAPD/HD 2.0% 1.6% 1.5% 1.6%

14



OBJECTIVEThe aim of this study is to analize the cost effectiveness between HD and CAPD on ESRDpatients

15

HEMODIALISA

CAPD


MAIN CAUSE OF CHRONIC KIDNEY DISEASE IN THE UNITED STATES (1995-1999)

Caused Incident

DM 44 %

Hypertension and vascular disease 27%

Glomerulonefritis 10%

Nefritis Insterstitialis 4%

Cyst and other congenital disease 3%

Systemic Disease (ex Lupus and Vasculitis) 2%

Neoplasma 2%

16

Source: Buku ajar Ilmu Penyakit Dalam (2006)


CAUSED OF RENAL FAILURE WHO UNDERGOING HEMODIALYSIS IN INDONESIA

Caused Incident

Glomerulonefritis 46,39%

DM 18,6%

Obstruction and Infection 12,85%

Hypertension and Infection 8,46%

Others caused 13,65%

17

source: Buku ajar Ilmu Penyakit Dalam (2006)


RENAL REPLACEMENT THERAPY

No Renal Replacement

I Dialysis

A. Peritoneal Dialysis (DP)

B. Hemodialysis

II Renal Transplants

Life Donor

Funeral Donor

18

Source: Buku ajar Ilmu Penyakit Dalam (2006)


HEMODIALYSIS

19

CAPD


HEMODIALYSIS VS PERITONEAL DIALYSIS

Hemodialysis Peritoneal Dialysis

Benefit Done by a team of health professionals

Be able to socialize with other hemodialysis patients who will

provide emotional support

Not be done alone as PD

Done in fewer days than the PD

Gives more freedom than HD

Can be done at home, can be done at the time of travel,

while sleeping

Can be done alone

Does not take a lot of food and fluid restriction as in HD

It takes no needles

Loss Cause fatigue during the HD session

Led to the emergence of problems such as low blood pressure,

blood clots during dialysis access

Increase the risk of bloodstream infection

The procedure is quite difficult as some people

Increase the risk of infection peritonitis

20Source: (WebMD 2011)


ESTIMATION COST OF HD AND CAPDCountry Average cost of HD

per month

Average cost of CAPD

per month

HD Reimburstment

from Government

CAPD Reimburstment

from Government

Banglades 370 454,5 68% 0%

Cina 500 500 50-90% 50-90%

Hongkong 2,560 1,070 100% 100%

India 160-280 325 0% 0%

Indonesia 450-900 450 10-30% 40%

Jepang 3,480 3,200 100% 100%

Korea 1,160 1.100 80% 80%

Malaysia 520 315 40% 100%

Pakistan 300 800 70% 0%

Singapura 1,001 618 80% 80%

Sri Langka 324 700-800 60% 0%

Taiwan 1,615 1,032 100% 100%

21Source: Departement of Medicine and Therapeutics (2001)

PD Utilization > 80%, Government Policy


COST COMPARISON BETWEEN HEMODIALYSIS AND CAPDCountry HD CAPD

Swedia 99,084 74,880

USA In Center: 51,252

Satellite: 42,067

Self Care: 29,961

26,959

Hongkong 30,678 12,843

Turkey 22,759 22,350

Malaysia 8,853 8,325

22

Source: Departement of Medicine, Tung Wah Hospital, (2006)Cost of PD less than HD, lower

utillization, physician incentives, main reason in

many countries(Kei Lo 2007)


QUALITY OF LIFE DIALYSIS PATIENTAccording to (Coccossis, et al., 2008) renal failure patients who receivedhemodialysis or peritoneal dialysis action / CAPD found to have a decreasedquality of life, with different areas.

Some studies showed that HD patients reported having better on physicalquality, sleep and sexual relationship. For some mental study found thatpatients who commit acts of HD have more depressive symptoms comparedwith PD. This can happen because the HD patients should be connected tothe machine during dialysis routinely. On the other hand the high rate ofsuicide in patients with HD were reported due to the violation dietary cloud.

