Although increasing research attention is being paid to CKD worldwide, (regardless of the perspective - patient, healthcare or society), there is a need to investigate and improve understanding about the economic impact of CKD in distinct contexts. As kidney transplantation has been the optimal treatment for ESRD, it is important to examine the costs that are associated with this as well as to examine factors that might encourage the donation. There is a need also to investigate the provision and delivery of care whilst taking account of the changing policy context. Therefore, this PhD research project examined these economic aspects of CKD and ESRD.
1.4.2. Objectives of this thesis
Firstly, this thesis attempted to estimate the relationship between HRQoL and CKD severity and the consequent economic impact due to reduced HRQoL among a representative sample in the UK (Chapter 2). This analytical investigation was undertaken in order to help inform economic evaluations of CKD therapy particularly evaluations that target early interventions that are designed to arrest progression from mild to more severe disease categories. The results of this analysis contribute also to the important task of assessing as accurately as possible the projected burden of CKD and ensuring that sufficient resources are allocated appropriately over time.
Secondly, given the fact that policy changes may affect distinct groups differently, Chapter 3 presents the results of an investigation of disparities among ESRD inpatients regarding depression (a common medical illness among ESRD patients), anaemia (a common complication), hospital outcomes (inpatient mortality, discharge destination and length of stay) and hospital costs. This investigation comprised a series of analyses of the largest all-payer inpatient dataset in the US. The data set also afforded an opportunity to investigate the impact of health care payment policy changes including the Medicare ESRD prospective payment system and the Affordable Care Act on disparities in use of services. Although disparities in healthcare are common, arguably they are endemic to the US compared to other high-income countries [273]. As ESRD is expensive and access to
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RRTs is limited in many circumstances, there is considerable potential for disparities to occur in relation to the management of this condition. An inpatient setting is where severe cases tend to present themselves and, therefore, any disparities in this context warrant particular scrutiny.
While kidney transplantation has been considered as the optimal treatment for ESRD patients, it relies on the willingness of donors and in the case of deceased donation, their families, to donate. The third element of this thesis aims to examine support for donation, in particular tissue donation among citizens from 27 European countries (Chapter 4). Public attitudes to organ donation vary across jurisdictions. Numerous studies have examined the factors that are associated with public attitudes to organ or tissue donation with the common aim of improving understanding about potential barriers to this activity. However, the legal circumstances extant in a country, reservations on the part of an individual regarding the perceived safety of donation, as well as an individual’s motivations and their relationship to factors (such as access for family members to transplant programs), combine to create a complex context within which attitudes are framed and actuated. The results of the investigation that are presented in this chapter provide a better understanding about heterogeneity in relation to support for donation across different legislative environments and various categories of motivations, thereby providing potential insights for the development of policies designed to encourage donation.
Finally, despite the evident medical benefits of LDKT, there is limited information about the healthcare costs and the economic impacts of LDKT at an individual (recipient and donor) level, and at a societal level in the UK. While organ shortage remains a huge problem and people can still die while waiting for a transplant, there is an urgent need to provide empirical data in order to inform better policy aimed at encouraging kidney donation. The original aim of Chapter 5 was to address these issues by examining data provided by Belfast Trust to describe and evaluate alternative forms of RRT - dialysis, DDKT and LDKT – using data from one program in Northern Ireland. However, due to the unexpected circumstances related to COVID-19 pandemic, the original plan could not be pursued as data access became impossible.
Instead, Chapter 5 reviews the evolution of LDKT practices in Northern Ireland over the last 10 years and examines the impact of program evolution on candidature, outcomes and the implications for future research.
48 1.4.3. Structure of this thesis
In summary, this thesis comprises four inter-related studies, which form six chapters as following:
Chapter 1 - Introduction
Chapter 2 - Health-related quality of life among patients with chronic kidney disease and the associated economic burden in the United Kingdom
Chapter 3 - Inpatient care for end-stage renal disease patients in the United States Chapter 4 - Understanding support for tissue donation across 27 European countries Chapter 5 - Perspectives on living donor kidney transplantation in Northern Ireland:
implications for cost-effectiveness studies Chapter 6 - Discussion and conclusion
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