1.3. ECONOMIC IMPACT OF CKD AND ESRD
1.3.3. Healthcare cost of CKD and ESRD
CKD and ESRD have imposed a profound economic burden on the healthcare system regardless of payers [247]. While 0.15% of global population could benefit from RRTs, they absorb 2-4% of healthcare budget worldwide [259]. High-income countries typically spend 2-3% of their healthcare budget on ESRD treatment although this
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condition represents under 0.03% of their population [260]. Moreover, the total cost of ESRD is normally lower than that of the milder stages of CKD which are more prevalent [226]. These facts do not only emphasize the burden of CKD and ESRD but also call for action to accurately estimate and effectively minimize the burden of the condition.
In the US, the total healthcare expenditure spent on CKD and ESRD exceeded $120 billion in 2017 and accounted for 33.8% of total Medicare fee-for-service, of which over $84 billion was spent on CKD and roughly $36 billion was spent on ESRD [136].
This 5% increase compared to 2016 figure was mainly due to an increase in the number of ascertained CKD cases (mostly early stages 1-3 CKD) [136]. In a country where nearly one sixth of GDP is spent on healthcare like the US, the rapidly escalating cost of ESRD has been considered as a potential crisis for the healthcare system [261]. The annual spending increased with the severity of disease and was estimated to be
$34,604, $35,526, and $41,496 for stage 1-2, stage 3, and stage 4-5 CKD, respectively.
Regarding ESRD, although the total spending on PD has grown overtime, on average, PD remains less costly than HD, which is a common situation in developed nations [155]. In 2017, the annual spending per person was highest in HD ($91,795), followed by PD ($78,159), and transplant patients ($35,817) [136]. Using the pooled 2002-2011 Medical Expenditure Panel Survey data, Ozieh et al. examined the health care costs of CKD in the US from a broader payer perspective rather than solely Medicare [262].
This study reported comparable results to USRDS report that the unadjusted mean expenditure on CKD was $39,873 compared to $5,411 for those without kidney disease [262]. They also found that the total expenditures decreased among the uninsured, minority and low-middle income individuals [262], all of which partly reflect the issue of uneven access to care in the US [263]. Another particular issue occurring in the US is the lack of financial disincentives to encourage physician to slow CKD progression and delay dialysis initiation [264]. Thus, more patients initiate dialysis while this might not be necessary or reflect the patients’ best interests. This tendency has imposed an increasing financial burden on the healthcare system due to the expensive nature of dialysis. Given the demographic, clinical, and lifestyle shifts in the population and improvements in RRTs in the US, the number of ESRD patients was projected to reach 1,259,000 in 2030 [265], a striking number that will challenge health services and policy makers.
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In other high-income settings, for example in the UK, stages 3-5 CKD costed the NHS
£1.44 to £1.45 billion which accounted for 1.3% of NHS spending in 2009-2010 [266].
Over half of this was spent on ESRD although this population only comprised 2% of CKD population. In France, the annual cost varied from €87,036 for in-centre HD to
€13,536 for a functioning transplant kidney (follow-up to 6 months after renal transplantation) [267]. In Sweden, annual costs (including inpatient, hospital-based outpatient and medication costs) of patients on HD, PD, having a transplanted kidney, and non-dialysis stage 4-5 CKD patients were estimated to be 45 (39-51), 29 (22-37), 11 (10-13) and 4 (3.6-4.5) times higher than that of a matched general cohort [268]. In Italy, the societal costs of non-dialysis stage 4 and stage 5 CKD were €7,422 (±€6,255) and €8,971 (±€6,503), respectively. Taking into consideration both direct medical costs and non-medical costs (such as travel, special food, and losses of productivity), the overall societal costs for non-dialysis stage 4 and stage 5 CKD exceeded €1.8 billion and represented 1.11% of Italy GDP in 2013 [269]. It is noted that most studies focused on estimating costs associated with late stages CKD or ESRD although the milder stages of CKD normally incur higher total costs [226].
Regarding low- and middle-income countries (LMIC), the annual cost for HD varied from $3,424 to $42,785, and annual cost for PD varied from $7,974 to $47,971 [270].
These variabilities in costs were mostly related to the approach that was used to calculate the direct medical cost and the unit costs (for example, resource-poor countries had to pay a large amount of money for imported resources). Direct medical cost was the key cost-driver for both HD and PD wherein drugs and consumables were most important for HD, and dialysis solutions and tubing were most important for PD [270]. Although these costs are somewhat lower than those arisen in high-income countries, they are still beyond patient’s affordability, given the inadequate coverage of universal healthcare [270]. Numerous issues exist in LMIC. They often lack rigorous care models for CKD [271] and screening programs [272] to prevent CKD progression. This leads to larger numbers of late stage CKD and ESRD which then imposes a profound impact on the ill- equipped healthcare system [272]. Similar to high-income countries, the small proportion of ESRD population consumes a considerable share in the limited budget of LMIC. However, the inadequate funding issue is more prominent in LMIC, which then leads to lack of access to RRTs. In fact, Liyanage et al. estimated that 93% of those
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receiving RRTs resided in high or high-middle income countries, representing a 70-fold difference of RRTs prevalence between the rich and the poor countries [132].