CHRONIC KIDNEY DISEASE FINANCIAL AND ECONOMIC COSTS DR. P. G. - - PowerPoint PPT Presentation

• DR. P. G. MAHIPALA

MBBS, MSC, MD, MBA, FCMA,DED, DM, DBS, DPM DIRECTOR GENERAL OF HEALTH SERVICES MINISTRY OF HEALTH DECEMBER 10, 2013

CHRONIC KIDNEY DISEASE FINANCIAL AND ECONOMIC COSTS

Common causes es of CRF – W Worldwi wide e

• Diabetic nephropathy – 30%
• Chronic intestitial nephritis – 20%
• Chronic glomerular nephritis – 17%
• Chronic pyelonephritis – 10%
• Chronic glomerular sclerosis – 04%
• Renal vascular disease
• Polycystic kidney disease
• Unknown

CAUSES OF CKD IN SRI LANKA

• Common causes of CKD are

similar to the global (diabetes, hypertension etc) - Other than for certain regions in dry zone

• Most of the CKD cases

reported from the dry zone - primary cause is under investigation

Management of patients with CRF

• A. Conservative Management

(Symptomatic Management)

• Control of High Blood Pressure
• Management of Heart Failure
• Correction of Anaemia
• Correction of Electrolyte abnormalities
• Management of Renal bone disease
• Management of IHD, Hyperlipidaemia
• Control of Diabetes etc.

Management of patients with CRF (cont…)

• B. Above + Renal Replacement Therapy
• Renal Transplantation
• Chronic Haemodialysis
• Chronic Ambulatory Peritoneal Dialysis

• Premature Mortality
• High Morbidity
• Burden on the Family
• Frequent hospital admissions/ bystander
• Loss of breadwinner
• Loss of income
• Expenses for treatment
• Psychological stresses
• Burden to the government on

expenditure and resource allocation

• Burden to the community

Burden of Disease

The Risk Areas

• Increasing number of CKD

cases & uneven distribution

• Case load more in certain

areas i.e. regional clustering

• Affect low socioeconomic

group i.e. young male farmers

Padaviya 1000 Medawachchiya 3500 Anuradhapura 1800 Kebithigollewa 300 Medirigiriya 800 Polonnaruwa 800 Dehiattakandiya 300 Girandurukotte 2250

North Central Province North Western Province Uva Province Eastern Province

ISSUES & CONCERN RNS

• Slowly progressive disease -

Patients seek treatment at late stages & often require dialysis/ transplantation

• High economical cost for

patient, family & state

• 2005 - 350 million rupees

spent for management of renal disease (dialysis, transplant etc.)

ECONOMIC OMIC PERSPEC PECTIV IVE

• Yearly about 2000 new patients seek treatment for

ESKD (i.e. dialysis or transplantation)

• Failure to find solutions may cost millions of

rupees worth of productivity due to premature morbidity & mortality

• Around 4% - 5% of the annual health budget is

spent on the management of patients

NATIONAL L COLLA LABORATIVE RESEAR ARCH EFFORT

• MoH (Epidemiology, Environmental

Health Division & NCD Units)

• Provincial/Regional Health Authorities
• Universities & Research Institutes
• Clinicians/Nephrologists/ Pathologists
• Public Health/ Community Physicians
• National Science Foundation
• National Water Supply & Drainage

Board

• Office of Registrar of Pesticides

NATION IONAL RESEARCH RCH PROJECT CT

Multisectoral, multidisciplinary research effort built upon on existing evidence

• Population prevalence study
• Hospital-based CKD registry
• Environmental study (high & low prevalence areas)
• Postmortem study (cases & controls)
• Case control study - Urine metal analysis
• Case control study - Nail & hair analysis for arsenic
• Study on herbal remedies (aristolochic acid)
• Randomized clinical trial

CKD Scientific Committee Meeting

RECOMME MMENDATIONS

• Regulatory control to ensure appropriate use of agrochemicals and

fertilizers

• Hazardous waste remediation
• Regulatory control to prevent environmental pollution (e.g. discarding

batteries containing heavy metals)

• Ensure access to safe drinking water
• Collaborative action with all stakeholders e.g. Ministries of Agriculture,

Water Supply, Irrigation, Social services & Scientific Affairs

PADAVIYA MEDAWACHCHIYA

Pattern of treatment source by visit

• Initially greatest dependence is on the government hospitals.
• Later visits are more diversified suggesting that the people are looking for alternate

approaches.

