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Study compares dialysis reimbursement around the globe

December 13, 2018

  • Dialysis reimbursement policies in most countries are focused on conventional in-center hemodialysis, although home hemodialysis and peritoneal dialysis might contribute to quality of life and cost savings.
  • The reimbursement for dialysis in low- and middle-income countries is insufficient to treat all patients with kidney failure and has a disproportionately high impact on public health expenditure in those countries.
Washington, DC (December 13, 2018) -- A new study has examined how countries around the world compare in providing reimbursement for dialysis care received by patients with kidney failure. The findings, which appear in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN), may help government officials make dialysis reimbursement more equitable and sustainable.

Worldwide, increasing numbers of patients are developing kidney failure and need to undergo kidney transplantation or dialysis. Transplantation is usually the best option, but most patients are treated with dialysis due to deficiencies in infrastructure, a scarcity of donor organs, and contraindications to transplantation. Some assessments of average dialysis costs have been published, but no comprehensive worldwide comparison of national government reimbursement for dialysis care has been done using data collected at a particular moment in time to provide a snapshot view

To perform such a comparison, Arjan van der Tol, MD, PhD, Raymond Vanholder, MD, PhD (University Hospital Ghent, in Belgium), and their colleagues surveyed nephrologists in 90 countries (one per country). The online survey evaluated government reimbursement fees for hemodialysis and peritoneal dialysis, criteria that are used to reimburse dialysis, incentives for self-care dialysis, measures to prevent the development or progression of CKD, and the prevalence of dialysis per country.

Among the study's findings:
  • Of the 90 survey respondents, governments from 81 countries (90%) provided reimbursement for maintenance dialysis.
  • In all countries, strategies to decrease the financial burden of kidney failure--such as programs to help prevent the progression of chronic kidney disease or promote more cost-saving dialysis modalities (home hemodialysis of peritoneal dialysis)--were underutilized.
  • The higher the Gross Domestic Product per capita, the greater the absolute expenditure for dialysis by national governments.
  • High income countries spent higher absolute amounts on dialysis reimbursement, but the percent of total health care budget spent on dialysis was lower than in low and middle income countries.
  • In low income countries, the absolute amounts of dialysis reimbursement were insufficient to provide equitable and sustainable access to dialysis care for all patients in need.
"Worldwide, we need better initiatives to improve care of patients with kidney failure with a focus on improving access to transplantation, increasing provision of prevention strategies to reduce the need of kidney replacement therapy, implementing cheaper ways to provide dialysis services to patients in need, and improving the quality of supportive renal care for end-stage kidney disease that does not involve dialysis," said Dr. van der Tol.

In an accompanying editorial, Edwina Brown, DM, FRCP (Hammersmith Hospital, London) noted that curtailing costs of dialysis is essential to enable dialysis provision to grow, but that "the environmental tapestry influencing dialysis modality distribution is much more complex than simply government policy or reimbursement."
Study co-authors include Norbert Lameire MD, PhD, Rachael Morton MScMed, PhD, Wim Van Biesen MD, PhD, and Raymond Vanholder, MD, PhD.


RM: funding by the Australian NHMRC Fellowship #1150989. Speaker's honorarium from Baxter Healthcare and Amgen Australia in the last 3 years (but not related to this study).

WVB: Speaker fees and travel grants from Fresenius Medical Care and Gambro/Baxter (but not related to this study).

RV: Travel costs: Nikisho; travel costs and speaker's honorarium: BBraun; advisor: Astra-Zeneca (but not related to this study).

The article, entitled "An International Analysis of Dialysis Services Reimbursement," will appear online at on December 13, 2018, doi: 10.2215/CJN.08150718.

The editorial, entitled "Influence of Reimbursement Policies on Dialysis Modality Distribution Around the World," will appear online at on **, 2018.

The content of this article does not reflect the views or opinions of The American Society of Nephrology (ASN). Responsibility for the information and views expressed therein lies entirely with the author(s). ASN does not offer medical advice. All content in ASN publications is for informational purposes only, and is not intended to cover all possible uses, directions, precautions, drug interactions, or adverse effects. This content should not be used during a medical emergency or for the diagnosis or treatment of any medical condition. Please consult your doctor or other qualified health care provider if you have any questions about a medical condition, or before taking any drug, changing your diet or commencing or discontinuing any course of treatment. Do not ignore or delay obtaining professional medical advice because of information accessed through ASN. Call 911 or your doctor for all medical emergencies.

Since 1966, ASN has been leading the fight to prevent, treat, and cure kidney diseases throughout the world by educating health professionals and scientists, advancing research and innovation, communicating new knowledge, and advocating for the highest quality care for patients. ASN has more than 20,000 members representing 131 countries. For more information, please visit or contact the society at 202-640-4660.

American Society of Nephrology

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