Letters 152
Letter from North America
DIALYSIS DILEMMAS The
increasing incidence of diabetes and an ageing population are
contributing to an epidemic of end-stage renal disease (ESRD)
both in the USA and India. Most of these patients with ESRD
require dialysis—haemodialysis (HD) and peritoneal dialysis
(PD)—for survival. The rapidly rising number and costs of
dialyses are creating a dilemma regarding the modality of
dialysis, its method of delivery and reimbursement policies
both in the USA and India.
Since 1970, the number of patients on
chronic dialysis in the USA has increased 100-fold. In 2005,
in the USA, more than 500 000 patients received treatment for
ESRD, an average annual increase of 4%–6%. The greatest rate
of growth occurred among patients >75 years of age and those
with co-morbid conditions such as diabetes mellitus and
hypertension. Experts predict an epidemic of ESRD in the next
25 years due to the continued growth in the number of new
patients with ESRD (projected 2 million by 2030), as well as
lower mortality rates of patients with ESRD (a 10% reduction
in mortality in the past decade).
The rapid rise in patients requiring
dialysis in the USA resulted in growth of the dialysis centre
industry, which is composed of approved independent and
hospital-based or affiliated facilities. All dialysis centres
are regulated and subsidized by the Federal Government, which
grants exclusive licences to providers to supply long term
dialysis within a designated territory. These facilities are
reimbursed through the Health Care Financing Administration (HCFA)
with Medicare funds. The ESRD programme consumes 6.4% of the
Medicare budget. Scarcity of funds caused the Federal
Government to cut back on its reimbursement rates in the
mid-1990s. However, that cost-cutting proved deadly. A
National Kidney Foundation report published in 1995 found that
American patients on dialysis had a much higher mortality rate
(24%) than patients on dialysis in other countries (10% in
Japan, 10% in Germany and 11% in France). The report claimed
that cost-cutting in the form of poorly trained staff and
inefficient use of dialysis machines seemed to be a factor in
45 000 US deaths. A campaign was launched in 1995 by the
National Kidney Foundation to improve patient care at dialysis
centres and decrease deaths.
Dialysis centres and companies providing
the required machines and expertise are a big industry in the
USA. The largest companies in this industry are Fresenius
Medical Care (FMC), Baxter and DaVita Inc. FMC reported a 33%
increase in net revenue for the first quarter of 2007 to US$
2321 million (38% growth in dialysis services). The average
revenue per dialysis treatment increased by 6% to US$ 329. As
of 31 March 2007, FMC treated 169 216 patients worldwide (in
2914 clinics), which represents a 27% increase in patients
compared to the past year. The international segment served
50 484 patients (in 620 clinics), an increase of 17% over the
past year. FMC delivered approximately 6.41 million dialysis
treatments worldwide, which represents an increase of 28% over
a year. Competition is provided by Baxter and DaVita
Inc., both of which had similar growth patterns.
A similar trend of a rise in patients with
ESRD requiring dialysis is expected in the near future in
India. It is estimated that about 100 000 people suffer from
ESRD each year in India, of which only about 20 000 get
treated. Over three-fourths of the people suffering from ESRD
do not get treated, largely due to a lack of awareness of the
disease and treatment options, inadequate access to care and
affordability. A high prevalence of diabetes and heart disease
is possibly the reason for the rapid rise in renal disease in
India. The mean age of patients with ESRD in India is between
32 and 42 years, compared with 60 and 63 years in developed
countries. Although the alternative option of renal
transplantation for the treatment of ESRD is well developed in
India, it is severely hampered due to a lack of donors and the
absence of a strong deceased donor programme. Therefore, even
patients who can afford transplantation have to opt for
dialysis as the only possible treatment.
Estimates suggest that there are about
14 500 patients surviving on HD and about 3000 patients
surviving on PD in India. The remaining 2500–3000 patients are
those surviving a renal transplant. There are an estimated 400
dialysis units in India with about 1000 dialysis centres.
Among the patients who need dialysis, only 5% can afford it.
Some social activists propose that the Indian Government
should subsidize the costs of dialysis, as the American
Government does. Each dialysis treatment costs up to Rs 2000
(about US$ 50). All dialysis machines are imported and the
government has waived customs duties on them. Each machine
costs Rs 6–10 lakh (US$ 15 000–US$ 25 000). Maintenance is
also expensive. Machines and consumables such as the dialysers
and tubing used for HD are generally imported. Because of the
high costs and restricted availability of HD, some suggest
that PD is a viable option for the Indian healthcare system.
Unlike HD, consumables for PD are manufactured locally and are
easily available in India. Across Asia, PD is preferred in
several countries because of its low infrastructure
requirements, low cost and applicability to a wide range of
patients. The governments of Hong Kong and Singapore have even
announced a ‘PD first’ policy to encourage providers to
consider PD as the first-line of therapy for renal failure.
Some public health experts argue that PD is even more relevant
in India, given the geographical expanse. The lack of
utilities such as electricity, water treatment, sewage
management, poor personal hygiene, as well as a lack of
healthcare infrastructure such as trained nephrologists,
dialysis nurses and technicians all support this argument.
In this emerging epidemic of ESRD, experts
argue that more stress on preventive measures may reduce the
overall burden of the disease and its treatment, both in the
USA and India. Primary prevention of diabetes, community-based
screening to facilitate early detection of people with
diabetes, improving glycaemic and blood pressure control of
people with diabetes in the primary care setting, and the
establishment of dedicated renal clinics are some of the
measures proposed.
|