Hospital No expenditure <100 101- 500 501- 1000 >1000 Total Medawachchiya 17 5 24 2 48 35.4 10.4 50.0 4.2 0.0 100.0 Padaviya 26 1 14 4 1 46 56.5 2.2 30.4 8.7 2.2 100.0 Anuradhapura 1 2 3 6 16.7 33.3 50.0 0.0 0.0 100.0 Private Sector 1 7 4 2 2 16 6.3 43.8 25.0 12.5 12.5 100.0

Cost of clini nic care

Cost of clini nic visit Cost item (n) Median (LKR) Inter-quartile range Travel (n=274)

100.00 58.75-140.70

Accompanying person (n=64)

131.00 61.00-261.00

Food (n=279)

80.00 50.00-100.00

Drugs (n=102)

200.00 90.00-316.25

Laboratory investigations (n=37)

300.00 105.00-450.00

Other (n=53)

50.00 40.00-70.00

Total (n=300)

280.50 150.00-520.00

Indirect cost in seeking ng clini nic care Cost item (n) Median(LKR) Inter-quartile range (LKR)

Lost income by patient (n=11) 495.00 350.00-550.00 Payment for covering work (n=43) 1000.00 800.00-1000.00 Lost income by family members (n=35) 900.00 625.00-1000.00 Total (n=84) 900.00 625.00-1000.00

Direct cost of the hospital alizat ation n at Anurad adha hapura a TH

Cost item (n) Median (LKR) Inter-quartile range Travel (n=132) 365.00 240.00-830.00 Accompanying person (n=99) 310.00 200.00-480.00 By-stander (n=21) 100.00 55.00-755.00 Food (n=117) 220.00 155.00-440.00 Visiting (n=67) 750.00 240.00-2000.00

Cost item (n) Median (LKR) Inter-quartile range Drugs (n=11) 200.00 90.00-250.00 Medical consumables (n=3) 150.00 100.00-235.00 Laboratory investigations (n=2) 915.00 70.00-1760.00 Non-medical consumables (n=49) 180.00 70.00-300.00 Payments to staff (n=3) 20.00 20.00-30.00 Total (n=132) 1225.00 755.00-2960.00

Direct cost of the hospital alizat ation n at Anurad adha hapura a TH

Indirect cost due to hospi pital alizat ation n episo sode de

Cost item (n) Median (LKR) Inter-quartile range

Lost income by patient (n=3) 500.00 500.00-600.00 Payment for covering work (n=7) 800.00 800.00-800.00 Lost income by family members (n=29) 1000.00 600.00-1000.00

Item Detailed cost per month (LKR) Total cost per month (LKR) Personnel 2,231,781.22 Medical 390,266.75 Nursing 1,346,870.09 Paramedical 88,119.90 Support 406,524.48 Overheads 783,988.99 Cleaning services 307,241.55 Laundry services 113,205.47 Security services 132,711.12 Meals 230,830.84

Hotel cost st of hospital alizat ation n in the renal al unit

Utilities 946,610.19 Fuel 130,446.34 Water 145,253.08 Electricity 660,886.30 Telecommunication 10,024.47

Total 3,962,380.40

This does not involve the cost of dialysis – the intervention. In general cost on personnel is the largest component of a hospital stay.

Hotel cost of hospitalization in the renal unit (cont…)

• Average number of patients hospitalized per

month is 1182.

• Based on this unit cost of hospitalization LKR

3351.32 is per patient per day

• Median duration of stay is one day (apart

from the intervention (dialysis) cost)

Cost of Dialysis is

Cost item Cost (LKR) Hospitalization 1675.66 Haemodialysis 4900.00 Drugs 607.47 Total 7183.13 Cost of haemodialysis was estimated in a sample of 58 patients in the high dependency unit of Teaching Hospital, Anuradhapura.

Cost of drugs s borne by house seho holds Hospital No expense <100 101- 500 501- 1000 >1000 Total Medawachchiya

17 5 24 2 48 35.4 10.4 50.0 4.2 0.0 100

Padaviya

26 1 14 4 1 46 56.5 2.2 30.4 8.7 2.2 100

Anuradhapura

1 2 3 6 16.7 33.3 50.0 0.0 0.0 100

Private Sector

1 7 4 2 2 16 6.3 43.8 25.0 12.5 12.5 100

Cost of investigat ations ns borne ne by househo holds Hospital

No expense <100 101- 500 501- 1000 >1000 Total

Medawachchiya

28 1 5 2 36 77.8 2.8 13.9 5.6 100

Padaviya

15 8 15 4 42 35.7 19.0 35.7 9.5 100

Anuradhapura

2 2 1 1 6 33.3 33.3 16.7 16.7 100

Private Sector

1 4 2 4 11 0.0 9.1 36.4 18.2 36.4 100

Issues es - from a cost of care e perspec ective

• Travel costs are high in accessing regular clinic care;

sometimes more than one location.

• Multiple clinic visits within a short period - results in

wastage of resources to the health system and the household

Impact on patients’ family and the community

• Changes in the unit of family due to the illness
• in the domains of resource allocation;
• consumption patterns;
• setting priorities;
• maintaining social relationships;
• participation in community activities.
• Children’s education is affected
• Social and emotional cost due to Stigma
• The entire community is affected due to deteriorating

human resources and material resources.

Futu ture e Loss of earnings

• Considering future loss of income - using the scenario

building technique to estimate lost earnings (using the following assumptions)

• Model income range in Medawachchiya Rs 7501-

15,000 (mid-point 11,250 ) and Padaviya 2501-7500 (mid-point 5000);

• Unemployment rate is 4.2% in Medawchchiya and

7.3$ Padaviya (based on survey data);

• Patient are generally in the age group 40 to 60;
• Individual could work, if not for their illness up to 60,

but now leaves workforce at 50;

• Life table values (W.I. de Silva, IHP) used to

calculate probability of survival;

• Individual’s income grows at 3.5% per annum;
• Discount rate is 5%;
• The lost earnings then for a decade
• Loss to labour force at 50 with potential to

have worked till 60 is

• Rs 1,034,909 in Medawachchiya
• Rs 445,076 in Padaviya.

