original article cost of peritoneal dialysis and haemodialysis across

Nephrol Dial Transplant (2013) 28: 2553–2569doi: 10.1093/ndt/gft214Advance Access publication 4 June 2013

Cost of peritoneal dialysis and haemodialysis across the world

Akash Nayak Karopadi1,2,

Giacomo Mason1,

Enrico Rettore3

and Claudio Ronco1,4

1International Renal Research Institute Vicenza (IRRIV), San Bortolo

Hospital, Vicenza, Italy,2Departments of Chemical Engineering and Economics, BITS Pilani,

Rajasthan, India,3Facoltà di Economia, Università degli Studi di Padova, Padova, Italy

and4Department of Nephrology, Dialysis and Transplantation, San

Bortolo Hospital, Vicenza, Italy

Correspondence and offprint requests to: ClaudioRonco; E-mail: [email protected]

Keywords: continuous ambulatory peritoneal dialysis (capd),economic analysis, economic impact, haemodialysis, perito-neal dialysis

ABSTRACT

Peritoneal dialysis (PD) as a modality is underutilized in mostparts of the world today despite several advantages includingthe possibility of it being offered in the remotest of locationsand being significantly more affordable than haemodialysis(HD) in most cases. In this article, we will compare the cost ofHD and PD in several countries to demonstrate that PD is lessthan, or at least as expensive as, HD. A thorough literaturesurvey of EMBASE and PUBMED was conducted; 78 articleswhich compared the annual PD and annual HD costs werefinally selected. Careful attention was paid to the method-ology followed by each study and the year it was published in.Our final calculations included 46 countries (20 developedand 26 developing). We found that the cost of HD wasbetween 1.25 and 2.35 times the cost of PD in 22 countries(17 developed and 5 developing), between 0.90 and 1.25times the cost of PD in 15 countries (2 developed and 13 de-veloping), and between 0.22 and 0.90 times the cost of PD in9 countries (1 developed and 8 developing). From our analy-sis, it is evident that most developed countries can providePD at a lesser expense to the healthcare system than HD. Theevidence on developing countries is more mixed, but in mostcases PD can be provided at a similar cost where economiesof scale have been achieved, either by local production or bylow import duties on PD equipment.

INTRODUCTION

In 2008, there were ∼1.75 million patients worldwide who reg-ularly received renal replacement therapy in the form of

dialysis, of which 89% or ∼1.55 million were on haemodialysis(HD) and ∼11% or ∼197 000 patients were on peritonealdialysis (PD). Out of the 197 000 patients on PD, ∼59% werereceiving treatment in developing countries and the remaining41% in developed countries. In the case of HD, nearly 62% ofthe patients were being treated in developed countries and theremaining 38% in developing countries [1].

At the current level of technology, it is not unreasonable toconsider HD and PD as clinically equivalent modalities whenwe consider the general population of end-stage renal disease(ESRD) patients, with similar survival rates at 6, 12, 24, 36, 48and 60 months. This is confirmed by the United States renaldata system (USRDS) 2012 Annual Report, which adjusted forall possible patient characteristics [2] including age, sex, race,ethnicity and primary diagnosis. The same report goes on tosay that the quality of life of PD patients is at least as good asthat of HD patients—if not better. In continuation, we willthus consider HD and PD as perfect substitutes from an econ-omic standpoint.

There are several published articles which compare theannual per patient cost of PD with that of HD. In 2008, Justet al. [3] published a review article, which reported the ratio ofHD to PD costs in various developing and developedcountries. The article concluded that HD is a more expensivemodality than PD in developed countries, but sufficient datawere not available to make any generalizations about the costsin developing countries. In 2001, Li and Chow [4] highlightedthat the cost of HD was generally greater than PD in the devel-oped Asian countries, while the reverse was true in the case ofdeveloping Asian countries. In 2010, an article by Abu-Aishaand Elamin [5] examined the situation of PD in Africa; therewere only a few countries in which PD was cheaper than HD,

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while in most African countries PD is as expensive as—or moreexpensive than—HD. The paper also highlighted that PD as amodality is still at very early stages of development in Africa.

The purpose of this article is to provide an insight on howPD compares with HD in terms of annual per patient costs indifferent parts of the world. For our purposes, PD includesboth continuous ambulatory peritoneal dialysis (CAPD) andautomated peritoneal dialysis (APD), while HD includeseither in-centre HD or hospital HD (but not home HD). Wehave made an effort to clearly differentiate between thevarious methodologies followed in estimating the costs by thestudies we considered. The results are reported as the HD/PDratio (the annual per patient cost of HD divided by the annualper patient cost of PD). For each country, we will also reportthe PD utilization rate, APD usage, PD per million population(PMP) rate and number of PD patients in 2008.

MATERIALS AND METHODS

A thorough literature survey of EMBASE and PUBMED(between 1992 and January 2013) was conducted. Articleswhich contained the terms ‘peritoneal dialysis or continuousambulatory peritoneal dialysis’ and ‘renal dialysis or HD’ and‘economics or health economics or cost or costs or expendi-tures’ were included. Articles published as editorials, letters orconference abstracts were rejected. A total of 79 articles werefinally included in our study. Table 1 is an exhaustive list of allthese studies, categorized according to country.

It is believed that a reliable cross-country comparison ofcost data is difficult to perform because therapies comprised ofa different blend of services and products. We found that theseconcerns were further complicated by the variability of the datacompared between individual reports and by incomplete trans-parency. There was no consistent method of capturing cost dataas different investigators performed them at different times indifferent countries with different motives. In order to highlightsuch differences in methodology, we classified studies into threebroad categories depending on the comprehensiveness of thecost analysis. The most important factors to consider in evaluat-ing the studies in this regard are:

(i) Did the authors include all possible economic impli-cations of the therapy, or did they limit their scope to thebasic treatment only?

