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Due to the improvement of chronic kidney disease (CKD) care, as well as the technological and scientific advances in RRT modalities, there has been a slowing-down of ESRD progression, an improvement in life expectancy and a better HRQoL of the patients [6,7]. This improvement, therefore, has transformed ESRD from a terminal disease to a chronic condition with a long-life treatment [6,7]. Hemodialysis and PD are the two common forms of dialysis therapy for ESRD [8-10].
Although 30-40% of ESRD patients could be effectively treated with PD while they are waiting KT, such figures are far away from the current 11% who are undergoing PD . The results of the Spanish Renal Registry reported that in 2017 only a 17.1% of patients who started an RRT did it on PD, while a 78.0% started in some modality of hemodialysis . These results are in agreement with those reported by the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) . According to this registry, among the patients who started a RRT in 2015, only the 11% did it on PD and the 85% on HD .
This actually means that many potential candidates to PD are actually being treated with HD, with the consequent increase in the burden of the disease (economical, personal and social). According to the Spanish Society of Nephrology Registry, the prevalence of RRT has been continuously increasing over the past ten years . Because ESRD is a prevalent condition that requires a long-life treatment, which comprises a highly complex technology and high consumption of human and material resources, it represents a huge economic burden for health systems.
Different cost analyses have found lower costs associated with KT as compared with other RRT modalities [2,3,12,14]. Regarding dialysis, currently available scientific evidence suggest that HD therapy is more expensive than PD therapy in developed countries [5,14,15].
The Spanish National Health System (SNHS) is public, universal and mostly free of charge for the patients except for the share of out-of-pocket expenditure . In 2002, health competences were transferred to the regional level, resulting in 17 regional health ministries with budget holding responsibility and primary jurisdiction over the organization and delivery of health services within their territory .
Because dialysis entails a significant impact on the Health System budget, it is extremely important to accurately know the cost of these techniques.
The purpose of this study is to describe and compare the main direct health costs (monetary value) of dialysis provision (PD and HD) in the Josep Trueta University Hospital and its region during years 2017 and 2018.
Retrospective analysis of a prospective database.
Ethic Committee Approval
This study was approved by The Institutional Review Board of the Josept Trueta University Hospital, which waived the need for written informed consent of the participants.
Josept Trueta University Hospital is a level III University Hospital located in Gerona (Catalonia, Spain), which offers specialized assistance to a potential population of approximately 800,000 people. It is a reference Hospital of the Integrated Healthcare System under the authority of the Catalonian Institute of Health (CIH). The nephrology service consists of a HD Unit and a PD Unit. The HD has 12 beds (10 beds for chronic patients and 2 ones for acute treatments). There are 2 dialysis shifts: one in the morning from 8 to 14 and the other in the afternoon from 4 to 9 pm.
The PD Unit offers all the techniques and/or modalities of peritoneal dialysis: Continuous ambulatory peritoneal dialysis (CAPD) and Automated peritoneal dialysis (APD). APD is usually performed at night. Regarding CAPD, the treatment scheme is flexible and can be adjusted daily to the activities and schedules of each patient. Independently of the technique, the patient does not need to go to the hospital, except for regular visits (approximately every 1-2 months). Additionally, there is a contracted private out-patient center that provides HD treatments to the vast majority of patients doing HD. Our hospital does not currently offer “home hemodialysis”.
The study sample included all the patients receiving dialysis treatment, either PD or HD (including incident patients) independently of treatment duration at both the Nephrology Service of the Josep Trueta University Hospital and the out-patient dialysis clinic, during the years 2017 and 2018.
Cost analysis was carried out from the perspective of the regional health System CIH. Healthcare system costs were obtained via CIH. Other costs, such as transport services, food services, other non-medical materials, etc. were obtained via multiple sources. Besides the cost of the procedure, the different items considered in the model included cost of personnel, equipment, vascular (HD) and peritoneal (PD) access, consumables, drugs, laboratory tests, other medical supplies, structure, transport, and complications.
Peritoneal dialysis: Weighted average costs (CAPD and APD) were calculated. Prices of PD treatment per session were extracted from the awarding prices of the regional public procurement contracts CS/CC00/11 00425650/13/MAR , including the specific tariffs of icodextrin and bicarbonate-based PD solutions (both of them with premium prices).