(The large difference in these values stems from differences in modal income level and unemployment rates)

• Support should be provided by social welfare system at

household level.

• The current provisions should be increased, and linked

to inflation to ensure the patient welfare.

• Other supports should be available (e.g. better modes
• f transport to hospitals and clinics)

Conclusions

• The

health system allocations should be increased to face the epidemic and high cost for treatment; at least to the regions affected.

• This may reduce the indirect costs faced by long

waiting times at clinics and for OPD care

• This will reduce the need for households to purchase

drugs and undergo investigations in the private sector

• It will enable more persons to

undergo essential life-saving renal replacement therapy.

• The health system needs to respond to the

continuing direct costs by ensuring an efficient and effective service.

By

• systematic forecasting of needs;
• planning for the expansion and coordination of

services;

• ensuring that secondary and tertiary prevention

strategies.

500 1000 1500 2000 CKD MSD X 100 Health X 100

• Urgent measures to be taken to prevent the

epidemic - economic impact.

• Effects are transmitted through the labour

market by

• Lost productivity
• withdrawal from the labour force
• premature death
• Carer’s labour
• The costs of seeking care are significant
• The economic impact further

impoverish the affected.

Improving patien ent and househ ehold welfare

• Close to client care:
• currently the hospitals in Padaviya and

Medawachchiya are addressing this need to an extent

• regular drug supplies;
• investigation facilities:
• inpatient care facilities;
• increasing the number of Medical Officers

designated for CKD care

• Patient empowerment through awareness.
• about their illness and their rights as care seekers.
• Training of health care providers in psycho-

social impacts related to long term and terminal illness.

Institution Supplied in 2013 Total Available Polonnaruwa 10 16 Maligawatte 10 20 Kandy 10 42 Ampara 04 06 Karapitiya 08 14 Kurunegala 06 12 Anuradhapura 10 32 NHSL 13 Kalubowila 06 Batticaloa 03 Jaffna 05 Monaragala 03 Badulla+Maharagama + Rathnapura + LRH 08 Total 58 178

Dial alysi sis s Machi hine nes s in Governm nment nt Hospi pital als

Year Total Health (Mn. Rs) MSD Spent (Mn. Rs.) Spent on Specifically CKD (MN. Rs) 2009 67,448 12,906 123.4 2010 80,027 14,824 183.4 2011 82,179 18,351 204.1 2012 93,771 23,792 245.3 2013 115,487 (Provisional) 25,000 (provisional) 238.3 (Provisional

Expend nditure Medical al Supplies

Consumables/Drugs 2009 2010 2011 2012 2013 Baciliximab 0.65 23.2 35.6 13.7 31.7 Bicarbonate and related 4.9 11.8 20.7 1.9 3.1 Administration set 0.7 0.7 0.8 20.0 2.0 AV Fistula Needle 0.7 1.1 3.7 0.5

• Blood line set

7.4 5.0 18.1 2.3

• Cyclosporin

27.2 52.3 56.8 155.2 46.3 Double lumen catheter 2.6 5.2 1.4 9.5 1.0 Epioetin 5.8 25.1 14.4 24.1 85.4 Evorilimus 0.2 5.2 8.2 41.3 7.4 Hollow fibre dialyser 0.7

• 1.2
• 6.0

Mycophenolate 49.2 55.8 47.2 62.8 60.7 PD catheter + Solution 16.0 19.2 27.8 15.8 15.1 Tacrolimus 8.1 1.6 3.5 11.4 11.7

TOTAL 123.4 183.4 204.1 345.3 238.3

Expend nditur ure of most specifi fic drugs ugs and consu sumab ables s for CKD (Million n Rs. )

Institution Consultant Vascular and Transplant Surgeons Consultant Nephrologists NHSL 02 01 Kandy 01 02 Anuradhapura 01 01 Karapitiya 01 01 Maligawatte 01 02 Polonnaruwa 01 Kurunegala 01 Jaffna 01

Fine ner Special alty Consul ultant ants

Year NHSL + CNTH Kandy Private 2007 42 77 25 2008 55 58 76 2009 50 88 67 2010 63 100 97 2011 67 99 64

No of Kidney tran ansplan ants

Year No of Units Total Spent 2012 09

• Rs. 19 Million

2013 58

• Rs. 116 Million

Capital Cost for Dialysis Machines

Other equipments supplied to Maligawatte NINDT alone (apart from above machines – Rs 300 Million in 2013

Year Total Requests Requests related to kidney disease 2011 4,799 289 2012 4,355 258 2013 (till now) 3,894 198

Request for President’s Fund

• National Institute of Nephrology, Dialysis, and

Transplantation – 403 Million Rs.

• Anuradhapura renal care and renal research

centre – 200 Million Rs.

Building ngs s for CKD