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The use of polyglucose as a peritoneal dialysis (PD) fluid extends time on PD treatment. It is anticipated, therefore, that the share of patients treated with PD will be positively influenced. The relationship between extension of PD treatment time and an increase of the PD treatment share, however, is complex and needs further investigation. In th...
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Context 1
... scenarios were defined to explore the direct effects of ETOT. These scenarios differ from the null scenario in the transition rates from PD to HD. For the period 1990-1999, technique survival on PD was calculated. Figure 2 shows the technique survival on PD, for patients starting their PD treatment in the period 1990-1999. Using the Renine data, it was found that for The Netherlands, median time on PD until a transition to HD was 3.9 years for all PD patients. In PD patients with ultrafiltration failure, Wilkie et al. [1] found a median extension of technique survival on PD of 22 months as a result of the use of polyglucose as a dialysis fluid. Peers et al. [6] found an extended continuous ambu- latory peritoneal dialysis (CAPD) technique survival of at least 1 year. It was estimated that incidence of ultrafiltra- tion failure in PD patients is 5% in the first year of treatment, 30% after 3 years of PD treatment and 50% after 4 years ...
Context 2
... monthly transition rates for later years on treatment in the Markov model were adjusted to express the increased time on PD treatment in such a way that the median time on PD of 3.9 years increased by 8, 10 and 12 months. Figure 2 shows the survival curve for the scenario with the ETOT of 10 months, compared with the observed survival curve in the period ...
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... Models have also been developed to provide cost-effectiveness analyses for ESRD. Some use multistate transition models (Haller et al. 2011a;Liem et al. 2012;Rodina-Theocharaki et al. 2012;Teerawattananon et al. 2007;Weijnen et al. 2003) to simulate the use of more preemptive grafts, (Liem et al. 2012) more transplants from living donors, (Haller et al. 2011a) or increasing use of PD. (Teerawattananon et al. 2007;Weijnen et al. 2003) Some are based on individual simulations of a cohort of incident patients and generate random patient profiles and medical histories for each patient. (Lee et al. 2006) Because most of these models aimed to predict future prevalence counts, they have simulated prevalent patient cohorts mixed with incoming new patients on a calendar time axis. ...
... Models have also been developed to provide cost-effectiveness analyses for ESRD. Some use multistate transition models (Haller et al. 2011a;Liem et al. 2012;Rodina-Theocharaki et al. 2012;Teerawattananon et al. 2007;Weijnen et al. 2003) to simulate the use of more preemptive grafts, (Liem et al. 2012) more transplants from living donors, (Haller et al. 2011a) or increasing use of PD. (Teerawattananon et al. 2007;Weijnen et al. 2003) Some are based on individual simulations of a cohort of incident patients and generate random patient profiles and medical histories for each patient. (Lee et al. 2006) Because most of these models aimed to predict future prevalence counts, they have simulated prevalent patient cohorts mixed with incoming new patients on a calendar time axis. ...
In order to better understand and then optimize the trajectories followed by end-stage renal disease patients, it was necessary to develop tools to model these complex trajectories. The different treatment modalities were not compared but a comprehensive approach was preferred taking into account an integrated vision where treatment modalities are considered complementary and non-competitive. We used compartments models which took into account competitive risk and a mixture model for survival with fraction not at risk. The model parameters were estimated from the data from the Renal Epidemiology and Information Network registry. Reimbursement data from the national health insurance (SNIIRAM) were also used. The prediction tool developed was used to evaluate the consequences in terms of expected 15- years restricted lifetime and average cost per month for different strategies in a medicoeconomic analysis, in partnership with the Haute Autorité de Santé. The final aim of this work is to offer decision support tools based on strategies best adapted to patients’ needs. The tools developed in this work could also serve as a basis for a simulation platform to accompany public decision-makers in their reflection on health organization
... The parameters of the model were estimated by using the first 180 months of follow-up (15 years). The transition rates were presumed constant within seven time intervals: [0-6] months, [6][7][8][9][10][11][12] months, [12][13][14][15][16][17][18] months, [18][19][20][21][22][23][24] months, [24][25][26][27][28][29][30][31][32][33][34][35][36] months, months and [60-180] months. ...
