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INA HEA, Jakarta 2015
COST EFFECTIVENESS ANALYSIS ON CHRONIC DIALYSIS : COMPARISON BETWEEN HAEMODIALYSIS AND CHRONIC
AMBULATORY PERITONEAL DIALYSIS
ELSA NOVELIA
BPJS Kesehatan
INA HEA, Jakarta 2015
BACKGROUND
LITERATURE REVIEW
FRAMEWORK CONSEPTS
METHODOLOGY
RESULT
DISCUSSION
CONCLUSION
2
INA HEA, Jakarta 2015
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)
INA HEA, Jakarta 2015
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)
INA HEA, Jakarta 2015
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)
INA HEA, Jakarta 2015
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)
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
COST OF ESRD
231,51
336,20
417,68
482,07
2010 2011 2012 2013
Cost of ESRD (Billion RP)
9
Source: PT Askes Data (2013)
INA HEA, Jakarta 2015
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
Source: PT Askes Data (2013)
COST OF ESRD
INA HEA, Jakarta 2015
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)
INA HEA, Jakarta 2015
QUALITY OF LIFE
Chronic Disease (ESRD)
Poor Quality of Life Poor Mental Health
12
INA HEA, Jakarta 2015
RENAL REPLACEMENT THERAPY
WORLDWIDE CAPD120 THOUSAND (2009)
INDONESIA CAPD800 OR 10 % OF HD (2009)
13
INA HEA, Jakarta 2015
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
Source: PT Askes Data (2013)
INA HEA, Jakarta 2015
OBJECTIVEThe aim of this study is to analize the cost effectiveness between HD and CAPD on ESRDpatients
15
HEMODIALISA
CAPD
INA HEA, Jakarta 2015
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)
INA HEA, Jakarta 2015
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)
INA HEA, Jakarta 2015
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)
INA HEA, Jakarta 2015
HEMODIALYSIS
19
CAPD
INA HEA, Jakarta 2015
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)
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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)
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
HYPOTESIS
CAPD cost effective compare to HD
25
INA HEA, Jakarta 2015
• 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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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.
INA HEA, Jakarta 2015
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.
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
NON PARAMETRIK TEST
36
Uji statistik Kualitas hidup per dimensi Mann-Whitney U-Test
Uji statistik Kualitas hidup per dimensi Kolmogorov-Smirnov
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
CE PLAN
41
Cost Differences (+)
Effect Diferences (-) Effect Differences (+)
Dominant
Cost Differences (-)
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
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
INA HEA, Jakarta 2015
THANK YOU
51