23


FRAMEWORK CONCEPTS

24

Quality of life

Age

Gender

Education

Job

Duration of HD

Duration of CAPD

Disease before suffer from ESRD

Renal Replacement

Total cost of HD

ICER

Renal Replacement

HD

Total cost of CAPD

HD Patient Quality of life

CAPD Patient Quality of life

Renal Replacement

CAPDACER

ACER

Independent Variable Dependent Variable


HYPOTESIS

CAPD cost effective compare to HD

25


• Cross Sectional • Direct medical cost (INA

CBGs)• Indirect medical cost

(questionnaire)• Opportunity cost

(questionnaire)• Quality of life (SF 36)

Research Design

• HD : RS PMI Bogor• CAPD: Patient Home• April – May 2014

Location and Time • Population:

• HD Patient :PMI Bogor Hospital

• CAPD Patient: Fatmawati Hospital

Population and Sample

26


DIRECT MEDICAL COST : HEMODIALYSIS PACKET (TARIF RS TIPE B, REGIONAL I) 2014

Variable Cost (Rp)Cimino Operation 1.324.036,-Hemodialysis packetRental Machines and roomMedical FeeConsumable HD Set and Hemodialysis fluiddrugs and BMHPBlood TransfusionLaboratoryDiagnostic investigationOther CostOne Session of HD 982.650,-

Cost per year (2 times/week) 102.195.600,-Cost per year (2 times/week) + Cimino Operation 103,519,636,-

27


DIRECT MEDICAL COST : HEMODIALYSIS PACKET (TARIF RS TIPE A, REGIONAL I) 2014

Variabel Biaya (Rp)

Cimino Operation 3.063.114

Hemodialysis packet

Rental Machines and room

Medical Fee

Consumable HD Set and Hemodialysis fluid

drugs and BMHP

Blood Transfusion

Laboratory

Diagnostic investigation

Other Cost

One Session of HDCost per year (2 times/week)

1.380.582,-143.580.528,-

Cost per year (2 times/week) + Cimino Operation 146.643.642,-

28

Assumptions calculation from new patients in 2012 Indonesian Renal Registry (IRR) (19.621 patients), BPJS will be burdened Rp.2.031.158.777.956, - when

patients get HD in Hospital type B and becomesRp. 2,877,294,899,682, - when patients received HD in Type A Hospital


CAPD DIRECT MEDICAL COST(TARIF INA CBGS RSUP FATMAWATI)

Variable Cost (Rp)Catheter 3.063.114Routine CAPD Packet Consumable CAPD Set include fluids for 30 days

- Dianeal 1,5% = 90- Dianeal 2,5% = 90- Minicap = 120

Jasa Pengiriman CAPD SetMedical feeSub Total Cost 5.940.000,-Routine Packet per year (4 times per day) 71.280.000,-

Transfer set every 6 month depend on medical indication 250.000,-Transfer set in one year 500.000,-Cost per year + Transfer set per year 71.780.000,-Total cost per year 74.843.114,-

29

When compared with hemodialysis treatment, the direct medical care cost of CAPD provide the difference in cost of Rp. 562 662 038 162, - lower or 28% lower than hemodialysis in Type B Hospital and Rp.1.408.798.159.888, - in Type A Hospital or 51 , 04% lower.


DISTRIBUTION OF DIRECT NON MEDICAL COST FOR HEMODIALYSIS PATIENT

Variable Min (Rp) Max (Rp)

Mean (Rp)

Median(Rp)

Transportation 6.500 400.000 43.763 27.500Food/Drink 5.000 90.000 14.859 2.500HD Cost per session 11.500 490.000 58.622 30.000

Cost per month(2 session per week)

103.500 4.410.000 468.976 240.000

Cost per year 1.236.000 52.920.000 5.627.712 3.120.000

30

These costs must be quite burden for patients whose income < Rp 500.000, -. Although the direct medical costs not borne by the patient, direct non-medical costs alone is quite a burden for hemodialysis patients.


LOSS INCOME OF HD PATIENT’S

Variable Min(Rp)

Max(Rp)

Mean(Rp)

Median

Loss of income per month

Patient - 16.000.000 1.522.000 640.000Family who are waiting during HD session - 450.000 280.000 280.000Lost of income per month - 16.450.000 1.802.000 920.000Lost of income per year 197.400.000 21.624.000 11.040.000

31

CAPD patients and their families do not have to lose time working for CAPD action. It can be concluded indirect costs of the action CAPD is Rp.0


HD VS CAPD QUALITY OF LIFE

Variable Total Persentase (%)Whole SampleLess Quality 43 48,9Good Quality 45 51,1HD PatientLess Quality 42 53,8Good Quality 36 46,2CAPD Patient Less Quality 1 10Good Quality 9 90

32


CONECTION BETWEEN INDEPENDENT VARIABLE WITH DEPENDENT VARIABLE

Variable Quality of life OR(95% CI)

P-ValueLeer Quality Good Quality

Renal ReplacementHDCAPD

42 (53,8%)1 (10,0%)

36 (46,2%)9 (90,0%)

10,5 (1,269-86,901) 0,015*

Age< 45 year>= 45 year

17 (54,8%)26 (45,6%)

14 (45,2%)31 (54,4%)

1,448 (0,601-3,486) 0,546

GenderManWomen

26 (53,1%)17 (43,6%)