(ii) Did the authors adjust for patient characteristics in orderto avoid the selection bias that is inherent to the choiceof administering HD or PD, or not?

The three categories resulting from these considerations are:

(i) cost-benefit analyses, cost-effectiveness analyses or cost-utility analyses;

(ii) cost identification analyses or synthesis studies or calcu-lation of yearly cost using basic treatment only;

(iii) reimbursement given for the therapy depending onstandard tariffs.

It is important to note that Category 1 comprises of studieswhich take into account patient characteristics, and therefore,can be considered the most reliable estimates among these cat-egories. Neither Category 2 nor Category 3 makes any allow-ances for heterogeneity in patient characteristics. Studies inthe latter categories might not achieve the quality and depth ofthe former, since they consider a more restricted range of cost:in fact, they do not include costs due to hospitalization, com-plications, emergency medicines, transportation and so on.However, we would like to point out that not considering suchdimensions leads to more conservative estimates of the costadvantage of PD over HD. Let us take transportation costs asan example: an HD patient is required to travel to a clinic or ahospital 13 times a month on average, while a PD patient doesnot need to travel as often. In this respect, an assessmentlimited to basic costs only will result in lower estimate of thedifference between PD and HD costs.

Given the lack of consistency between reports, we decidedto state our results using the ratio between the per patient annualcost of HD to that of PD; for example an HD/PD ratio of 1.50signifies that HD is on average 50% more expensive than PD.This approach, which was followed by Just et al. [3], has numer-ous advantages in an economic perspective: first of all, it avoidspossible biases introduced by heterogeneity in currency, eliminat-ing the need for conversion rates. Furthermore, currency valuesare influenced by inflating prices; by using the HD/PD cost ratio,we overcome the difficulties implied by adjusting for inflation.

Some countries had multiple studies conducted on PD andHD costs. To determine a single value of the HD/PD cost ratiofor each country, we used the following method:

(i) First, we divided papers between recent (published in2005 and after) and less recent (before 2005).

(ii) Second, we only considered recent papers (a total of 40out of 79), except for six countries including Canada,Sweden, Switzerland, the Netherlands, Denmark andPhilippines (7 papers out of 79).

(iii) Third, we calculated the average HD/PD ratio by takingthe arithmetic mean of ratios when more than oneobservation remained for the same country.

In addition, in order to obtain an estimate of the prevalentHD/PD cost ratio for a number of countries for which wecould not find any recently published literature or any reliablegovernment agency to contact [which may otherwise be con-sidered interesting because of their peculiarities, be it high PDpatients adjusted for population (PD PMP) rates or renewedgovernment policy for dialysis], we devised a mail survey to beadministered to senior nephrologists in such countries. Wewere able to collect data from a total of eight countries. For anoverview of the questionnaire, please refer to Appendix 1. Theresults of the survey process are detailed in Appendix 2. Itshould be noted that nephrologists were asked for their esti-mate of basic treatment costs, in order to avoid any possiblebias that could arise by not considering patient characteristics;for this reason, they are comparable with a Category 2 type ofstudy in the framework provided above.

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Table 1. Studies comparing HD and PD costs (arranged according to the country and yearof publication)

Source Country Year ofpublication

HD/PD costratio

Methodologicalnotes

North America

McMurry et al. [24] USA 1997 1.43 CB

Bruns et al. [25] USA 1998 1.52 CB

Shih et al. [6] USA 2005 1.2 CB

Berger et al. [26] USA 2009 1.37 CB

USRDS Annual Report [2] USA 2012 1.3 CB

BC Renal Council Project[27]

Canada—BritishColumbia

1994 1.77 CB

Goeree et al. [28] Canada—Ontario 1995 1.98 CB

Coyte et al. [29] Canada—Ontario 1996 1.6 CB

Lee et al. [30] Canada—Alberta 2002 1.9 CB

Latin America

Cherchiglia et al. [31] Brazil 2010 0.8 CB

Abreu et al. [32] Brazil 2012 1.05 CB

Pacheco et al. [33] Chile 2007 1.02 CB

Neil et al. [16] Chile 2009 1.03 CB

Arredondo et al. [34] Mexico 1998 1.71 CE

Neil et al. [16] Mexico 2009 1.53 CB

Gadola et al. [35] Uruguay 2008 0.81 B

Hurtado et al. [36] Peru 2005 0.82 B

Lobo et al. [37] Argentina 2011 Equal reimb. R

Pecoits-Filho et al. [38] Colombia 2009 Similar cost B

Europe

Rodriguez-Carmona et al.[39]

