EVALUASI EKONOMI BIAYA PENANGANAN GAGAL GINJAL

Transcription

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
BACKGROUN
D
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)
3
CLASSIFICATION OF CKD
Penanda Tahapan CKD
Kode CKD (ICD-9-CM)
eGFR ≥90 ml/min/1.73 m2, ACR ≥30 mg/g
eGFR 60–89, ACR ≥30
eGFR 30–59
eGFR 15–29
eGFR <15
585.1 Chronic kidney disease, Stage 1
585.2 Chronic kidney disease, Stage 2 (mild)
585.3 Chronic kidney disease, Stage 3 (moderate)
585.4 Chronic kidney disease, Stage 4 (severe)
585.5 Chronic kidney disease, Stage 5
Keterangan: ACR adalah Albumin/Creatinin Ratio
Source: National Health and Nutrition Examination Survey (2002)
4
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)
5
ESRD PATIENT AND VISIT TO
HOSPITAL
2010
2011
2012
2013
ESRD
number
Ratio /100.000
members
number
Ratio/100.000
members
number
Ratio/100.000
members
number
Ratio/ 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
Source: PT Askes Data (2013)
6
DM AND HYPERTENSION
TOTAL OF PATIENT
DIAGNOSIS
DM
HYPERTENSION
2010
2011
2012
2013
414.906
348.518
371.243
380.887
482.150
511.661
527.816
522.125
Sources: PT Askes Data (2013)
7
COST CONSEQUENCES OF ESRD TREATMENT
1 trillion USD in next 10
years
(World Kidney Day Organisation 2013)
32 billion USD/year
(Harvard Stem Cell Institute 2011)
8
COST OF ESRD
Cost of ESRD (Billion RP)
482,07
417,68
336,20
231,51
2010
2011
2012
2013
9
COST OF ESRD
Year
Cost of ESRD
Cost of Health Care
% cost of ESRD compare to
cost 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 RENAL REPLACEMENT
Transplant 172
Million (Rp) +
immunosuppressant
drugs per year 68
Million
HD 2 times a week,
CAPD 53-70
5 hours,
Million (Rp) +
54 – 72 (Rp) Million
Catheter 10 Million
Source: Karopadi (2013)
11
QUALITY OF LIFE
Chronic Disease
(ESRD)
Poor Quality of Life
Poor Mental Health
12
RENAL REPLACEMENT THERAPY
WORLDWIDE CAPD
INDONESIA CAPD
120 THOUSAND (2009)
800 OR 10 % OF HD (2009)
13
HD VS CAPD
TREATMENT
HD
CAPD
Ratio CAPD/HD
2010
2011
2012
334,382
408,800
491,520
6,571
6,464
7,497
2.0%
1.6%
1.5%
2013
557,095
8,645
1.6%
14
OBJECTIVE
The aim of this study is to analize the cost effectiveness between HD and CAPD on ESRD
patients
HEMODIALISA
CAPD
15
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%
Source: Buku ajar Ilmu Penyakit Dalam (2006)
16
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%
source: Buku ajar Ilmu Penyakit Dalam (2006)
17
RENAL REPLACEMENT THERAPY
No
I
Renal Replacement
Dialysis
A. Peritoneal Dialysis (DP)
B. Hemodialysis
II
Renal Transplants
Life Donor
Funeral Donor
Source: Buku ajar Ilmu Penyakit Dalam (2006)
18
CAPD
HEMODIALYSIS
19
HEMODIALYSIS VS
PERITONEAL DIALYSIS
Benefit
Hemodialysis
Peritoneal Dialysis
Done by a team of health professionals
Gives more freedom than HD
Be able to socialize with other hemodialysis patients who will Can be done at home, can be done at the time of travel,
provide emotional support
while sleeping
Not be done alone as PD
Can be done alone
Done in fewer days than the PD
Does not take a lot of food and fluid restriction as in HD
It takes no needles
Loss
Cause fatigue during the HD session
The procedure is quite difficult as some people
Led to the emergence of problems such as low blood pressure,
Increase the risk of infection peritonitis
blood clots during dialysis access
Increase the risk of bloodstream infection
Source: (WebMD 2011)
20
PD Utilization > 80%,
Government Policy
ESTIMATION COST OF HD AND CAPD
Average cost of HD
Average cost of CAPD
HD Reimburstment
CAPD Reimburstment
per month
per month
from Government
from Government
Banglades
370
454,5
68%
0%
Cina
500
500
50-90%
50-90%
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%
1,615
1,032
100%
100%
Country
Hongkong
Taiwan
Source: Departement of Medicine and Therapeutics (2001)
21
COST COMPARISON BETWEEN HEMODIALYSIS
AND CAPD
Country
HD
CAPD
Swedia
99,084
74,880
USA
In Center: 51,252
26,959
Satellite: 42,067
Self Care: 29,961
Hongkong
30,678
12,843
Turkey
22,759
22,350
Malaysia
8,853
8,325
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) 22
QUALITY OF LIFE DIALYSIS PATIENT
According to (Coccossis, et al., 2008) renal failure patients who received
hemodialysis or peritoneal dialysis action / CAPD found to have a decreased
quality of life, with different areas.
