Proceedings of the 3rd Asian Chapter Meeting of the ISPD November 22 24, 2007, Hiroshima, Japan Peritoneal Dialysis International, Vol. 28 (2008), Supplement 3 0896-8608/08 $3.00 +.00 Copyright 2008 International Society for Peritoneal Dialysis Printed in Canada. All rights reserved. THE STATUS OF, AND OBSTACLES TO, CONTINUOUS AMBULATORY PERITONEAL DIALYSIS IN THAILAND Kriang Tungsanga, Talerngsak Kanjanabuch, Nanta Mahatanan, Kearkiat Praditpornsilp, Yingyos Avihingsanon, and Somchai Eiam Ong Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand The prevalence of dialysis in Thailand is 282 per million population, and utilization of peritoneal dialysis (PD) is only 4.6% of the utilization of hemodialysis (HD). The causes of low PD utilization include a relatively higher cost of PD care, especially from the patient s perspective; less incentive for PD care on the part of health care providers and hospitals; fewer continuing medical and nursing education programs in PD; unavailability of certified PD nurses; lack of confidence in the quality of PD care; fewer offers of PD as a renal replacement therapy option during pre-dialysis counseling; fear of peritonitis on the part of the patient, and also fear of burdening family members; a less stringent government policy regarding the PD first strategy. To increase PD utilization. mandatory strategies are lower PD cost, make all PD equipment reimbursable, launch a stringent PD first policy, provide incentives to health care providers and hospitals, and improve the quality of PD care. Perit Dial Int 2008; 28(S3):S53 S58 www.pdiconnect.com KEY WORDS: Continuous ambulatory peritoneal dialysis; obstacles to PD utilization. The Nephrology Society of Thailand has been collect ing data for the Thailand Renal Replacement Therapy Registry annually for more than a decade. The Correspondence to: Kriang Tungsanga, Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok 10330 Thailand. fmedkts@md2.md.chula.ac.th latest survey (2006) shows an overall prevalence of end-stage renal disease (ESRD) of 303 per million population (pmp) and an incidence of 155 pmp (Praditpornsilp K, Chittinandana A, Supaporn T, Prasithsiriku W, Achavanuntakul B, Jirajan B, et al. Thailand Renal Replacement Therapy Registry Report 2007. Presented at the Nephrology Society of Thailand annual meeting, 4 August 2007, Petchburi). Maintenance hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation (KT) respectively accounted for 269, 13, and 21 cases pmp. The percentage utilization of PD was only 4.6% of the utilization of HD and has been consistently low throughout the last decade. The low percentage utilization of PD as compared with HD is similar to that in many other Asian countries (1 6), with the exception of Hong Kong, Korea, and Singapore which have had remarkable success with PD in Asia (7,8). DISCUSSION REASONS FOR LOW PD UTILIZATION IN THAILAND Several causal mechanisms may be contributing to the low percentage of PD utilization in Thailand (Table 1). Cost of Dialysis: The cost of dialysis, whether PD or HD, can be estimated from two perspectives. From the government s perspective, only direct costs (materials, machines, and staff service) and the costs of peritonitis care or hospitalization are estimated. Thus, it has been TABLE 1 Factors Contributing to Low Utilization of Peritoneal Dialysis (PD) in Thailand 1. Cost of PD 2. Health care provider s perspective 3. Patient s and society s perspectives 4. Government policy S53
PROCEEDINGS OF THE 3RD ASIAN CHAPTER MEETING OF THE ISPD JUNE 2008 VOL. 28, SUPPL 3 PDI falsely claimed for more than a decade that PD is more expensive than HD (9). Given that impression, policymakers in the area of health have diverted support more toward HD than PD. However, a patient or societal perspective, indirect costs (such as costs for travel or for opportunity loss) should also be considered in the equation. Teerawattananon et al. recently assessed the economic impact should the Royal Thai government support renal replacement therapy (RRT) nationwide (10). They compared the lifetime costs for PD and HD care in Thailand. From a government