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

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

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

Prevalence Rates Per Million Population Of Treated ESKD By All Four World Bank Country Classifications Groups   HIC UMIC LMIC LIC Median(IQR) ESKD 956 (750-1234) 610 (348-833) 288 (208-568) 4 (4-4) Total Dialysis 569 (408-767) 383 (195-660) 89 (23-201) 3 (1-7) Hemodialysis 506 (355-692) 349 (193-579) 67 (14-160) 4 (1-8) Peritoneal dialysis 49 (36-72) 26 (11-49) 2 (0-10) 0 (0-1) Transplantation 368 (215-541) 80 (29-163) 25 (5-33) - IQR=interquartile range

Incident rate of treated ESKD (per million population/year), USRDS 2018 Taiwan: 493 U.S. 378 Canada 200 UK 120 Australia 117 Norway 106 Russia 58 South Africa 22

Prevalent rate of treated ESKD (per million population/year), USRDS 2018 Taiwan 3392 Japan 2599 U.S. 2196 Canada 1346 U.K. 956 Norway 950 Russia 303 South Africa 181

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

Prevalence of dialysis per million population, USRDS 2018 Country Dialysis ESKD Taiwan 3151 (3392) Japan 2532 (2599) U.S. 1582 (2196) Canada 786 (1346) U.K. 440 (953) Norway 282 (950) Russia 245 (303) S.Africa 156 (181)

Kidney transplantation rate per million population, USRDS 2018 Japan

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(-8.80+0.04*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

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

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

Distribution Of Type Of Dialysis Driven By Government Policies

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. 2018 38:172-178

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)

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

prevalent incident incident incident prevalent USRDS 2018; Home Dialysis: U.S. large dialysis organizations 88% center HD, 10% on PD, 2% on Home HD Peritoneal Dialysis - Improved outcomes - Improved technology - Urgent Start prevelant

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

483 had contraind to PD or HD PATIENT PREFERENCE IN DIALYSIS SELECTION: NECOSAD 1997-2001 (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

What About the Cost?? USRDS 2018

What About The Finances USRDS 2018: Total Medicare ESRD expenditures per person per year 2004-2016 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

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

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

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

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

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