Spain 1996 1.58 CB

Villa et al. [40] Spain 2011 1.4 CU

Haller et al. [41] Austria 2011 1.68 CU

Sandoz et al. [42] Switzerland 2001 1.41 B

Blotiere et al. [43] France 2010 1.39 CB

Benain et al. [44] France 2007 1.63 CB

Bonan et al. [45] France 1994 1.46 S

Jacobs et al. [46] France 1997 2.1 S

Islam et al. [47] France 1999 1.46 CI

Baroni et al. [48] Italy 1994 1.88 CI

Brunetti et al. [49] Italy 1998 1.56 CI

De Negri et al. [50] Italy 1997 1.52 CI

La Greca et al. [51] Italy 1994 1.47 S

Maiorca et al. [52] Italy 1997 1.15 CB

Continued

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Table 1. Continued

Source Country Year of publication HD/PD cost ratio Methodological notes

Martina et al. [53] Italy 1994 1.81 CI

Jeantet et al. [54] Italy 2002 1.88 CI

Tediosi et al. [55] Italy 2001 1.53 CB

Pontoriero et al. [56] Italy 2007 1.81 CB

Baboolal et al. [57] UK 2008 1.94 CB

Grun et al. [58] UK 2003 1.11 B

Kirby et al. [59] UK 2001 0.97 B

Cantaluppi et al. [60] UK 2000 1.65 B

Beech et al. [61] UK 1993 1.39 S

Haycox et al. [62] UK 1996 1.48 CB

MacKenzie et al. [63] UK 1998 1.14 CB

Moore et al. [64] UK 1999 1.76 CE

De Wit et al. [65] The Netherlands 1998 1.54 CE

Salonen et al. [66] Finland 2003 1.2 CB

Hallinen et al. [67] Finland 2009 1.38 CB

Maschorek et al. [68] Denmark 1998 1.34 CI

Karlberg et al. [69] Sweden 1992 2.00 CI

Cantaluppi et al. [60] Sweden 2000 1.40 B

Sennfalt et al. [70] Sweden 2002 1.32 CU

Neil et al. [16] Romania 2009 1.45 CB

Kleophas et al. [71] Germany 2007 1.00 CI

Kontodimonpoulos et al. [72] Greece 2006 1.18 CB

Kontodimonpoulos et al. [73] Greece 2008 1.18 CU

Cleemput et al. [74] Belgium 2010 1.25 R

Cala et al. [75] Croatia 2007 1.53 CB

Africa

Arogundade et al. [76] Nigeria 2011 0.7 B

Abu-Aisha et al. [5] Senegal 2010 1.38 B

Abu-Aisha et al. [5] South Africa 2010 0.58 B

Abu-Aisha et al. [5] Sudan 2010 0.89 B

Abu-Aisha et al. [5] Kenya 2010 1.33 B

Mahmoud et al. [77] Egypt 2010 0.22 B

Katz et al. [8] Morocco 2011 Similar cost B

Katz et al. [8] Tunisia 2011 Similar cost B

Katz et al. [8] Ghana 2011 N/A NA

Katz et al. [8] Rwanda 2011 N/A NA

Continued

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RESULTS

For the purpose of this paper, we have divided the world intosix regions, i.e. North America, Latin America, Asia andMiddle East, Africa, Europe and Pacific. A summary of allpapers, including the estimate of HD/PD cost ratios, year ofpublication and type of methodology, is provided in Table 1.Table 2 summarizes all the country-level data for the PD util-ization rate, APD usage rate, PMP for PD and HD and totalnumber of PD patients in 2008. Table 3 is the final list of ourestimates of HD/PD cost ratios in 46 countries. We also in-cluded a visual summary of our results in the form of a map in

Figure 1. In the following, we present a brief examination ofrelevant factors, region by region.

Table 1. Continued

Source Country Year of publication HD/PD cost ratio Methodological notes

Asia

Neil et al. [16] China 2009 1.16 CB

Nayak et al. [78]a India 2013 1.25 CB

Jeloka et al. [79] India 2012 0.90 CB

Abraham et al. [80] Pakistan 2008 0.81 B

Abraham et al. [80] Sri Lanka 2008 0.85 B

Van Bui et al. [17] Vietnam 2008 Similar cost B

Naidas et al. [18] Philippines 1998 1.14 CE

Prodjosudhadi et al. [10] Indonesia 2006 1.03 B

Morad et al. [81] Malaysia 2005 1.08 B

Hooi et al. [82] Malaysia 2005 1.06 CE

Lim et al. [83] Malaysia 1999 0.81 CE

Teerawattanon et al. [84] Thailand 2007 1.07 CU

Neil et al. [16] Thailand 2009 1.13 CB

Li and Chow [4] Japan 2001 1.09 B

Fukuhara et al. [15] Japan 2007 0.85 CB

Yu et al. [85] Hong Kong 2007 2.35 B

Neil et al. [16] Singapore 2009 1.38 CB

Utas et al. [12] Turkey 2008 1.16 CB

Erek et al. [13] Turkey 2004 1.02 CB

Najafi et al. [11] Iran 2010 1.08 B

Oceania

Howard et al. [19] Australia 2009 1.44 CU

Ashton et al. [20] New Zealand 2007 1.58 CB

Category 1 studies: CU/CE/CB—Comprehensive cost utility/cost effectiveness/cost benefit study which includes all possible economicimplications of therapy and controlling for patient characteristics (except loss of work hours, emergency transport, emergency medicines).aAccounts for all possible economic implications including indirect non-medical costs loss of work hours, emergency transport, emergencymedicines and communication costs. (Calculated for CAPD 4 exchanges daily versus in-centre HD three times weekly).Category two Studies: CI–cost identification study, S—synthesis study, B—Cost calculated or estimated on the basis of basic treatment cost(costs due to complications, transportation, extra medications, loss of productivity are not included).Category 3 studies: R—Amount of reimbursement given for the therapy.

North AmericaCountry Year No. of

studiesFinal HD/PDcost ratio

USA 2012,2009, 2005

5 1.29

Canada 2002 1 1.90

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Table 2. Number of dialysis patients, number of PD patients PD utilization rates, APD utilizationrates and PMP prevalent rates in 2008

No. Country Dialysispatients. (‘000)

PD Util.(% tot)

PDPts.

APDUtil.