Staff cost (doctors, nurses and nurse assistants) were extracted from the book of incomes of the CIH . The cost of patient training was included in the salary of the nursing staff.
Costs associated with the peritoneal catheter placement and the number of interventions were calculated from unpublished data of the calculation of the costs of PD in Catalonia in 2015 year performed by the Catalonian Group of PD.
Cost of days of admission and cost per day of admission were calculated according to the information supplied by the Josep Trueta University Hospital.
The cost of other complications was calculated according to Arrieta . The cost of peritonitis, including laboratory examinations, staff, medical supplies, and drugs was 266.4€ and 278.9€ for CAPD and APD, respectively . All costs were updated to the year of analysis with the overall Consumer Price Index (CPI).
The costs associated with the structure were calculated from unpublished data of the calculation of the costs of PD in Catalonia in 2015 year.
Hemodialysis in contracted out-patient HD center (CHDC):
Prices of CHDC treatment per session were extracted from the Command SLT/244/2016  including the tariff for conventional HD and the premium one for Online Hemodiafiltration (OLHDF).
The cost for the administration has been broken down into different items: Days of admission and cost per day of admission contributed by the hospital; vascular access; and patients transportation. For calculating total costs; the cost of structure; staff; equipment maintenance and amortization; and water consumption were prorated from the HD sessions performed in the Josep Trueta Hospital to those patients treated in contracted out-patient HD clinics.
Hemodialysis in Josep Trueta Hospital (HDH): Prices of HDH treatment per session and number of sessions were extracted from hospital data including the specific prices for conventional HD medical products and the premium tariff corresponding to OLHDF treatments.
Staff cost (doctors, nurses and nurse assistants) were extracted from the book of incomes of the CIH .
Cost per hospital day and, therefore, total costs for hospitalization were calculated according to the information supplied by the Josep Trueta University Hospital. The cost of other complications was calculated according to Arrieta . The term other complications included the vascular access complications, such as surgical thrombectomy and fistulography: 2,243.9 €; mechanical or endovascular thrombolysis: 2,711.3 €; or pharmacological thrombolysis: 2249.2 €. All costs were updated to the year of analysis with the overall Consumer Price Index (CPI). Pharmacy and laboratory costs were calculated from data extracted from Hospital accounting system. Structure costs have been prorated 3:1 as compared with PD. Transportation associated costs have been calculated by averaging the lowest of each modality (individual and collective) according to the Command SLT/244/2016 . Water consumption per monitor was calculated from the data provided the manufacturer and the price was averaged from “The price of water in Catalonia, 2016. Annual water price report” . Reimbursement to Hospital for each dialysis session was extracted from the Command SLT/244/2016 . All costs were updated to the year of analysis with the overall Consumer Price Index (CPI).
A standard statistical analysis was performed using MedCalc Statistical Software version 19.1.5 (MedCalc Software bv, Ostend, Belgium; https://www.medcalc.org; 2020). Descriptive analysis included mean (standard deviation), 95% confidence interval (CI) and percentages as appropriate. We examined the distribution of continuous variables with a D’Agostino-Pearson test. For comparing quantitative variables, a two-tailed unpaired-samples Student’s t test or the Mann-Whitney U test were used as appropriate. Categorical variables were compared using a Chi-square test and a Fisher`s exact test, as needed.
The number of prevalent patients on PD and HD (including those treated in the Josep Trueta Hospital and those in contracted out-patient HD center) were 68 and 156, respectively, in 2017 and 72 and 159, respectively, in 2018 (Table 1). At the time of starting RRT, there was not significant differences in mean age between patients underwent PD [62.2 (15.3) years)] and those underwent HD [60.1 (16.19) years], p=0.4618. Among the 53 patients who started dialysis in 2017 in Hospital Trueta, 27 patients did it on PD and 26 ones on HD. Regarding 2018 year, 30 patients started on PD and 15 on HD. From the administration perspective, the total costs of dialysis per prevalent patient/year in 2017 were 20,458.5 €, 49,079.0 € and 52,837,2 € for the PD, HDH, and CHDC, respectively (Table 2). On the other hand, the total costs of dialysis per prevalent patient/year in 2018 were 21,752.6 €, 39,104.8 €, and 53,937.3 € for the PD, HDH, and CHDC, respectively (Table 3). As compared with PD, in 2018, CHDC resulted 32.184,7 € more expensive than PD, while HDH was 17.352,2 € more expensive than PD. In other words, CHDC was 2.48 and 1.38 times more expensive than PD and HDH, respectively.