perspective, the cost of PD was slightly lower than that for HD (Figure 1). For example, for a patient 30 years of age, the lifetime cost was estimated at B6.8 million for PD and B7.0 million for HD (about US$205 000 and US$210 800 respectively). For a patient 70 years of age, the cost declined to B3.1 million and B3.2 million respectively (US$93 400 and US$96 400 respectively). That lifetime Figure 1 Lifetime cost for providing peritoneal dialysis (PD) and hemodialysis (HD) to Thai end-stage renal disease patients as initial treatment. Adapted with permission from (10). cost difference was quite marginal. However, from a societal perspective, when the costs of traveling and of opportunity loss for a companion during patient transfer were included, the lifetime cost of care for the 30-year-old ESRD patient became B7.3 million (US$220 000) for PD about B 0.9 million (US$27 100) or 13% less than the cost for HD. From a survey among nephrologists about strategies to increase utilization of continuous ambulatory PD (CAPD) in Thailand (Tungsanga K. Unpublished data), the most frequent suggestion from respondents (65%) was that the direct cost (for example, for PD fluid) should be lowered (Table 2). Fortunately, in January 2008, the Royal Thai government announced a PD first policy to launch support for RRT for Thai citizens. Hopefully, a tremendous leap in PD utilization will occur soon in Thailand. Problems Related to Dialysis Personnel (Health Care Provider Perspective): Four important personnel factors emerge as impediments to PD utilization: Incentives Continuing medical (and nursing) education (CME) and clinical skills Formal pre-rrt counseling Commitment to PD by nephrologists In Thailand, government hospitals are allowed to add a 10% 20% surcharge on the cost of medical supplies, but a negligible surcharge on other costs. For PD, this surcharge reaches approximately B1000 to B2000 (US$30 to US$60) per patient per month. The total HD cost, usually presented as a package fee per HD session, contributes about B4000 to B6000 (US$120 to US$180) per patient per month to hospitals. Notably, personnel salaries are not included in the foregoing total. Not only does the hospital gain from PD services seem to be less attractive than that from HD services, TABLE 2 Suggestions by Thai Nephrologists (n = 153) on Potential Strategies to Improve Utilization of Continuous Ambulatory Peritoneal Dialysis (CAPD) in Thailand A Survey Suggestion Mentioned by (n) (%) 1. Direct costs of CAPD (especially peritoneal dialysis fluid) should be lowered. 100 65 2. Professional fees for nephrologists and nurses should be enhanced (similar to HD service). 83 54 3. CAPD reimbursement scheme should be more cost-recovered 67 36 4. Stringent PD-first policy should be established. 55 36 5. Others. 30 20 HD = hemodialysis. S54
PDI JUNE 2008 VOL. 28, SUPPL 3 PROCEEDINGS OF THE 3RD ASIAN CHAPTER MEETING OF THE ISPD the professional fee for personnel providing the PD services is also less than that for personnel providing the HD services. Altogether, nephrologists and dialysis nurses might earn one tenth of the HD fee when delivering PD services (Table 3). The effect of higher HD reimbursement rate on hospitals and personnel has been quite substantial. Since the announcement by the Ministry of Finance in 1998 of a reimbursement policy for civil servants and their family members, and the follow-up announcement (in 1999) by the Social Security Office of the Ministry of Labor for corporate workers, for RRT taking place at private hospitals, centers providing HD have shown far more substantial growth than have those providing PD care: specifically, the HD:PD center growth ratio has been 8:1 (Figure 2). Similarly, trained PD nurses are fewer in number than HD nurses are. In a 2007 survey (Kanjanabuch T. Unpublished data), the nurses providing PD services nationwide, either fixed PD or rotating PD and HD, numbered merely 36 and 39 respectively, whereas the nurses providing HD care, either certified (that is, having more than 5 years of HD experience and passing standardized tests organized by the Nephrology Society of Thailand and