TotalPMP

PDPMP

HDPMP

North America

1 USA 378.8 7.0 26 517 5 1244 87 1157

2 Canada 22.2 18.0 3989 5 656 120 536

Latin America

3 Brazil 83.8 11.0 9226 5 443 47 396

4 Chile 12.8 5.0 640 5 802 39 763

5 Mexico 62.4 65.8 41 089 3 574 378 196

6 Uruguay 2.6 8.9 227 3 726 65 661

7 Peru 5.1 16.7 860 1 181 30 151

8 Argentina 24.4 3.9 952 1 610 24 586

9 El Salvador 2.9 76.5 2249 2 [86] 424 324 100

10 Colombia 17.7 36.6 6478 3 [86] 399 146 253

Europe

11 Spain 22.8 9.6 2191 3 515 49 465

12 Austria 4.0 8.8 355 4 492 43 443

13 Switzerland 2.9 9.3 269 3 383 36 347

14 France 31.4 7.5 2352 4 573 43 530

15 UK 24.7 17.0 4194 4 440 75 365

16 TheNetherlands

6.0 20.1 1209 4 366 74 292

17 Finland 1.7 21.6 365 5 322 70 252

18 Denmark 2.6 22.8 591 5 474 108 366

19 Italy 36.1 9.6 3463 4 816 78 737

20 Sweden 3.6 23.8 848 5 388 92 296

21 Romania 6.5 19.2 1254 1 344 66 278

22 Greece 9.0 8.3 748 4 819 68 751

23 Belgium 7.2 9.0 648 5 667 59 608

24 Croatia 2.8 8.7 244 2 624 54 570

25 Germany 66.7 4.8 3201 3 808 39 769

Africa

26 Nigeria 1.3 0.75 10 1 8 0.06 8

27 Senegal 0.1 18.0 26 1 5 1 4.2

28 South Africa 4.0 29.0 1170 1 107 32 75

29 Sudan 1.5 6.5 100 1 49 3 46

30 Kenya 0.3 12.0 30 1 11 4 7.5

31 Egypt 2.3 2.0 45 1 421 0.3 421

32 Morocco 5.0 0.6 30 1 163 1 162

Continued

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USA. Several papers which compare per patient annualcosts of PD with HD have been published, including apaper by Shih et al. [6] in 2005 which compared the twoannual costs after adjusting for patient characteristics. In2008, a total of 26 500 [1] patients were on PD. This cor-responds to a PD utilization rate of ∼7%. The total dialy-sis PMP is 1244, out of which PD PMP is 87 and theHD PMP is 1157. According to the USRDS 2012 AnnualReport [2], the annual per patient cost of HD is ∼USD87 500 per year, while that of PD is ∼USD 66 750. This

amounts to a difference of more than USD 20 000 peryear per patient.

Canada. In 2008, Canada had ∼4000 patients on PD, with amuch higher PD penetration than the USA, amounting to18% [1]. The overall dialysis PMP is 656, out of which PDPMP is 120 and HD PMP is 536. PD is also significantly lessexpensive than HD.

Table 2. Continued

No. Country Dialysis patients.(‘000)

PD Util. (%tot)

PDPts.

APDUtil.

TotalPMP

PDPMP

HDPMP

33 Tunisia 6.7 3 200 1 670 20 650

34 Ghana 0.1 0 NA NA 2 0 2

35 Rwanda 0.1 100 30 1 4 4 0

Asia

36 China 114.3 14 16 000 1 86 12.1 74

37 India 26.5 24.5 6500 1 24 5.8 18

38 Bangladesh 16.8 1.6 269 1 113 1.8 111

39 Pakistan 6.1 0.7 43 1 28 0.2 28

40 Sri Lanka 0.7 2.0 13 1 31 0.7 30

41 Nepal 1.0 4.4 45 1 36 1.6 34

42 Vietnam 6.1 16.4 1007 1 71 11.5 59

43 Philippines 7.5 12.7 952 1 80 10.1 70

44 Indonesia 8.8 9.7 774 1 34 3.3 31

45 Malaysia 16.7 12.5 2083 1 609 76.1 533

46 Thailand 21.8 5.5 1198 1 331 18.2 313

47 Japan 277.5 3.3 9157 4 2179 71.9 2107

48 South Korea 41.3 19.0 7840 2 855 162.5 693

49 Taiwan 53.2 9.3 4952 3 2323 216 2107

50 Hong Kong 4.3 79.4 3410 1 616 488.5 127

51 Singapore 3.8 18.8 711 1 842 158.3 684

52 Turkey 46.2 12.5 5774 3 653 81.6 571

53 Iran 16.9 6.8 1150 1 259 17.6 241

Oceania

54 Australia 9.6 23.0 2205 5 465 105 360

55 New Zealand 2.1 36.0 762 4 503 183 320

All data on PD utilization rates, APD utilization rates, PMP rates of PD patients are taken from Jain et al 2012 [1]. Overall PMP and PMP ofHD patients were calculated using the PD utilization and PD PMP data.Code used for APD usage: 1≤ 12.5%, 2 = 12.5–25%, 3 = 25–37.5%, 4 = 37.5–50%, 5 ≥ 50%.

