1. Varying Patterns of ESKD Care Globally: Achieving Equity
Fredric Finkelstein
Yale University

2. Factors related to national, regional, and global variations in the incidence of treated and untreated ESKD

3. Geographic variations in the incidence rate of treated ESKD (per million population/year): USRDS 2018

4. Prevalence Rates Per Million Population Of Treated ESKD By All Four World Bank Country Classifications Groups
HIC
UMIC
LMIC
LIC
Median(IQR)
ESKD
( )
( )
( )
(4-4)
Total Dialysis
( )
( )
(23-201)
(1-7)
Hemodialysis
( )
( )
(14-160)
(1-8)
Peritoneal dialysis
(36-72)
(11-49)
(0-10)
(0-1)
Transplantation
( )
(29-163)
(5-33) -
IQR=interquartile range

5. Incident rate of treated ESKD (per million population/year), USRDS 2018
Taiwan:
U.S
Canada UK
Australia
Norway
Russia
South Africa 22

6. Prevalent rate of treated ESKD (per million population/year), USRDS 2018
Taiwan
Japan
U.S
Canada
U.K
Norway
Russia
South Africa 181

7. Trends in the prevalence of treated ESKD per million population, 2003-2016 USRDS 2018
Taiwan
U.S.
Brazil
Russia

8. Prevalence of dialysis per million population, USRDS 2018
Country Dialysis ESKD
Taiwan (3392)
Japan (2599)
U.S (2196)
Canada (1346)
U.K (953)
Norway (950)
Russia (303)
S.Africa (181)

9. Kidney transplantation rate per million population, USRDS 2018
Japan

10. Data from European and Oceania (16 countries)
Association between age and prevalence of patients received RRT in 20 high-income countries data
Data from European and Oceania (16 countries)
Data from USA, Japan, Taiwan and Singapore
12,000
Prevalence of RRT (pmp)=
exp( *Age [years, p<0.001])*106
10,000
8,000
Prevalence of RRT (pmp)
6,000
4,000
2,000 10 20 30 40 50 60 70 80
Age (years)
a) Data from Australia, New Zealand, Austria, Belgium, Denmark, Finland, France, Greece, Iceland, Norway, Spain, Sweden, the Netherlands, United Kingdom, Canada and Saudi Arabia

11. Center HD
Distribution of the percentage of prevalent dialysis patients using in-center HD, home HD, or PD, USRDS 2018 C E N T R H D PD

12. Mortality Over Time: USRDS 2018
Dramatic drops in mortality over time for Pd in recent years

13. Distribution Of Type Of Dialysis Driven By Government Policies

14. Hong Kong and Thailand Hong Kong has PD First policy
Government Policy Drives Practice Patterns
Hong Kong has PD First policy
80% of patients are maintained on PD
Patients in Hong Kong understand that costs need to be contained to protect the low tax structure and universal health coverage
Patient survival
Technique survival
Changsirikulchai S et al Perit Dial Int :

15. Mexico (Jalisco)
Available Resources Drive Practice Patterns
PD utilization had been 90% because of lack of availability of HD facilities
PD utilization now down to 50% because of marked expansion of HD facilities (in large part because of large dialysis organization expansion)
Cost of PD is low: government does contracting and there is competition from a local Mexican company (the power of the single purchaser)

16. United States Government or private insurance pays for all care
Finances Drive Practice Patterns
Government or private insurance pays for all care
90% of dialysis is provided by for profit companies who build dialysis units and work to keep the HD chairs filled with patients to maximize revenue
Because of rising costs, “bundled” payment system started in 2010 which makes PD more profitable

17. prevalent
incident
incident
incident
prevalent
USRDS 2018; Home Dialysis: U.S. large dialysis organizations % center HD, 10% on PD, 2% on Home HD
Peritoneal Dialysis Improved outcomes
- Improved technology
- Urgent Start
prevelant

18. Europe (UK, Belgium, Netherlands), Canada, Australia
Patient education drives practice patterns
Government provides equitable support of health care
CKD clinics are supported (“low clearance” clinics)
Emphasis on palliative care
Emphasis on patient centered care
Emphasis on patient education
18-25% of patients on home therapies

19. 483 had contraind to PD or HD
PATIENT PREFERENCE IN DIALYSIS SELECTION: NECOSAD (Jager: AJKD 43:891,2004)
1347 patients
864 able to make choice
483 had contraind to PD or HD
416 start PD
445 start HD
386 start HD
97 start PD
38% of patients start PD

20. What About the Cost?? USRDS 2018

21. What About The Finances
USRDS 2018: Total Medicare ESRD expenditures per person per year
Transplant is the least expensive
PD is less costly than HD – if the cost of PD solutions is kept at a reasonable levels
ESA utilization is < 1/3 of that of HD patients
Iron utilization is much lower than with HD HD PD
transplant
PD is $16,000 per year cheaper than HD

22. Decisions About Support of ESKD Care
Each country/region selects the amount of ESKD funding as a proportion of the overall healthcare budget.
Locally acceptable rationing criteria with transparent methods for their application need to be developed
Two general principles related to financing of healthcare can be applied to dialysis: a) optimal use of resources b) making the services available in an equitable manner to all
Problem of equity, availability, quality of care

23. South Africa Nigeria Public-private partnerships to expand ESKD care
The government pays for care only for patients who are transplant candidates
Government provides no support or oversight of ESKD coverage
Dialysis units owned privately, often by nephrologists
Patients pay for their own care

24. Kenya Tanzania
Government has decided to build HD units in all 47 states in the country and pay for 2x/week HD
Workforce resources limited
Problem of oversight of HD facilities
Government decided to pay for ESKD services for government employees
Expansion of dialysis services around the country, generally industry sponsored

25. Ethiopia
Almost no ESKD facilities until 3-4 years ago, other than a few small private dialysis facilities
ISN supported the training of two nephrologists
Small dialysis facility created in St. Paul’s Hospital, a teaching hospital in Addis
University of Michigan decided to support a transplant program at St. Paul’s
The Chinese government creates a dialysis unit in the main teaching hospital in Addis, the Black Lion Hospital
A nephrology fellowship is created at the Black Lion

26. Decisions About Support of ESKD Care
Each country/region selects the amount of ESKD funding as a proportion of the overall healthcare budget.
Locally acceptable rationing criteria with transparent methods for their application need to be developed
Two general principles related to financing of healthcare can be applied to dialysis: a) optimal use of resources b) making the services available in an equitable manner to all
Problem of equity, availability, quality of care