... Models have also been developed to provide cost-effectiveness analyses for ESRD. Some use multistate transition models [30,[33][34][35][36] to simulate the use of more preemptive grafts [36], more transplants from living donors [34] or increasing use of PD [33,35]. Some are based on individual simulations of a cohort of incident patients and generate random patient profiles and medical histories for each patient [25]. ...
... Models have also been developed to provide cost-effectiveness analyses for ESRD. Some use multistate transition models [30,[33][34][35][36] to simulate the use of more preemptive grafts [36], more transplants from living donors [34] or increasing use of PD [33,35]. Some are based on individual simulations of a cohort of incident patients and generate random patient profiles and medical histories for each patient [25]. ...
Nephrologists need to better understand the impact of their decisions about long-term treatment strategies. Healthcare planning requires the anticipation of demand. Indicators from ESRD registries are especially difficult to interpret when the underlying dynamic process is not well understood. Therefore, we have developed a statistical tool to study the course of incident ESRD patient cohorts over time and to quantify, by simulations, the impact of various expected changes or new strategies.
Based on the data from 67 258 ESRD adult patients, we first estimated transition rates between 10 different modalities of treatment ('compartments') with a multistate model. In a second step, we predicted the number of patients in each compartment at each time point for a cohort of 1000 patients for 180 months after the onset of renal replacement therapy (RRT). We tested two scenarios to illustrate the possibility of simulating policy changes.
Increased use of non-assisted automated peritoneal dialysis (PD) (from 7.7 to 19.2% at RRT onset) will not substantially influence the proportion of total RRT time in PD for patients aged 18-44 without diabetes. Improving access to kidney transplants from cadaveric donors for patients aged 45-69 with diabetes will increase the 15-year restricted mean lifetime by 5 months and the time spent with a functioning graft (34 versus 23%).
A model based on patients' treatment trajectories can improve the description and understanding of RRT as a dynamic phenomenon. Its use for simulation may help professionals and decision-makers to optimize renal organization and care.
... [25][26][27][28][29] We found in many studies, that for data analysis use of the Markov property by modeling the exponential distribution is not unreasonable for multistage disease progression of cancer or chronic disease by Markov assumption. [30][31][32][33] Therefore, we constructed the likelihood function using a time-homogeneous Markov model with a negative exponential waiting time (hereafter called time) in each stage ( Table 1). The stage-specific hazard rates were estimated by maximizing overall likelihood to time to kidney failure, using the following formula: ...
The process of kidney failure in renal transplant recipients with chronic allograft dysfunction is characterized by a progressive decline in glomerular filtration rate over time that it is determined by the 5-stage model. This study used stage-based statistical survival analysis to predict graft survival in renal transplant recipients with chronic allograft dysfunction.
In a single-center, retrospective study, 214 renal transplant recipients with chronic allograft dysfunction were investigated at a university hospital in Iran from 1997 to 2005. At each patient visit, kidney function was assessed using glomerular filtration rate and stage of disease.
The estimated stage-specific hazard rates of disease progression are stage one, 453.936; stage two, 485.040; stage three, 545.808; and stage four; 649.488 per 1000 person-years. The estimated mean times in each stage were as follows: kidney damage with normal or increased glomerular filtration rate, 26.43 months; kidney damage with mildly decreased glomerular filtration rate, 24.74 months; moderate kidney disease, 21.98 months; and severe kidney disease; 18.48 months. These estimates yield a mean time from stage 1 to kidney failure of 91.63 months. The probability of graft survival was predicted using estimated stage-specific hazard rates. The 18th, 58th, 118th, and 155th months death-censored graft survival probabilities were 0.99, 0.75, 0.25, and 0.10.
In this method of survival analysis, we can determine a statistical model according to a real clinical model in renal transplant recipients with chronic allograft dysfunction. It enables us to determine the stage-specific hazard rates of disease progression. These findings can help nephrologists to understand the kidney disease process and better predict graft survival.