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Table 3. Final table for estimates of HD/PD cost ratio in 46 countries arranged according to year ofpublication

No. Country Year Type ofstudy

No. of recentstudies

Total No. ofstudies

Final HD/PD costratio

1 India 2013, 2012 CB, CB 2 2 1.08

2 USA 2012, 2009,2005

CB, CB, CB 3 5 1.29

3 Brazil 2012, 2010 CB, CB 2 2 0.93

4 Argentina 2011 R 1 1 1.00

5 Spain 2011 CU 1 2 1.40

6 Austria 2011 CU 1 1 1.68

7 Nigeria 2011 B 1 1 0.70

8 France 2011, 2007 CB, CB 2 5 1.51

9 Belgium 2010 R 1 1 1.25

10 Senegal 2010 B 1 1 1.38

11 SouthAfrica

2010 B 1 1 0.58

12 Sudan 2010 B 1 1 0.89

13 Kenya 2010 B 1 1 1.33

14 Egypt 2010 B 1 1 0.22

15 Iran 2010 B 1 1 1.08

16 Chile 2009, 2007 CB, CB 2 2 1.03

17 Mexico 2009 CB 1 2 1.53

18 Uruguay 2009 B 1 1 0.81

19 Colombia 2009 B 1 1 1.00

20 Finland 2009 CB 1 2 1.38

21 Romania 2009 CB 1 1 1.45

22 China 2009 CB 1 1 1.16

23 Thailand 2009, 2007 CB, CE 2 2 1.10

24 Singapore 2009 CB 1 1 1.38

25 Australia 2009 CU 1 1 1.44

26 UK 2008 CB 1 8 1.94

27 Greece 2008, 2006 CU, CB 2 2 1.18

28 Pakistan 2008 B 1 1 0.81

29 Sri Lanka 2008 B 1 1 0.85

30 Vietnam 2008 B 1 1 1.00

31 Turkey 2008 CB 1 2 1.16

32 Italy 2007 CB 1 9 1.81

33 Germany 2007 CI 1 1 1.00

34 Croatia 2007 CB 1 1 1.53

35 Japan 2007 CB 1 2 0.85

36 Hong Kong 2007 B 1 1 2.35

Continued

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Table 3. Continued

No. Country Year Type ofstudy

No. of recentstudies

Total No. ofstudies

Final HD/PD costratio

37 New Zealand 2007 CB 1 1 1.58

38 Indonesia 2006 B 1 1 1.03

39 Peru 2005 B 1 1 0.82

40 Malaysia 2005,2005

CE, B 2 3 1.07

41 Canada 2002 CB 0 1 1.90

42 Sweden 2002,2000

CU, B 0 1 1.36

43 Switzerland 2001 B 0 1 1.41

44 TheNetherlands

1998 CE 0 1 1.54

45 Denmark 1998 CI 0 1 1.34

46 Philippines 1998 CE 0 1 1.14

Final HD/PD ratio was estimated by calculating the arithmetic mean of HD/PD ratios reported in studies classified as recent (we consideredstudies published in 2005 or newer as recent studies). In the case of a few countries (Canada, Sweden, Switzerland, the Netherlands,Denmark and Philippines), no recent data were available so the final ratio was estimated using 2002, 2002 and 2000 combined, 2001, 1998,1998 and 1998 data, respectively.Arranged by the year of most recently available data. The types of study are also given.Studies with CU/CE/CB methodology account for all possible costs and patient characteristics, studies with CI methodology account for allcosts but not patient characteristics, studies with B only account for basic treatment costs without hospitalization and complications andstudies with R methodology just show the reimbursement provided for the therapy.

F IGURE 1 : Map summarizing the HD/PD ratios in 51 countries (survey data included). Countries are placed in three categories: (i) HD/PDratio <0.90. (ii) HD/PD ratio between 0.90 and 1.25. (iii) HD/PD ratio >1.25. Map was generated using Stata 12 (StataCorp. 2011. Stata StatisticalSoftware: Release 12. College Station, TX: StataCorp LP.)

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There are few countries in Latin and Central America thatuse PD in a majority of the cases. Some examples includeMexico, El Salvador and Guatemala, which have PD utilizationrates of 66, 76.5 and 56% [1], respectively. Costa Rica and Co-lombia also have much higher PD utilization rates than theworld average, with 48 and 37% [1], respectively. The LatinAmerican region has the highest absolute number of patientson PD, surpassing Asia and North America. In general, PDtends to be very affordable in countries which have local man-ufacturing facilities for CAPD bags (such as Mexico). Overalldialysis PMP rates vary from ∼30 in Nicaragua to as high as802 in Chile [1]. On average, this group of countries has anoverall dialysis PMP of 377 (280 HD and 97 PD) and thereforea high PD utilization rate of 26% [7].

PD utilization rates vary from as low as 5% in Germany to>20% in Scandinavian countries and in the Netherlands [1].The reason for this variation is due to the fact that the reim-bursement structures are very different from country tocountry. In France and Germany, the reimbursement for HDis significantly higher than the reimbursement for PD, whilein Italy the reimbursement does not vary with the modality.The usage of APD is higher than in most parts of the world,and due to well-structured healthcare systems, hardly any out-of-pocket payments are made towards dialysis treatment. Onaverage, HD in Europe is significantly more expensive (by 30–60%) than PD. Overall dialysis PMP rates are relatively high,ranging from 322 in Finland to 819 in Greece.

Most countries in Africa are very new users of PD. Giventhat solutions are often imported, PD is more expensive thanHD in most countries, and PD utilization rates are very low,with the exception of South Africa. Cost data (except Egyptand Nigeria) are taken from the paper by Abu-Aisha andElamin [5] and a paper by Katz et al. [8]. A recent paper byOkpechi et al. [9] found that PD is significantly cheaper thanHD in South Africa if locally manufactured solutions are used.However, the HD/PD ratio of 0.58 reported in this paper iscalculated based on the use of imported solutions.

