Claudia Geue

Global variation in renal replacement therapy for end-stage renal disease

BACKGROUND Incidence rates of renal replacement therapy (RRT) for end-stage renal disease vary considerably worldwide. This study examines the independent association between the general population, health care system and renal service characteristics and RRT incidence rates. METHODS RRT incidence data (2003-2005) were obtained from renal registries; general population age and health and macroeconomic indices were collected from secondary sources. Renal service organization and resource data were obtained through interviews and questionnaires. Linear regression models were built to establish the factors independently associated with RRT incidence, stratified by the Human Development Index where required. False discovery rate (FDR) correction was adjusted for multiple testing. RESULTS Across the 46 countries (population 1.25 billion), RRT incidence rates ranged from 12 to 455 (median 130) per million population. Gross domestic product (GDP) per capita [incidence rate ratio (IRR): 1.02 per

Exploring the Association between Macroeconomic Indicators and Dialysis Mortality

1000 increase, P(FDR) = 0.047], percentage of GDP spent on health care (IRR: 1.11 per % increase, P(FDR) = 0.006) and dialysis facility reimbursement rate relative to GDP (IRR: 0.76 per GDP per capita-sized increase in reimbursement rate, P(FDR) = 0.007) were independently associated with RRT incidence. In more developed countries, the private for-profit share of haemodialysis facilities was also associated with higher incidence (IRR: 1.009 per % increase, P(FDR) = 0.003). CONCLUSIONS Macroeconomic and renal service factors are more often associated with RRT incidence rates than measured demographic or general population health status factors.

Global differences in dialysis modality mix: the role of patient characteristics, macroeconomics and renal service indicators

BACKGROUND AND OBJECTIVES Mortality on dialysis varies greatly worldwide, with patient-level factors explaining only a small part of this variation. The aim of this study was to examine the association of national-level macroeconomic indicators with the mortality of incident dialysis populations and explore potential explanations through renal service indicators, incidence of dialysis, and characteristics of the dialysis population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Aggregated unadjusted survival probabilities were obtained from 22 renal registries worldwide for patients starting dialysis in 2003-2005. General population age and health, macroeconomic indices, and renal service organization data were collected from secondary sources and questionnaires. Linear modeling with log-log transformation of the outcome variable was applied to establish factors associated with survival on dialysis. RESULTS Two-year survival on dialysis ranged from 62.3% in Iceland to 89.8% in Romania. A higher gross domestic product per capita (hazard ratio=1.02 per 1000 US dollar increase), a higher percentage of gross domestic product spent on healthcare (1.10 per percent increase), and a higher intrinsic mortality of the dialysis population (i.e., general population-derived mortality risk of the dialysis population in that country standardized for age and sex; hazard ratio=1.04 per death per 10,000 person years) were associated with a higher mortality of the dialysis population. The incidence of dialysis and renal service indicators were not associated with mortality on dialysis. CONCLUSIONS Macroeconomic factors and the intrinsic mortality of the dialysis population are associated with international differences in the mortality on dialysis. Renal service organizational factors and incidence of dialysis seem less important.

The EVEREST study: an international collaboration*

BACKGROUND An increase in the dialysis programme expenditure is expected in most countries given the continued rise in the number of people with end-stage renal disease (ESRD) globally. Since chronic peritoneal dialysis (PD) therapy is relatively less expensive compared with haemodialysis (HD) and because there is no survival difference between PD and HD, identifying factors associated with PD use is important. METHODS Incidence counts for the years 2003-05 were available from 36 countries worldwide. We studied associations of population characteristics, macroeconomic factors and renal service indicators with the percentage of patients on PD at Day 91 after starting dialysis. With linear regression models, we obtained relative risks (RRs) with 95% confidence intervals (CIs). RESULTS The median percentage of incident patients on PD was 12% (interquartile range: 7-26%). Determinants independently associated with lower percentages of patients on PD were as follows: patients with diabetic kidney disease (per 5% increase) (RR 0.93; 95% CI 0.89-0.97), health expenditure as % gross domestic product (per 1% increase) (RR 0.93; 95% CI 0.87-0.98), private-for-profit share of HD facilities (per 1% increase) (RR 0.996; 95% CI 0.99-1.00; P = 0.04), costs of PD consumables relative to staffing (per 0.1 increase) (RR 0.97; 95% CI 0.95-0.99). CONCLUSIONS The factors associated with a lower percentage of patients on PD include higher diabetes prevalence, higher healthcare expenditures, larger share of private-for-profit centres and higher costs of PD consumables relative to staffing. Whether dialysis modality mix can be influenced by changing healthcare organization and funding requires additional studies.

