PUK12
A REVIEW OF COST OF ILLNESS STUDIES IN
PATIENTS WITH END STAGE RENAL DISEASE
Rosirene Paczkowski1, Kirsi Norrbacka1, Kate Van Brunt1, and Tessa Kennedy-Martin2
1Eli
2Kennedy
BACKGROUND
• End-stage renal disease (ESRD) is a debilitating medical
condition of chronic kidney failure, also known as stage 5
chronic kidney disease. In ESRD the kidneys are
permanently impaired, and patients may require dialysis or
renal replacement therapy (RRT).
• Over the past 30 years, the prevalence of ESRD has
increased worldwide.1 By the end of 2008, around 2.3
million patients had received RRT.2 Some 530,000 patients
were living with a transplanted kidney, with the remainder
receiving dialysis – either haemodialysis (HD;
n=1,580,000) or peritoneal dialysis (PD; n=190,000).2
• RRT is intensive and costly: according to the US Renal
Data System 20123, 1.3% of US Medicare patients had
ESRD in 2010, yet they accounted for 7.5% of Medicare
spending.
OBJECTIVE
The objective of this scoping literature review was to
identify and document published cost of illness (COI)
journal articles that describe the economic impact of
ESRD in selected countries.
METHODS
Lilly and Company, Indianapolis, IN, USA
Martin Health Outcomes Limited, Brighton, UK
Study Overview
Patient-level data
•
National-level total (direct + indirect), direct, and indirect
costs are provided for ESRD, dialysis and transplant.
•
Ten studies4,7,11–16 reported annual patient-level healthcare
costs for ESRD (Table 5).
•
Caution should be exercised in drawing comparisons
across studies, given that
•
A 2013 study16 presented regression coefficients and cost
multipliers associated with tobacco use status and each
patient’s demographic characteristics, diabetes treatment,
complications, and comorbidities. ESRD treated with
dialysis or kidney transplantation was associated with
~300% and ~500% higher costs, respectively.
•
A comparison of costs between patients with/without DM
reported that adjusted annual per-patient costs post-ESRD
onset were significantly higher for patients with diabetes
mellitus (DM) versus those without DM (p<0.0001).17
•
A 2006 study18 noted substantial ESRD-related
nonmedical costs that fell on employers.
•
−
Each study took a different approach to costing
−
The resource use items on which analyses were
based were not consistent
−
Methodologies and costing years varied.
Table 5 includes ESRD costs per patient level. Annual
healthcare costs of dialysis and transplant was reviewed
on a per patient level.
National-level data
• Two studies4,6 reported total costs of ESRD (direct +
indirect costs), whereas two5,7 reported direct healthcare
costs of ESRD only (Table 2).
• The key cost driver of healthcare costs in the Canadian
study4 was HD undertaken in a medical centre; this was
followed by the cost of ongoing transplant for a
functioning kidney and then the cost of PD.
• In the Spanish
the main cost driver was that of
dialysis treatment sessions.
study,6
Table 2. Total annual national direct costs for ESRD
patients (in millions)
• This project was a scoping review – an approach that
examines the extent, range and nature of research
activity in a given field; though similar to a systematic
review, it does not define outcome parameters a priori.
• The search protocol defined the focus of review (patient
population, relevant study designs and characteristics,
outcomes of interest, perspectives and limitations); the
search strategy; study selection criteria; data extraction
methods; and data synthesis methods.
• The search strategy identified studies quantifying the
economic burden of ESRD in adults in nine countries
(Australia, Canada, France, Germany, Italy, Japan, Spain,
UK and USA).
Country
Total cost
Direct cost
Indirect
cost
Canada4
$Can 1857
$Can 1273
$Can 583
England5
Spain6
£780
€1829
€1407
UK7
£184.5*
USA7
$3611*
Cost
year
2000
€423
2010
2001
• Results were de-duplicated and downloaded into a
reference database.
• Costs were not always limited solely to direct healthcare
and indirect costs. 4,6 For example, the 2012 English
study5 estimated that annual transport costs for a patient
to attend dialysis was £50 million. These transport costs
are often not captured in studies; also typically
overlooked are social/community care costs, or personal
costs associated with renovations to accommodate home
dialysis.
•
•
We identified 2094 de-duplicated references from the
combined search in which 57 manuscripts remained
after review of titles/abstracts and 40 after full-text
review (Figure 1).
• Three studies4,6,7 reported total annual direct healthcare
costs of dialysis (Table 3); they all found the economic
burden of HD to be considerably higher than PD.
Country
Reports not published as peer-reviewed journal articles
were not included in the review.