For PD, the cost per session (cps) was 54.86 € and 67.14 € in years 2017 and 2018, respectively. This means an increase of 12.28 (22.4%) € (table 3). Interestingly, the rate of icodextrin usage was the really very similar in 2017 (22 %) and in 2018 (23%), p=0.8344. However, the rate of bicarbonate usage was significantly higher in 2018 (90.5%) than in 2017 (72%), P=0.0410. The total cps of the CHDC in 2017 and 2018 was 228.5 € each, respectively. The cost is itemized in Table 4.
The cps of HDH was 332.7 € and 474.7 € in 2017 and 2018, respectively. Such increase was mainly due to the greater number of OLHDF sessions in 2018 (1,142 that represented a 41% of the HD sessions) than in 2017 (915 that represented only the 20% of the HD sessions). Nevertheless, for HDH, it can be observed a reduction in 9,974.14 € in 2018 as compared with 2017 per prevalent patient. The costs were broken down in Table 5.
Regarding complications, independently of the technique, the highest cost was associated with hospital admissions. The cost attributable to complications was much lower with PD (average cost per prevalent patient/year 250.4 and 359.3 in 2017 and 2018, respectively) than with CHDC (average cost per prevalent patient/year 2,131.2 and 2,486.4 in 2017 and 2018, respectively) or with HDH (average cost per prevalent patient/year 1,844.0 and 3,770.7 in 2017 and 2018, respectively).
This study collected and analyzed costs relating to materials; pharmacy; personnel (doctors, nurses and nurse assistants); administrative and hospitalization fees; hospitalizations due to complications; patient transportation; as well as other incidentals, to establish economic parameters.
The results of this study suggested that on average, the costs associated with HD are greater than those of PD. When comparing total costs (including those of dialysis sessions, complications-hospital admissions, and patient transportation) of PD versus HD (combining both CHDC and HDH) it can be observed that HD resulted in an extra charge per prevalent patient/year of 31,631.8 € in 2017 and 29,013.0 € in 2018.
It should be pointed out that, within hemodialyzed patients, the cost is greater among those treated in CHDC (52,837.2 € and 53,937.3 € in 2017 and 2018, respectively) than among those treated in the Josep Trueta Hospital (49,079.0€ and 39,104.8 € in 2017 and 2018, respectively).
Regarding those HDH patients there was a saving costs of 191,893.9 € between 2017 and 2018. This cost saving was due to the reduction in the incidence of complications, for being precise, the decrease in the number of days of hospitalization in a hospital different than Josep Trueta Hospital. When comparing our results with the current literature, it can be observed that with the exception of the Berger et al study  that reported a total cost significantly greater than ours for HD (232,934.9 €) and for PD (161,433.9 €) (values calculated according the current exchange rate), our results are in line with the published literature (Table 6).
The higher costs associated with HD treatment comparing with PD treatment is not surprising [5,14-16,20,23-28]. In the HDH patients’ group, the cost of hospital staff (doctors, nurses and nurse assistants) represented the greatest weight on the total costs (487,450.7 € and 436,198.7 € in 2017 and 2018, respectively). In fact, personnel costs were a 32.0% and a 32.8% of the total cost associated with HDH in 2017 and 2018, respectively. These results did no differ from those reported by Vaccaro & Sopranzi in 2017 , who showed that personnel associated costs had the greatest impact on the direct costs of HD.
Although in agreement with Vaccaro & Sopranzi  the cost of hospital staff for PD was significantly lower representing a 6.5% and a 7.4% of the total costs of PD in 2017 and 2018, respectively, these figures are lower than those reported by them . The cost associated with dialysis, either HD or PD, was slightly greater than that reported by Wong et al. , especially for PD, which resulted to be an 87.8% more expensive in our study, while HD resulted to be a 19.8% more expensive in ours.