Cost-Effectiveness of HBV and HCV Screening Strategies – A Systematic Review of Existing Modelling Techniques

Rates of initiation of renal replacement therapy (RRT), use of home modalities of treatment and patient outcomes vary considerably between countries. This paper reports the methods and baseline characteristics of countries participating in the EVEREST study (n = 46), a global collaboration examining the association between medical and non-medical factors and RRT incidence, modality mix and survival. Numbers of incident and prevalent patients were collected for current (2003–05) and historic (1983–85, 1988–90, 1993–95 and 1998–2000) periods stratified, where available, by age, gender, treatment modality and cause of end stage renal disease (diabetic versus non-diabetic). General population age and health indicators and national-level macroeconomic data were collected from secondary data sources. National experts provided primary data on renal service funding, resources and organization. The median (inter quartile range) RRT incidence per million of the population (pmp) was 130 pmp (102–167 pmp). The general population life expectancy at 60 was 22.1 years (19.7–23.1 years) and 6.9% had diabetes mellitus (5.4–9.0%). Healthcare spending as a percentage of gross domestic product was 8.1% (5.6–9.3%). Countries averaged nine dialysis facilities pmp (4–12 pmp), with 69.0% (43.9–99.0%) owned by the public or private not-for-profit sector. The number of nephrologists ranged from 0.5 to 48 pmp (median 12 pmp). The heterogeneity of EVEREST countries will enable modelling to examine the independent association between medical and non-medical factors on RRT epidemiology.

Evaluating the impact of the alcohol act on off-trade alcohol sales: a natural experiment in Scotland.

Introduction Studies evaluating the cost-effectiveness of screening for Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) are generally heterogeneous in terms of risk groups, settings, screening intervention, outcomes and the economic modelling framework. It is therefore difficult to compare cost-effectiveness results between studies. This systematic review aims to summarise and critically assess existing economic models for HBV and HCV in order to identify the main methodological differences in modelling approaches. Methods A structured search strategy was developed and a systematic review carried out. A critical assessment of the decision-analytic models was carried out according to the guidelines and framework developed for assessment of decision-analytic models in Health Technology Assessment of health care interventions. Results The overall approach to analysing the cost-effectiveness of screening strategies was found to be broadly consistent for HBV and HCV. However, modelling parameters and related structure differed between models, producing different results. More recent publications performed better against a performance matrix, evaluating model components and methodology. Conclusion When assessing screening strategies for HBV and HCV infection, the focus should be on more recent studies, which applied the latest treatment regimes, test methods and had better and more complete data on which to base their models. In addition to parameter selection and associated assumptions, careful consideration of dynamic versus static modelling is recommended. Future research may want to focus on these methodological issues. In addition, the ability to evaluate screening strategies for multiple infectious diseases, (HCV and HIV at the same time) might prove important for decision makers.

PATHway I: design and rationale for the investigation of the feasibility, clinical effectiveness and cost-effectiveness of a technology-enabled cardiac rehabilitation platform

Background and Aims A ban on multi-buy discounts of off-trade alcohol was introduced as part of the Alcohol Act in Scotland in October 2011. The aim of this study was to assess the impact of this legislation on alcohol sales, which provide the best indicator of population consumption. Design, Setting and Participants Interrupted time–series regression was used to assess the impact of the Alcohol Act on alcohol sales among off-trade retailers in Scotland. Models accounted for underlying seasonal and secular trends and were adjusted for disposable income, alcohol prices and substitution effects. Data for off-trade retailers in England and Wales combined (EW) provided a control group. Measurements Weekly data on the volume of pure alcohol sold by off-trade retailers in Scotland and EW between January 2009 and September 2012. Findings The introduction of the legislation was associated with a 2.6% (95% CI = −5.3 to 0.2%, P = 0.07) decrease in off-trade alcohol sales in Scotland, but not in EW (−0.5%, 95% CI = −4.6 to 3.9%, P = 0.83). A statistically significant reduction was observed in Scotland when EW sales were adjusted for in the analysis (−1.7%, 95% CI = −3.1 to −0.3%, P = 0.02). The decline in Scotland was driven by reduced off-trade sales of wine (−4.0%, 95% CI = −5.4 to −2.6%, P < 0.001) and pre-mixed beverages (−8.5%, 95% CI = −12.7 to −4.1%, P < 0.001). There were no associated changes in other drink types in Scotland, or in sales of any drink type in EW. Conclusions The introduction of the Alcohol Act in Scotland in 2011 was associated with a decrease in total off-trade alcohol sales in Scotland, largely driven by reduced off-trade wine sales.