Some studies showed that HD patients reported having better on physical
quality, sleep and sexual relationship. For some mental study found that
patients who commit acts of HD have more depressive symptoms compared
with PD. This can happen because the HD patients should be connected to
the machine during dialysis routinely. On the other hand the high rate of
suicide in patients with HD were reported due to the violation dietary cloud.
23
Independent Variable
Dependent Variable
FRAMEWORK
CONCEPTS
Age
Gender
Education
Job
Duration of HD
Quality of life
Duration of CAPD
Disease before suffer from ESRD
Renal Replacement
Total cost of HD
Renal Replacement
HD
ACER
HD Patient Quality of life
ICER
Renal Replacement
CAPD
Total cost of CAPD
ACER
CAPD Patient Quality of life
24
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)
Location and
Time
• HD : RS PMI Bogor
• CAPD: Patient Home
• April – May 2014
• Population:
• HD Patient :PMI
Bogor Hospital
• CAPD Patient:
Fatmawati Hospital
Population
and Sample
Research
Design
26
DIRECT MEDICAL COST : HEMODIALYSIS PACKET (TARIF RS TIPE
B, REGIONAL I) 2014
Variable
Cost (Rp)
Cimino Operation
1.324.036,-
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 HD
982.650,-
Cost per year (2 times/week)
102.195.600,-
Cost per year (2 times/week) + Cimino Operation
103,519,636,INA HEA, Jakarta 2015
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
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 becomes
Rp. 2,877,294,899,682, - when patients received HD in Type A Hospital
Blood Transfusion
Laboratory
Diagnostic investigation
Other Cost
One Session of HD
Cost per year (2 times/week)
1.380.582,143.580.528,-
Cost per year (2 times/week) + Cimino Operation
146.643.642,INA HEA, Jakarta 2015
28
CAPD DIRECT MEDICAL COST
(TARIF INA CBGS RSUP FATMAWATI)
Variable
Cost (Rp)
Catheter
3.063.114
Routine CAPD Packet
Consumable CAPD Set include fluids for 30 days
- Dianeal 1,5% = 90
- Dianeal 2,5% = 90
When compared with hemodialysis treatment, the direct medical care cost of
- Minicap
= 120
Jasa Pengiriman CAPD Set
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.
Medical fee
Sub 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
Total cost per year
71.780.000,INA HEA, Jakarta 2015
74.843.114,29
DISTRIBUTION OF DIRECT NON MEDICAL COST
FOR HEMODIALYSIS PATIENT
Transportation
Food/Drink
HD Cost per session
6.500
5.000
11.500
Max
(Rp)
400.000
90.000
490.000
Cost per month
(2 session per week)
Cost per year
103.500
4.410.000
468.976
240.000
1.236.000
52.920.000
5.627.712
3.120.000
Variable
Min (Rp)
Mean
(Rp)
43.763
14.859
58.622
Median
(Rp)
27.500
2.500
30.000
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.