EuropeCountry Year No. of

studiesFinal HD/PD cost ratio

Spain 2011 2 1.40

Austria 2011 1 1.68

France 2011, 2007 5 1.51

Belgium 2010 1 1.25

Finland 2009 2 1.38

Romania 2009 1 1.45

UK 2008 8 1.94

Greece 2008, 2006 2 1.18

Italy 2007 9 1.81

Germany 2007 1 1.00

Croatia 2007 1 1.53

Sweden 2002, 2000 1 1.36

Switzerland 2001 1 1.41

TheNetherlands

1998 1 1.54

Denmark 1998 1 1.34

Latin AmericaCountry Year No. of

studiesFinal HD/PD cost ratio

Brazil 2012,2010

2 0.93

Argentina 2011 1 1.00

Chile 2009,2007

2 1.03

Mexico 2009 2 1.53

Uruguay 2009 1 0.81

Colombia 2009 1 1.00

Peru 2005 1 0.82AfricaCountry Year No.

StudiesFinal HD/PDcost ratio

Nigeria 2011 1 0.70

Senegal 2010 1 1.38

SouthAfrica

2010 1 0.58

Sudan 2010 1 0.89

Kenya 2010 1 1.33

Egypt 2010 1 0.22

Asia and Middle EastCountry Year No. of


India 2013,2012

2 1.08

Iran 2010 1 1.08

China 2009 1 1.16

Thailand 2009,2007

2 1.10

Singapore 2009 1 1.38

Pakistan 2008 1 0.81

Sri Lanka 2008 1 0.85

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Asia is a true showcase of very different dialysis penetrationrates. The overall dialysis rates can be as low as 24 in India andas high as 2323 in Taiwan. PD penetration rates are very lowin most developing countries like Pakistan, Sri Lanka, Nepaland Myanmar, but are as high as almost 80% in developedcountries like Hong Kong. China, Japan, Korea, Taiwan andIndia are among the largest contributors to the world PDpopulation.

China. As of 2008, China had the highest number of PDpatients in Asia with a total of ∼16 000 patients. Many localmanufacturers including Qingdao Huaren, Sichuan Qingshaand Shanghai Changcheng have emerged in recent years.

India. Dialysis penetration in India is still very low, mostlydue to its limited reimbursement structure. PD in India hasbecome significantly more affordable after the emergence oflocal manufactures like J Mitra Pvt Ltd. India is the seventhcountry with the largest number of PD patients (6500), behindMexico, USA, China, Brazil, Japan and South Korea.

Nepal. Nepal is a prime example of a country that cannotachieve economies of scale and cannot have local productionof CAPD bags given its small PD patient population; as of De-cember 2012, there were a total of 1000 HD patients and just45 PD patients. The government has recently been able toovercome the country’s inability to produce PD equipmentlocally by removing all import duties on CAPD bags. Nepalnow acquires bags from Baxter India at a cost of about 330Nepali Rupees per bag (a little under USD 4). This has madePD significantly less expensive than HD.

Bangladesh, Sri Lanka and Pakistan. The PD utilizationrate in these countries is low mainly due to the fact that PD issignificantly more expensive than HD. PD solutions are im-ported and the duty is high. Most patients on HD in thesecountries can afford just two sessions a week and several dropout due to prohibitive dialysis costs. Only a few patients inthese countries are reimbursed and that too by private insur-ance companies. Combining the three countries, there was atotal of just 325 patients on PD in 2008. Combined populationis nearly 350 million, which implies a PD PMP rate of <1.

Indonesia. The HD/PD ratio is ∼1.03 [10], indicating thatHD and PD cost nearly the same. CAPD is offered only in afew centres in the country and is not completely covered bythe health insurance scheme. The health insurance does notsupport most patients as it is primarily meant for governmentofficials.

Thailand. Thailand has recently implemented a PD firstpolicy, and PD utilization is growing rapidly. The total numberof PD patients in 2008 was 1198, making up roughly 5.5% of alldialysis patients [1]. Thailand does not locally produce PD sol-utions, but is able to import solutions at low or no duty.

Malaysia. The overall PMP of Malaysia is an impressive 331[1] which is comparable with PMPs of countries like the Neth-erlands, Sweden, Finland, Denmark and Switzerland. LikeThailand, Malaysia obtains its PD solutions at little or no dutyand the government favours the use of PD.

Iran. The PD utilization rate is ∼7% and the total number ofPD patients in 2008 was 1150 [11]. CAPD bags are manufac-tured by Samen Pharmaceuticals under the license of BaxterHealthcare Corporation. According to a paper by Najafi [11]in 2010, PD was reported to be cheaper than HD by at least7.5% which indicates a HD/PD ratio of at least 1.08. Since1995, CAPD use in Iran has been steadily increasing.

Turkey. According to a paper by Utas et al. [12] in 2008 anda paper by Erek et al. [13] in 2004, the HD/PD ratio in Turkeyis ∼1.16. PD solutions are locally manufactured in Turkey byEczacibasi-Baxter. In 2008, there were 5774 PD patients inTurkey [1].

Korea. In Korea, the government reimburses 90% of thetotal cost of dialysis irrespective of the modality. The catheterinsertion is done by a general surgeon in most of the cases.This can lead to a long wait before being initiated on PD andcould be considered an important deterrent to PD utilization.Despite all this, the PD utilization rate is 19% as of 2008 [1].

Taiwan. Over the last few years, an active effort has beentaken by the Taiwanese government to reduce HD domina-tion. In 2007 [14], PD reimbursement was increased by 20%while that of HD was reduced by 5%. From 2003–2007, thenumber of PD patients increased by almost 20%, while the in-crease in the number of HD patients was only ∼5.5%.