Geographic variation of inpatient care costs at the end of life

Introduction Exercise-based cardiac rehabilitation (CR) independently alters the clinical course of cardiovascular diseases resulting in a significant reduction in all-cause and cardiac mortality. However, only 15%–30% of all eligible patients participate in a phase 2 ambulatory programme. The uptake rate of community-based programmes following phase 2 CR and adherence to long-term exercise is extremely poor. Newer care models, involving telerehabilitation programmes that are delivered remotely, show considerable promise for increasing adherence. In this view, the PATHway (Physical Activity Towards Health) platform was developed and now needs to be evaluated in terms of its feasibility and clinical efficacy. Methods and analysis In a multicentre randomised controlled pilot trial, 120 participants (m/f, age 40–80 years) completing a phase 2 ambulatory CR programme will be randomised on a 1:1 basis to PATHway or usual care. PATHway involves a comprehensive, internet-enabled, sensor-based home CR platform and provides individualised heart rate monitored exercise programmes (exerclasses and exergames) as the basis on which to provide a personalised lifestyle intervention programme. The control group will receive usual care. Study outcomes will be assessed at baseline, 3 months and 6 months after completion of phase 2 of the CR programme. The primary outcome is the change in active energy expenditure. Secondary outcomes include cardiopulmonary endurance capacity, muscle strength, body composition, cardiovascular risk factors, peripheral endothelial vascular function, patient satisfaction, health-related quality of life (HRQoL), well-being, mediators of behaviour change and safety. HRQoL and healthcare costs will be taken into account in cost-effectiveness evaluation. Ethics and dissemination The study will be conducted in accordance with the Declaration of Helsinki. This protocol has been approved by the director and clinical director of the PATHway study and by the ethical committee of each participating site. Results will be disseminated via peer-reviewed scientific journals and presentations at congresses and events. Trial registration number NCT02717806. This trial is currently in the pre-results stage.

Scottish Keep Well health check programme: an interrupted time series analysis

Background: costs incurred at the end of life are a main contributor to healthcare expenditure. Urban–rural inequalities in health outcomes have been demonstrated. Issues around geographical patterning of the association between time-to-death and expenditure remain under-researched. It is unknown whether differences in outcomes translate into differences in costs at the end of life. Methods: we used a large representative sample of the Scottish population obtained from death records linked to acute inpatient care episodes. We performed retrospective analyses of costs and recorded the most frequent reasons for the last hospital admission. Using a two-part model, we estimated the probability of healthcare utilisation and costs for those patients who incurred positive costs. Results: effects of geography on costs were similar across diagnoses. We did not observe a clear gradient for costs, which were lower in other urban areas compared with large urban areas. Patients from remote and very remote areas incurred higher costs than patients from large, urban areas. The main driver of increased costs was increased length of stay. Conclusions: our results provide evidence of additional costs associated with remote locations. If length of stay and costs are to be reduced, alternative care provision is required in rural areas. Lower costs in other urban areas compared with large urban areas may be due to urban centres incurring higher costs through case-mix and clinical practice. If inequalities are driven by hospital admission, for an end of life scenario, care delivered closer to home or home-based care seems intuitively attractive and potentially cost-saving.

The SCottish Alcoholic Liver disease Evaluation: A Population-Level Matched Cohort Study of Hospital-Based Costs, 1991-2011.

Background Effective interventions are available to reduce cardiovascular risk. Recently, health check programmes have been implemented to target those at high risk of cardiovascular disease (CVD), but there is much debate whether these are likely to be effective at population level. This paper evaluates the impact of wave 1 of Keep Well, a Scottish health check programme, on cardiovascular outcomes. Methods Interrupted time series analyses were employed, comparing trends in outcomes in participating and non-participating practices before and after the introduction of health checks. Health outcomes are defined as CVD mortality, incident hospitalisations and prescribing of cardiovascular drugs. Results After accounting for secular trends and seasonal variation, coronary heart disease mortality and hospitalisations changed by 0.4% (95% CI −5.2% to 6.3%) and −1.1% (−3.4% to 1.3%) in Keep Well practices and by −0.3% (−2.7% to 2.2%) and −0.1% (−1.8% to 1.7%) in non-Keep Well practices, respectively, following the intervention. Adjusted changes in prescribing in Keep Well and non-Keep Well practices were 0.4% (−10.4% to 12.5%) and −1.5% (−9.4% to 7.2%) for statins; −2.5% (−12.3% to 8.4%) and −1.6% (−7.1% to 4.3%) for antihypertensive drugs; and −0.9% (−6.5% to 5.0%) and −2.4% (−10.1% to 6.0%) for antiplatelet drugs. Conclusions Any impact of the Keep Well health check intervention on CVD outcomes and prescribing in Scotland was very small. Findings do not support the use of the screening approach used by current health check programmes to address CVD. We used an interrupted time series method, but evaluation methods based on randomisation are feasible and preferable and would have allowed more reliable conclusions. These should be considered more often by policymakers at an early stage in programme design when there is uncertainty regarding programme effectiveness.