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

CHRONIC KIDNEY DISEASE FINANCIAL AND ECONOMIC COSTS DR. P. G. MAHIPALA MBBS, MSC, MD, MBA, FCMA,DED, DM, DBS, DPM DIRECTOR GENERAL OF HEALTH SERVICES MINISTRY OF HEALTH DECEMBER 10, 2013

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 •

Burden of Disease • 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

The Risk Areas • Increasing number of CKD cases & uneven distribution Medawachchiya • Case load more in certain 3500 Kebithigollewa areas 300 Padaviya 1000 Medirigiriya i.e. regional clustering 800 Anuradhapura Polonnaruwa 1800 • Affect low socioeconomic 800 group Dehiattakandiya 300 i.e. young male farmers Girandurukotte North Central Province 2250 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

ARCH EFFORT NATIONAL L COLLA LABORATIVE RESEAR • 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) CKD Scientific Committee • Case control study - Urine metal analysis Meeting • Case control study - Nail & hair analysis for arsenic • Study on herbal remedies (aristolochic acid) • Randomized clinical trial

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

Pattern of treatment source by visit MEDAWACHCHIYA PADAVIYA • Initially greatest dependence is on the government hospitals. • Later visits are more diversified suggesting that the people are looking for alternate approaches.

Cost of clini nic care No 101- 501- expenditure <100 500 1000 Hospital >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 visit Cost item (n) Median Inter-quartile (LKR) range 100.00 58.75-140.70 Travel (n=274) 131.00 61.00-261.00 Accompanying person (n=64) 80.00 50.00-100.00 Food (n=279) 200.00 90.00-316.25 Drugs (n=102) 300.00 105.00-450.00 Laboratory investigations (n=37) 50.00 40.00-70.00 Other (n=53) 280.50 150.00-520.00 Total (n=300)

Indirect cost in seeking ng clini nic care Median(LKR) Inter-quartile Cost item (n) 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 900.00 625.00-1000.00 (n=35) 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 310.00 200.00-480.00 person (n=99) 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

Direct cost of the hospital alizat ation n at Anurad adha hapura a TH Inter-quartile Cost item (n) Median (LKR) range Drugs (n=11) 200.00 90.00-250.00 100.00-235.00 Medical consumables (n=3) 150.00 Laboratory investigations 915.00 70.00-1760.00 (n=2) Non-medical consumables 180.00 70.00-300.00 (n=49) Payments to staff (n=3) 20.00 20.00-30.00 Total (n=132) 1225.00 755.00-2960.00

Indirect cost due to hospi pital alizat ation n episo sode de Median Inter-quartile Cost item (n) (LKR) 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

Hotel cost st of hospital alizat ation n in the renal al unit Item Detailed cost per Total cost per month month (LKR) (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 of hospitalization in the renal unit (cont…) 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.

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

Cost of drugs s borne by house seho holds No 101- 501- Hospital expense <100 500 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 No 101- 501- Hospital expense <100 500 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 ;