Figure 1. Flow chart of search strategy results
Total number of records
identified (n=3629)
Direct healthcare
HD:
HHD:
PD:
$Can 646
$Can 80
$Can 147
England7
HD:
PD:
£437
£67
Spain6
HD:
PD:
€1077
€85
Canada4
Lost productivity
HD:
$Can 113
$Can 63,045
2000
Canada4
Mean total
healthcare cost for
ESRD care per
patient
$Can 51,099
2000
France11
Mean weighted total
annual healthcare
cost of ESRD per
patient
Italy12
Mean total annual
cost for ESRD care
per patient
Japan13
Mean total annual
healthcare cost of
ESRD per patient
$41,681
2003
UK7
Mean weekly
healthcare costs for
ESRD with diabetes
Patients with DM:
£537 (weekly)
2001
USA14
Healthcare cost of
ESRD health state in $37,022
someone with T2DM
2000
USA7
Mean weekly
healthcare costs for
ESRD patients with
diabetes
Patient with DM:
$605 (weekly)
2001
USA15
Annual per-patient
healthcare costs of
ESRD with and
without DM
Patients with DM:
$96,014
Patients without
DM: $53,653
2002
€40,975
(US $45,327 PPP)
€31,472
($38,427 PPP)
2004
2003
2001
(CI: $3556-25,870)
Mean total annual
cost for ESRD
patients with T2DM
USA16
ESRD with dialysis:
$41,117
2010
(CI: $28,948-53,286)
ESRD with
transplant: $30,361
(CI: $2848-57,618)
2001
HD:
PD:
€250
€24
2010
• Only one study6 reported total costs associated with
transplant: for Spain, estimated to be €393 million.
• Five studies4–8 reported total annual direct healthcare
costs of transplant (Table 4).
Manuscript reviewed
for relevance (n=57)
CI, 95% confidence interval; DM, diabetes mellitus; ESRD, end-stage
renal disease; PPP, purchasing power parity; T2DM, type 2 diabetes
mellitus.
CONCLUSIONS
•
This review identified a number of informative studies on
the economic burden of ESRD, including costs split by
transplant and dialysis care.
•
However, significant gaps in the evidence base were
identified that warrant further research:
• One study7 provided data for both the UK and the USA.
Manuscripts excluded (n=17)
Not a cost study (e.g. review)
(n=11)
Non-English language (n=3)
Not ESRD (n=2)
Not journal paper (n=1)
Manuscripts for
inclusion (n=40)
• A breakdown of costs5 shows that ongoing care after the
first year is the biggest cost driver.
Table 4. Total national healthcare costs of transplant
(in millions)
Country
STUDY RESULTS
The 40 included studies used a range of study designs:
− 35 used existing data (e.g. published studies, hospital
records, registries and databases)
− Five were prospective studies.
• The focus of the studies varied:
− ESRD in general (n=16)
− Dialysis (n=16)
− Transplant (n=8)
− Diabetes (n=7).
Canada4
$Can 2
$Can 3
$Can 106
$Can 289
England5
Annual healthcare costs:
£225.4
Spain6
Annual healthcare costs:
€244
UK7
In patients with prior kidney
transplants:
T1DM patients:
£2.2
T2DM patients:
£0.4
All diabetes patients:
£2.6
In patients with new kidney transplants:
T1DM patients:
£2.5
T2DM patients:
£0.3
All diabetes patients:
£2.8
USA7
In patients with prior kidney
transplants:
T1DM patients:
$17
T2DM patients:
$205
All diabetes patients:
$222
In patients with new kidney transplants:
T1DM patients:
$68
T2DM patients:
$281
All diabetes patients:
$350
USA8
Aggregate hospital cost for kidney
transplant:
$31,000
Table 1. Number of studies reported by country
Number of studies
1
7
2
2
5
1
1
2
3
16
Total annual healthcare cost of
kidney transplant
Living kidney donor costs:
Cadaveric kidney retrieval:
Transplant care:
Functioning transplant care:
• There was a wide range of geographic settings (Table 1).
Country
Australia
Canada
France
Germany
Multi-country
Italy
Japan
Spain
UK
USA
($36,917 PPP)
National-level data: Transplant
Records excluded at abstract
review (n=2037)
•
$Aus 50,576
ESRD not on
dialysis: $14,713
$Can 33
HD, haemodialysis; HHD, home haemodialysis; PD, peritoneal dialysis;
Number of records after
duplicates removed
(n=2094)
Healthcare cost of
ESRD health state in
someone with T2DM
2000
PD:
Cost
year
Canada10
Table 3. Annual national cost of dialysis (in millions)
Cost
year
Direct healthcare
cost
Australia9
*Diabetic patient with ESRD
• The 2011 Spanish study6 reported total (direct and
indirect) annual dialysis costs for Spain. Costs in 2010
were €1327 million (HD), €109 million (PD).
Cost item
Mean total
healthcare cost of
ESRD per patient
2001
• Searches were conducted in MEDLINE and MEDLINE in
process, EMBASE, Science Citation Index, National
Health Service Economic Evaluation Database (NHS
EED), Health Economic Evaluations Database (HEED),
Cost-Effectiveness Analysis (CEA) Registry, RePEc
(Research Papers in Economics) and Health Technology
Assessment (HTA) database; these were supplemented
with reference checking.
SEARCH RESULTS
Country
2009–10
National-level data: Dialysis
• Two reviewers independently assessed the abstracts and
included manuscripts for relevance.
Table 5. Total annual healthcare costs of ESRD per
patient
Cost year
2000
2009–10
T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.
ISPOR 17th Annual European Congress; Amsterdam, The Netherlands; November 8-12,
2014
2010
•
2001
2008
There were few national-level studies
−
Most studies were retrospective
−
Even robust and informative studies have so far
taken a relatively narrow focus
−
Costs to non-healthcare budgets (e.g. social
services) and to patients (lost productivity, out-ofpocket costs) should also be quantified.
A prospective Europe-wide costing study of ESRD using
a consistent methodology across all countries and taking
a societal perspective would add significantly to the
evidence base.
Acknowledgements:
The authors thank Mick Arber for his expert insight in
devising and running the searches.
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