Japan. Patients are reimbursed 100% by the government ir-respective of the modality. The HD/PD ratio is ∼0.85 (Fuku-hara et al. [15]). There are some economic reasons for thisvalue, which is low when compared with other developedcountries; one reason could be the high cost of CAPD bags.PD penetration is also low, possibly explained by the fact thatdoctors receive an extra physician fee for prescribing HD,while there is no such fee in the case of PD. A paper by Kawa-guchi [14] in 2007 argued that low PD penetration in Japancould be better justified by non-economic reasons rather thaneconomic reasons. Some of the non-economic reasons are lackof information and knowledge about PD among patients, lack

Vietnam 2008 1 1.00

Turkey 2008 2 1.16

Japan 2007 2 0.85

HongKong

2007 1 2.35

Indonesia 2006 1 1.03

Malaysia 2005,2005

3 1.07

Philippines 1998 1 1.14

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of PD education for doctors, unwillingness by the patient orthe family to self-treat, desire to avoid complicated exchangeprocedures, lack of guarantee for extended use of peritonealmembrane as a dialyser, fear of peritonitis and encapsulatingperitoneal sclerosis.

Hong Kong. Hong Kong has the highest PD utilization rateand PD PMP rate in the world, with nearly 80% and 489, respect-ively [1]. This is largely due to the PD first policy, and alsohelped by the fact that PD is less than half as expensive as HD.

Singapore. Singapore has a PD utilization rate of nearly19%. The overall dialysis PMP is 842, out of which 684 is HDPMP and 158 is the PD PMP [1]. The government of Singa-pore offers the same reimbursement for both modalities. TheHD/PD cost ratio is 1.38 [16].

Vietnam. The number of patients on PD in Vietnam has in-creased considerably between 2003 (42 PD patients) and 2008(1007 PD patients). Like China, the PD growth is much attrib-uted to economic growth and enthusiasm of nephrologistsrather than government intervention. According to a paper byVan Bui [17] in 2008, the cost of PD may be slightly less thanthat of HD. The HD/PD ratio resulting from that assumptionis slightly >1.00.

Philippines. Philippines has a PD utilization rate of ∼12.5%.The number of patients on PD in 2008 was 952 [1]. Accordingto a paper by Naidas et al. [18] in 1998, the cost of PD was lessthan that of HD with a HD/PD ratio of ∼1.14.

Australia. Australia has a PD utilization rate of nearly 23%.The overall dialysis PMP is 465 [1] with a HD PMP of 360,and a PD PMP of 105. Low population density in several partsof the country could possibly contribute to higher PD utiliz-ations, because of longer distances to HD clinics. The HD/PDratio is also in favour of PD, with a value of 1.44 which was cal-culated from a paper by Howard et al. [19].

New Zealand. New Zealand has a PD utilization rate >36%.The overall PMP is 503, with 320 being the HD PMP and 183being the PD PMP [1]. A HD/PD ratio of 1.58 favours greateruse of PD (Ashton et al. [20]).

CONCLUSION

From our results, we can clearly see that PD is a more affordablemodality in most countries. This conclusion is further

corroborated by the fact that some cases (i.e. the basic cost assess-ments) do not consider the hidden costs like loss of productivityof patient and his family members and cost of transportation tothe centre. For this reason, any possible bias deriving from themeasurement error in costs is likely to underestimate—and notoverestimate—the cost advantage of PD over HD.

In some developing countries like Sudan and India, patientsreceive only twice weekly HD sessions instead of thrice weeklyHD sessions due to prohibitive costs. We should take this intoconsideration when we are looking at the relative costs. Again,this factor will lead to lower estimates for the overall cost ratio.The actual HD/PD ratios might be higher than the ones re-ported in this article. For these reasons, such measurementerrors deriving from heterogeneous methodologies (which arequite possibly present in this literature) do not invalidate ourconclusion that PD is overall more cost-effective than HD.

There was just one case (India) in which we needed toadjust the HD/PD cost ratio since it was originally calculatedfor thrice daily CAPD exchange versus thrice weekly HD ses-sions. The final estimate reported in the tables accountsinstead for four daily exchanges of CAPD versus thrice weeklyHD sessions.

It is clear from our results that the HD/PD cost ratiovaries significantly across countries. A thorough investi-gation of the determinants of such heterogeneity fallsbeyond the scope of this paper. However, we present someinsight into some factors that might contribute to this varia-bility. In Figure 2, we have included scatterplots that relateeach country’s HD/PD cost ratio to its Human DevelopmentIndex, the percentage of healthcare expenditure which isprivate and the number of PD patients adjusted for popu-lation (PDPMP) [1]. All three of these variables seem tobear a very significant correlation with our estimated ratios,which is evident from the r and P values. In Figure 3, weshow that in countries with access to low-cost PD equip-ment—either through local manufacturing or through lowimport duties—PD is on average significantly less expensivethan HD (see figures for data source references). A morethorough and in-depth analysis of such dynamics is left forfuture research.

From a macroeconomic standpoint, we can see that increas-ing PD utilization rates in developed countries (where PD issignificantly less expensive than HD) can help reduce theoverall healthcare expenditure. Currently, the USA spendsnearly 18% [21] of its GDP on healthcare (far higher than theOrganisation for Economic Cooperation and Developmentmember countries average of 9.5% [21]). A paper by Neil et al.[22] in 2009 argued that the USA could realize aggregatedsavings of over USD 1.1 billion in 5 years just on Medicare costsif PD utilization were increased to 15% (from the current 7%).Another example from the literature is an abstract by Chenet al. [23] in 2007, talking about potential savings achievablethrough a similar strategy in Singapore. It concludes by sayingthat an increase in PD utilization from 21 to 40% could result ina 5-year cumulative saving of nearly USD 25 million.

