The hidden financial catastrophe of chronic kidney disease under universal coverage and Thai “Peritoneal Dialysis First Policy”

Abstract

ObjectiveUniversal health coverage can decrease the magnitude of the individual patient's financial burden of chronic kidney disease (CKD), but the residual financial hardship from the patients' perspective has not been well-studied in low and middle-income countries (LMICs). This study aimed to evaluate the residual financial burden in patients with CKD stage 3 to dialysis in the “PD First Policy” under Universal Coverage Scheme (UCS) in Thailand.MethodsThis multicenter nationwide cross-sectional study in Thailand enrolled 1,224 patients with pre-dialysis CKD, hemodialysis (HD), and peritoneal dialysis (PD) covered by UCS and other health schemes for employees and civil servants. We interviewed patients to estimate the proportion with catastrophic health expenditure (CHE) and medical impoverishment. The risk factors associated with CHE were analyzed by multivariable logistic regression.ResultsUnder UCS, the total out-of-pocket expenditure in HD was over two times higher than PD and nearly six times higher than CKD stages 3–4. HD suffered significantly more CHE and medical impoverishment than PD and pre-dialysis CKD [CHE: 8.5, 9.3, 19.5, 50.0% (p < 0.001) and medical impoverishment: 8.0, 3.1, 11.5, 31.6% (p < 0.001) for CKD Stages 3–4, Stage 5, PD, and HD, respectively]. In the poorest quintile of UCS, medical impoverishment was present in all HD and two-thirds of PD patients. Travel cost was the main driver of CHE in HD. In UCS, the adjusted risk of CHE increased in PD and HD (OR: 3.5 and 16.3, respectively) compared to CKD stage 3.ConclusionsDespite universal coverage, the residual financial burden remained high in patients with kidney failure. CHE was considerably lower in PD than HD, although the rates remained alarmingly high in the poor. The “PD First' program” could serve as a model for other LMICs. However, strategies to minimize financial distress should be further developed, especially for the poor.

Financial Toxicity in Renal Patients (FINTORE) Study: A Cross-Sectional Italian Study on Financial Burden in Kidney Disease—A Project Protocol

“…We have considered that in the general population, the prevalence of financial need for material, psychological and behavioral domains is around 20-50% for adults aged 18-64 years and around 15-30% for adults aged ≥65 years [39]. Moreover, in previous studies on CKD patients, FT has a prevalence between 30% and 70% [22,[40][41][42][43][44]. Assuming that we are studying a population of subjects with CKD and that the primary endpoint is dichotomous (presence or absence of FT), we calculated an appropriate number of 137 patients when considering the lower limit of prevalence reported in the literature and 47 subjects when considering the upper limit of prevalence in the general and CKD population, respectively, taking into account a type I error of alpha 0.05 and a power of 80%.…”

Dialysis and kidney transplant practices and challenges in Thailand

“…Despite universal coverage, the residual financial burden remained high in dialysis patients. Of note, the expenditure from out‐of‐pocket HD spending was 2 times greater than those with PD, mainly related to travelling expenses 31 . A recent cost–benefit study applying the concept of willingness to pay on current real‐practice costs found that the ‘PD‐First’ policy is more cost‐effective than the ‘Free‐Choice Dialysis’ policy given the willingness to pay threshold of 4766 USD 32 .…”

“…Of note, the expenditure from out-of-pocket HD spending was 2 times greater than those with PD, mainly related to travelling expenses. 31 A recent cost-benefit study applying the concept of willingness to pay on current real-practice costs found that the 'PD-First' policy is more costeffective than the 'Free-Choice Dialysis' policy given the willingness to pay threshold of 4766 USD. 32 Home-based PD is more costeffective than in-centre HD and should be promoted, especially in low-resource settings.…”