30
LOSS INCOME OF HD PATIENT’S
Variable
Loss of income per month
Patient
Family who are waiting during HD session
Lost of income per month
Lost of income per year
Min
(Rp)
Max
(Rp)
Mean
(Rp)
Median
-
16.000.000
450.000
16.450.000
197.400.000
1.522.000
280.000
1.802.000
21.624.000
640.000
280.000
920.000
11.040.000
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
31
HD VS CAPD QUALITY OF LIFE
Variable
Whole Sample
Less Quality
Good Quality
HD Patient
Less Quality
Good Quality
CAPD Patient
Less Quality
Good Quality
Total
Persentase (%)
43
45
48,9
51,1
42
36
53,8
46,2
1
9
10
90
32
CONECTION BETWEEN INDEPENDENT VARIABLE WITH DEPENDENT
VARIABLE
(*) : statistical significant
Variable
Renal Replacement
HD
CAPD
Age
< 45 year
>= 45 year
Gender
Man
Women
Working
no
Working
Education
Low
High
Duration of HD/ CAPD
< 4 year
>= 4 year
Quality of life
Leer Quality
Good Quality
OR
(95% CI)
P-Value
42 (53,8%)
1 (10,0%)
36
9
(46,2%)
(90,0%)
10,5 (1,269-86,901)
0,015*
17 (54,8%)
26 (45,6%)
14
31
(45,2%)
(54,4%)
1,448 (0,601-3,486)
0,546
26 (53,1%)
17 (43,6%)
23
22
(46,9%)
(56,4%)
1,463 (0,628-3,408)
0,504
35 (57,4%)
8 (29,6%)
26
19
(42,6%)
(70,4%)
3,197 (1,213-8,429)
0,030*
6 (54,5%)
37 (48,1%)
5
40
(45,5%)
(51,9%)
1,297 (0,365-4,611)
0,936
29 (46,0%)
14 (56,0%)
34
11
(54,0%)
(44,0%)
0,670 (0,264-1,702)
0,544
33
QUALITY OF LIFE
DIMENSION
QoL Dimension
Variable
N
Mean
SD
T (t-test)
P-value
CAPD
10
257,500
73,645
-1,257
0,212
Haemodialisa
78
298,718
100,072
CAPD
10
540,000
177,638
0,285
0.777
Haemodialisa
78
514,103
279,830
CAPD
10
300,000
169,967
Haemodialisa
78
98,718
129,427
CAPD
10
270,000
94,868
Haemodialisa
78
111,538
135,781
General Health
Physical Function
Physical Role
4,464
<0.001*
Role of Emotions
4,701
<0.001*
34
QUALITY OF LIFE
DIMENSION
QoL Dimension
Variable
N
Mean
SD
T (t-test)
P-value
CAPD
10
182,000
20,709
6,218
<0.001*
Haemodialisa
78
124,167
58,334
CAPD
10
324,000
18,378
4,220
<0.001*
Haemodialisa
78
275,128
88,460
CAPD
10
180,000
10,540
7,165
<0.001*
Haemodialisa
78
131,730
51,703
CAPD
10
420,000
24,944
4,758
<0.001*
Haemodialisa
78
354,359
99,968
Pain
Energy
Social Function
Mental Health
35
NON PARAMETRIK TEST
Uji statistik Kualitas hidup per dimensi Mann-Whitney U-Test
Uji statistik Kualitas hidup per dimensi Kolmogorov-Smirnov
36
CRONBACH’S ALPHA IF ITEM
DELETED
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
37
TOTAL HD
COST
HD
INA CBGs
OOP
Direct Medical Cost
Direct Non Medical Cost
Indirect Cost
Total
min
max
mean
median
102,195,600
102,195,600
1,236,000
103,431,600
143,850,528
25,440,000
169,290,528
52,920,000
197,400,000
419,610,528
102,195,600
3,949,380
106,144,980
5,627,712
21,624,000
133,396,692
102,195,600
1,440,000
103,635,600
3,120,000
11,040,000
117,795,600
CAPD
Paket CAPD
OOP
Direct Medical Cost
Direct Non Medical Cost
Indirect Cost
Total
71,780,000
600,000
72,380,000
72,380,000
71,780,000
24,000,000
95,780,000
95,780,000
71,780,000
9,900,000
81,680,000
81,680,000
71,780,000
9,999,996
81,779,996
81,779,996
Data dalam Rp
38
EMOSIONAL ROLE CEA
ANALYSIS
Renal
Per year
Emotional
Replacement
ACER
Role
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
*CE(Cost Effectiveness) Plan
39
PHYSICAL ROLE CEA ANALYSIS
Renal Replacement
Per Year
Physical
ACER
Role
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(Cost Effectiveness) Plan
40
CE PLAN
Cost Differences (+)
Effect Diferences (-)
Effect Differences (+)
Dominant
Cost Differences (-)
41
Cost of Renal Replacement
Cost of CAPD 39% lower than HD (Peeters P 2000) cost analysis HD
and
CAPD
in
25
studies
This is in accordance with (Philip
2001), PD 10-40% lower than HD
in worldwide
CAPD provide a cost advantage
compared with hemodialysis
42
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
(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
(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.
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
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
43
INA HEA,
Jakarta 2015
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
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)
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
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
CAPD patients allowed to
travel every day, can work to
earn more and dialysis can be
done anywhere
(Nurchayati 2010)
(Coccossis, et al. 2008).
45
CONCLUSION
1. CAPD costs 39% lower than HD
2. Patients receiving hemodialysis measures 10.5 times more likely to have less quality of life compared
with patients receiving CAPD
3. 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 renal
replacement 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 the
selected 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 hemodialysis
or CAPD
Communicate with doctors, not prescribed expensive drugs, because patients take medications regularly
48
BPJS KESEHATAN
Approach 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 GOVERNMENT
Increase 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

EVALUASI EKONOMI BIAYA PENANGANAN GAGAL GINJAL

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