23 (46,9%)22 (56,4%)

1,463 (0,628-3,408) 0,504

WorkingnoWorking

35 (57,4%)8 (29,6%)

26 (42,6%)19 (70,4%)

3,197 (1,213-8,429) 0,030*

EducationLowHigh

6 (54,5%)37 (48,1%)

5 (45,5%)40 (51,9%)

1,297 (0,365-4,611) 0,936

Duration of HD/ CAPD< 4 year>= 4 year

29 (46,0%)14 (56,0%)

34 (54,0%)11 (44,0%)

0,670 (0,264-1,702) 0,544

33

(*) : statistical significant


QUALITY OF LIFE DIMENSION

QoL Dimension Variable N Mean SD T (t-test) P-value

General Health

CAPD

Haemodialisa

10

78

257,500

298,718

73,645

100,072

-1,257 0,212

Physical Function

CAPD

Haemodialisa

10

78

540,000

514,103

177,638

279,830

0,285 0.777

Physical Role

CAPD

Haemodialisa

10

78

300,000

98,718

169,967

129,427

4,464<0.001*

Role of Emotions

CAPD

Haemodialisa

10

78

270,000

111,538

94,868

135,781

4,701 <0.001*

34


QoL Dimension Variable N Mean SD T (t-test) P-value

Pain

CAPD

Haemodialisa

10

78

182,000

124,167

20,709

58,334

6,218 <0.001*

Energy

CAPD

Haemodialisa

10

78

324,000

275,128

18,378

88,460

4,220 <0.001*

Social Function

CAPD

Haemodialisa

10

78

180,000

131,730

10,540

51,703

7,165 <0.001*

Mental Health

CAPD

Haemodialisa

10

78

420,000

354,359

24,944

99,968

4,758 <0.001*

35

QUALITY OF LIFE DIMENSION


NON PARAMETRIK TEST

36

Uji statistik Kualitas hidup per dimensi Mann-Whitney U-Test

Uji statistik Kualitas hidup per dimensi Kolmogorov-Smirnov


CRONBACH’S ALPHA IF ITEM DELETED

37

No Dimension Cronbach’s Alpha if Item Deleted

1 Emotional Role 0,655

2 Physical Function 0,669

3 Mental Health 0,683

4 Energy 0,708

5 Pain 0,724

6 Social Function 0,726


TOTAL HD COST

min max mean median HDINA CBGs 102,195,600 143,850,528 102,195,600 102,195,600 OOP - 25,440,000 3,949,380 1,440,000 Direct Medical Cost 102,195,600 169,290,528 106,144,980 103,635,600 Direct Non Medical Cost 1,236,000 52,920,000 5,627,712 3,120,000 Indirect Cost - 197,400,000 21,624,000 11,040,000 Total 103,431,600 419,610,528 133,396,692 117,795,600

38

CAPDPaket CAPD 71,780,000 71,780,000 71,780,000 71,780,000 OOP 600,000 24,000,000 9,900,000 9,999,996 Direct Medical Cost 72,380,000 95,780,000 81,680,000 81,779,996 Direct Non Medical Cost - - - -Indirect Cost - - - -Total 72,380,000 95,780,000 81,680,000 81,779,996

Data dalam Rp


EMOSIONAL ROLE CEA ANALYSIS

39

*CE(Cost Effectiveness) Plan

Renal

Replacement

Per year Emotional

Role

ACER

HD 133.396.692 41,61 Rp 133.396.692/41,61 = 3.205.881,-

per emotional role

CAPD 81.680.000 67,05 Rp 81.680.000/67,05 = 1.218.195,-

per emotional role

ICER CAPD vs HD Dominant for cost and emotional role*

CAPD vs HD (Rp 81.680.000 - 133.396.692) / 67,05 –

41,61) = Rp 2.032.889,-

per extra emotional role


PHYSICAL ROLE CEA ANALYSIS

40

*CE(Cost Effectiveness) Plan

Renal Replacement Per Year Physical

Role

ACER

HD 133.396.692 41,20 Rp 133.396.692/41,20 = 3.237.784,-

per physical role

CAPD 81.680.000 70,25 Rp 81.680.000/70,25 = 1.162.705,-

per physical role

ICER CAPD vs HD Dominant for cost and physical role *

CAPD vs HD (Rp 81.680.000 - 133.396.692) / (70,25 -

41,20) =

Rp 1.780.265,- per extra physical role


CE PLAN

41

Cost Differences (+)

Effect Diferences (-) Effect Differences (+)

Dominant

Cost Differences (-)