Another advantage connected to PD is that it is not as de-pendent on infrastructure and geography as HD is. Countrieswhich are disadvantaged by either a lack of infrastructure or

PacificCountry Year No. of


Australia 2009 1 1.44

NewZealand

2007 1 1.58

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cannot provide HD to some patients because of unfavourablegeographical dispersion could possibly consider PD as analternative.

As we have shown before, market factors seem to play amajor role in PD utilization. Governments should realize thatthe bulk of PD costs arise from the market price of the CAPDbags. It has been observed that the market for CAPD bags in

most countries is monopolistic; this tends to drive up marketprices. It is a government prerogative to impose price control-ling strategies, so that ESRD patients can access medicalsupplies at a reasonable cost. For example, this can beachieved by reducing the import duty levied on PD materials.This will also have the benefit of progressively reducing prices,since lowering the barriers to trade allows more than one

F IGURE 2 : Scatterplots of the HD/PD cost ratio with relevant macroeconomic variables. (r and P result from Pearson’s correlations). UNDP.Human Development Index (http://hdr.undp.org/en/humandev), 2012. World Bank. Health Expenditure Indicators (http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS), 2012.

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http://hdr.undp.org/en/humandev





http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS









foreign producer to compete on the national market at thesame time, and also to take advantage of larger economies ofscale.

In the end, PD utilization can be effectively promoted bygovernments; some examples include the implementation of aPD first programme (as was done by Thailand recently), theencouragement of local manufacturing or production ofCAPD bags (done by India over the last decade) and the slash-ing of import duties on CAPD bags (as has been done inNepal and Malaysia).

ACKNOWLEDGEMENTS

We would like to personally thank the following for providingus with guidance throughout our study: Prof. Xueqing Yu(China), Dr Yong Lim Kim (South Korea), Dr KBM Hadiuz-zaman (Bangladesh), Prof. Dr. Harun-Ur-Rashid (Bangla-desh), Dr Dhavee Sirivongs (Thailand), Dr Klara Paudel(Nepal), Prof. Hung-Chun Chen (Taiwan), Dr Javier deArteaga (Argentina), Dr Zulma Cruz (El Salvador), Prof.Saraladevi Naicker (South Africa), Dr K S Nayak (India),Dr Ricardo Correa-Rotter (Mexico), Prof. Philip K T Li (HongKong), Dr Wai-Kei Lo (Hong Kong), Dr Roberto Pecoits-Filho (Brazil), Ali Khaled Abu-Alfa MD, FASN (USA) andMr. Reto Miozzari (Switzerland).

CONFLICT OF INTEREST STATEMENT

None declared.

(See related article by Rosner. Cost of renal replacement therapy.Nephrol Dial Transplant 2013; 28: 2399–2401.)

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APPENDIX 1

The following questions were included in our mail survey:

(i) What is the average cost of PD therapy every year (fourexchanges of CAPD or APD per day)? (include onlybasic treatment costs, basic medication costs, and basiclab testing costs)

(ii) What is the average cost of HD therapy per year (156sessions)? (include only basic treatment costs, basicmedication costs and basic lab testing costs)

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http://www.kce.fgov.be/index_fr.aspx?SGREF=14844&CREF=14962








(iii) What is the average peritonitis rate?

(iv) What is the average number of hospitalizations perpatient year on PD?

(v) What is the average starting salary for a junior nephrol-ogist?

(vi) Which company is the main provider of CAPD bags?Any local manufacturing?

(vii) (vii) How many patients on PD, HD today?

(viii) What is the current reimbursement policy for HD andPD? Any future government policies or strategies to in-crease CAPD penetration?

(ix) Who performs catheter insertion surgery in mostcases?

(x) Which year was CAPD first introduced?

APPENDIX 2

In all 19 surveys (10 were completed) were sent out to ne-phrologists in China (1/1), South Korea (1/1), Taiwan (1/1),Bangladesh (2/2), Thailand (1/1), Nepal (1/1), Argentina (2/2), El Salvador (1/1), Colombia (0/2), Guatemala (0/1), Indo-nesia (0/1), Poland (0/1), Hungary (0/1), Russia (0/1), Portu-gal (0/1) and Slovenia (0/1) (number of completed surveys/number of surveys sent).

In our survey we asked the respondent to estimate theaverage PD and HD cost based on regular treatment, regular

medicine and regular lab test costs. (complications and non-medical economic implications were not considered in the cal-culations in order to avoid biased estimates).

Received for publication: 31.1.2013; Accepted in revised form: 15.4.2013

HD/PD ratios calculated from responses in completedmail surveys.

Source Country Year HD/PDratio

Prof. Xueqing Yu China 2013 1.10

Prof. YL Kim SouthKorea

2013 1.20

Dr. KBMHadiuzzaman

Bangladesh 2013 1.00

Prof. Harun-Ur-Rashid

Bangladesh 2013 1.00

Dr. D. Sirivongs Thailand 2013 1.20

Dr. Klara Paudel Nepal 2013 1.30

Prof. HC Chen Taiwan 2013 1.20

Dr. J. de Arteaga Argentina 2013 1.00

Prof. G. Rosa Diez Argentina 2013 1.00

Dr. Zulma Cruz El Salvador 2013 1.20

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original article cost of peritoneal dialysis and haemodialysis across

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