... However, such an increase in daily therapy cost may be more than offset if the alternative would have been transfer and maintenance to a more expensive dialysis treatment, such as HD, as documented later in this manuscript. Budget impact models and Markov analysis have reported that such extension of time on PD therapy lowers the total costs of care over time by deferring the need for HD, which is generally found to be a more expensive treatment alternative [26,35,36]. Such analyses underscore the need to evaluate dialysis treatment costs as a total therapy rather than simply thinking of dialysis costs as the procurement expense of the supplies. ...
The worldwide incidence of kidney failure is on the rise and treatment is costly; thus, the global burden of illness is growing. Kidney failure patients require either a kidney transplant or dialysis to maintain life. This review focuses on the economics of dialysis. Alternative dialysis modalities are haemodialysis (HD) and peritoneal dialysis (PD). Important economic factors influencing dialysis modality selection include financing, reimbursement and resource availability. In general, where there is little or no facility or physician reimbursement or payment for PD, the share of PD is very low. Regarding resource availability, when centre HD capacity is high, there is an incentive to use that capacity rather than place patients on home dialysis. In certain countries, there is interest in revising the reimbursement structure to favour home-based therapies, including PD and home HD. Modality selection is influenced by employment status, with an association between being employed and PD as the modality choice. Cost drivers differ for PD and HD. PD is driven mainly by variable costs such as solutions and tubing, while HD is driven mainly by fixed costs of facility space and staff. Many cost comparisons of dialysis modalities have been conducted. A key factor to consider in reviewing cost comparisons is the perspective of the analysis because different costs are relevant for different perspectives. In developed countries, HD is generally more expensive than PD to the payer. Additional research is needed in the developing world before conclusive statements may be made regarding the relative costs of HD and PD.
Peritoneal dialysis (PD) is a viable but under-prescribed treatment for uremic patients. Concerns about its use include the bio-incompatibility of PD fluids, due to their potential for altering the functional and anatomical integrity of the peritoneal membrane. Many of these effects are thought to be due to the high glucose content of these solutions, with attendant issues of products generated during heat treatment of glucose-containing solutions. Moreover, excessive intraperitoneal absorption of glucose from the dialysate has many potential systemic metabolic effects. This article reviews the efforts to develop alternative PD solutions that obviate some of these side effects, through the replacement of part of their glucose content with other osmolytes which are at least as efficient in removing fluids as glucose, but less impactful on patient metabolism. In particular, we will summarize clinical studies on the use of alternative osmotic ingredients that are commercially available (icodextrin and amino acids) and preclinical studies on alternative solutions under development (taurine, polyglycerol, carnitine and xylitol). In addition to the expected benefit of a glucose-sparing approach, we describe an ‘osmo-metabolic’ approach in formulating novel PD solutions, in which there is the possibility of exploiting the pharmaco-metabolic properties of some of the osmolytes to attenuate the systemic side effects due to glucose. This approach has the potential to ameliorate pre-existing co-morbidities, including insulin resistance and type-2 diabetes, which have a high prevalence in the dialysis population, including in PD patients.
Peritoneal dialysis (PD) is as least as good as hemodialysis (HD) for the treatment of end stage kidney disease, considering morbidity and mortality, and better for quality of life. The best result is obtained when the patient can benefit of the sequential treatment, PD first and then HD if necessary. Furthermore, the cost of a patient treated by PD is less than the cost of the same patient treated by HD, at least in developed countries. But, all around the word, the rate of usage of PD don’t grow, or decline. One can expect that, as no medical reason can explain this, the cause is economic. Multiple economics aspects and expenses posts for DP are analyzed, as the results of some financial decisions taken in one country or the other, keeping in mind the French system or reimbursement. We conclude that economic incitations may help for the development of PD, if they don’t penalize one of the partners (insurance, clinics, doctors of patients), and if in the same time there is an improvement of the formation and information of doctors and patient.