Cost of Renal Replacement

Cost of CAPD 39% lower than HD This is in accordance with (Philip 2001), PD 10-40% lower than HD

in worldwide

(Peeters P 2000) cost analysis HD and CAPD in 25 studies

CAPD provide a cost advantage compared with hemodialysis

42


Another study in 16 755 patients with hemodialysis and peritoneal dialysis 1,260 patients found that peritoneal dialysis patients had higher scores on the mental dimension compared with hemodialysis patients, using a questionnaire SF 36 (Thong and Adrian a Kaptein

2008)

The positive thing of peritoneal dialysis is due to the addition of energy for feeling alive and well, able to do therapy at home, can do therapy during sleep, and feel independent. Patients in this study also feel good because it can perform CAPD own without requiring

the assistance of the medical team

(Noshad, et al. 2009), peritoneal dialysis had a statistically significantly better quality of life compared to hemodialysis in patients with diabetes and non-diabetes. Peritoneal dialysis patients have a higher value for all aspects.

(Thong and Adrian a Kaptein 2008) Research using a questionnaire developed by the experts mentioned that dialysis peritoneal dialysis patients score higher than hemodialysis patients on aspects of family life, independence, spiritual condition, energy level, and

living conditions

Statistics Significant : Quality of Life HD vs CAPD

(Albert W Wu 2004) peritoneal dialysis have a better quality of life compared with hemodialysis

(Peeters P 2000) HD and CAPD cost analysis on 25 studies.CAPD provide a cost advantage compared to hemodialsa

43


Hemodialysis patient dissatisfaction can be caused by stress facing dialysis procedure, the high frequency of visits to the hospital, waiting time in hemodialysis units and treatment of medical personnel at the hospital. Hemodialysis patients have symptoms of depression are higher and tend to commit suicide besides having

depressive symptomatology

Peritoneal dialysis patients in the 65 analysis meta studies showed that peritoneal dialysis patients have better characteristics and stress less than hemodialysis patients (Thong and Adrian a Kaptein 2008)

(Coccossis, et al. 2008) Hemodialysis patients have more experience in terms of anxiety and sleep disorders that affect the patient's emotions and feel overwhelmed with the strict provisions of the action routine hemodialysis

44


ROLE OF PHYSICAL

CAPD patient satisfaction increased as the opportunity to do a better recreation in terms of transportation, the

opportunity to obtain information, better life and the opportunity to gain new skills . (Coccossis et al. 2008).

2/3 patients receiving dialysis therapy never return to

normal activities or work, and many patients lose their jobs

(Nurchayati 2010)

CAPD patients allowed to travel every day, can work to earn more and dialysis can be

done anywhere(Coccossis, et al. 2008).

45


CONCLUSION1. CAPD costs 39% lower than HD2. Patients receiving hemodialysis measures 10.5 times more likely to have less quality of life compared

with patients receiving CAPD3. CAPD patient's quality of life is better compared with hemodialysis patients in the physical dimensions

of the role, the role of emotions, pain, energy, social functioning and mental health (proven statistically)

4. CAPD action is more cost effective than hemodialysis

46


ADVICE FOR PATIENT

Looking for information related to kidney disease

Finding the advantages and disadvantages of every kind of renal replacement therapy

Choosing CAPD if there are no complications to walk on CAPD

47


ADVICE FOR HOSPITAL

The team of doctors at the hospital are expected to assist the patient in deciding the type of renalreplacement therapy in accordance with the patient and provide more benefits for patient

Provide a complete and detailed description of hemodialysis and CAPD before the patient decides theselected action either directly to patients or in health seminars forums

Ensuring Patient CAPD fluid available from distributors and delivered directly to the patient's home.

Do not take additional cost from patient if all of its services has been included in the package hemodialysisor CAPD

Communicate with doctors, not prescribed expensive drugs, because patients take medications regularly

48


BPJS KESEHATANApproach to the hospital in order to make CAPD as first choice

Encourage the patient to take hemodialysis in lower type hospital if the patient is not allowed to take CAPD

CAPD action socializing through BPJS Center officer in hospital and through seminars

Monitor and coordinate with the hospital to make sure there is no additional costs are charged to the patient's with hemodialysis and CAPD

49


THE GOVERNMENTIncrease the number of hospitals that are able to provide services CAPD

Ensuring CAPD fluid supply imported from abroad are available and controlling costs so that the liquid is not too high

Analyze the possibility of CAPD fluid produced in Indonesia when there will be increasing number of CAPD patients in the future

CAPD campaigning as the first choice of renal replacement therapy for patients with ESRD

Evaluate the hospital that still take additional costs from HD and CAPD

Evaluate the INA CBGs rates for dialysis procedures

50


THANK YOU

51

cost effectiveness analysis on chronic dialysis ...inahea.org/files/hari2/4. elsa novelia.pdf ·...

Documents