When comparing the results of this study with those published in a Spanish setting, we also found that costs associated with HD are higher than those of PD [5,16]. Villa et al.  reported a total cost of 37,968 € and 25,826 € for HD and PD, respectively, in 2010 year. When we update the prices by using the CPI it results in an increase of the 8.6% between December 2010 and December 2018 . With this rate of variation, the updated costs of Villa et al. are 41,233.2 € and 28,047.0 € for the HD and PD, respectively. The weighted average costs for HD (HDH and CHDC) and for PD (CAPD and APD) in 2017 and 2018 in our study were 51,412.1 € and 21,124.0 €, respectively. These results actually mean that costs associate with HD in our study were greater than those reported by Villa et al., being the costs of PD lower .
When comparing our results (weighted average costs for 2017 and 2018 years) with those of Conde-Olasagasti et al.  (without CPI update), we found that while the cost of HD (both HDH and CHDC) was similar, the cost of the PD was 27,580 € lower in our study. This might be explained by a more efficient ratio of nurse/patient and by a low rate of complications.
The selection of a dialysis modality critically depends on disease progression at the time of referral to Nephrology. Early detection certainly bears on the variety of treatment options. Although patient outcomes with PD are comparable to or better than those with HD, and PD results in lower costs, not all the patients are candidates to initiate a RRT with PD. Some patients do not start on PD due to clinical reasons , but other ones due to patient-related challenges, including limited health literacy, cognitive decline, depression, comorbidities, cultural differences, etc. .
As the majority of patients could choose either PD or HD, it is extremely important to engage patient in dialysis modality decision . A greater involvement and education of patients, caregivers and hospital personnel (doctors, nurses and nurse assistants) will help in the decision-making process for choosing the dialysis modality that best fits for each patient, which, therefore, will significantly improve clinical and HRQoL outcomes . As mentioned in the introduction section, the dialysis provision is covered by the NHS resulting in a huge cost for the Public Administration. From the NHS perspective not only the clinical criteria but also the economic one matters when selecting therapeutic strategies. From a public budget holder perspective, the results of the current study suggested that treating 2.4 PD (weighted average for APD and CAPD) patients equates to providing dialysis to only one patient on HD (weighted average for HDH and CHDC), which in terms of cost is relevant for the sustainability of the NHS.
This fact may also have played a role in the relatively high rate of patients on PD found in our study (30.4% and 31.2% in 2017 and 2018, respectively) as compared with the figures published by Li et al.  or by the Spanish Renal Registry: 2017 report , which found that only an 11.0% and a 5.2% of the prevalent dialysis patients, respectively, were on PD. These findings may lead to the hypothesis that the health care financing model of a country or a region might have a significant influence on the RRT modality selection .
Finally, total cost of patient transportation per prevalent patient/year was 4,968.1 € for 2017 and 2018 each, respectively. These results are in line with those reported by Villa et al.  (5,515.8€, when updating the prices by using the CPI , but they were a 41.4% lower than those reported by Conde Olasagasti et al. . Such a difference might be mainly due to the huge difference in surface area between Gerona (5,910 km2) and Toledo (15,369 km2).
This study has limitations that should be taken into account when interpreting its results. The first one is its single center design. The costs of dialysis may only reflect the reality of Catalonia and more specifically, that in Gerona province. Although the methodology could be easily replicated in other regions, the important dispersion regarding healthcare budgets, healthcare expenditure per capita, prices and the specific body that holds each budget line, in other words, the concrete funding model for dialysis treatments, among the autonomous communities (and even between hospitals) would probably deliver different results in terms of dialysis costs.
The second limitation is the fact that we have used an “intent-to-treat” approach for cost calculation. Therefore, transfers between modalities definitively imply costs that may make difficult to allocate each of the modalities. Despite these limitations, this study provides a detailed cost analysis of both HD and PD, from the perspective of the Public Healthcare Administration as budget holder. This study suggested that total costs were lower on PD compared to HD, either HDH or CHDC, and that they were lower for HD in the Josep Trueta Hospital than the contracted out-patient HD center. Additionally, it should be highlighted the relatively high rate of patients on PD. Further studies, preferably prospective cost-effectiveness analysis should be performed to elucidate the most cost-effective RRT strategy.
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