the Renal Nurse Association of Thailand) or pre-certified, numbered 800 and 1100 respectively. Thus, the ratio of qualified dialysis nurses was 1:20 (PD:HD). More alarming was the finding that, the number of PD nurses in 13 teaching hospitals nationwide (who should be reliable trainers for future PD nurses), numbered only 15. When Thai nephrologists were asked about potential strategies to improve CAPD TABLE 3 Professional Fees Charged for Nephrologists and Dialysis Nurses at Government and Private Hospitals Dialysis Professional fee (US$/patient/month) type Nephrologists Dialysis nurses Government Private Government Private PD Free 9 15 Free NA HD a Free 120 180 Free, or 15 30 15 30 b per shift PD = peritoneal dialysis; HD = hemodialysis; NA = not applicable. a Professional fees for HD services are calculated per HD session, to a maximum of 48 sessions per month. However, the workload is always distributed among the personnel. In government hospitals, no professional fee is charged. b Certain government hospitals adopt a twilight service policy and add a professional fee surcharge similar to that in private hospitals. penetration in Thailand (Tungsanga K. Unpublished data), enhancement of professional fees was the second-most suggested approach (Table 2). Not only is the PD workforce short-staffed, but career development and CME for PD are currently less available than are opportunities and education related to HD (Table 4). In Thailand, a lack of board-certified nephrologists to take care of HD patients has led to the institution in medical schools of a 4-month training course on HD care for board-certified physicians in internal medicine. Although the latter course has existed for a decade, a similar program for PD training has never been established. Figure 2 Cumulative number of, and annual growth in, the number of continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) centers in Thailand (1974 2007). All PD centers also provide HD service. Most PD centers are government hospitals. The Ministry of Finance (govt.) announced reimbursement policies on renal replacement therapy for civil servants and their family members in 1998, and the Social Security Office (SSO), Ministry of Labor, did so for corporate workers in 1999. Reproduced with permission from Praditpornsilp K, Chittinandana A, Supaporn T, Prasithsiriku W, Achavanuntakul B, Jirajan B, et al. Thailand Renal Replacement Therapy Registry Report 2007. Presented at the Nephrology Society of Thailand annual meeting, 4 August 2007, Petchburi. S55
PROCEEDINGS OF THE 3RD ASIAN CHAPTER MEETING OF THE ISPD JUNE 2008 VOL. 28, SUPPL 3 PDI TABLE 4 Career Development and Continuing Medical Education (CME) on Dialysis Profession and activity PD HD Physicians (board-certified in internal medicine) 2-Year fellowship program 4-Month intensive course NA Registered nurses Certification by NST and RNAT NA (800) 4-Month intensive course in dialysis Training institutes (n) 1 13 Courses during the last 10 years (n) 3 >50 Attendees (n) 24 >1000 CME or workshop (2-day meeting) for physicians and nurses Courses (n) 1/year 1 2/year Attendees (n, all courses combined) 1500 5000 PD = peritoneal dialysis; HD = hemodialysis; NA = not available; NST = Nephrology Society of Thailand; RNAT = Renal Nurse Association of Thailand. A similar situation is seen in nurse training. Until now, no PD nurses have been officially certified by the Nephrology Society of Thailand and the Renal Nurse Association of Thailand; yet about 800 nurses have been certified in HD service. Although many short (1- to 2- week) PD training courses had been established, and the number of PD patients has been increasing over the years, the rate of PD growth is still relatively slow as compared with HD (Figure 2). To date, just three 4- month intensive courses, accommodating 8 nurses each, have been organized in a single hospital; more than fifty 4-month courses on HD have been organized in 13 medical institutes, covering more than 1000 HD nurses over a period of 10 years. A short 2-day CME meeting has accommodated about 1500 cumulative attendees learning about PD, as compared with 5000 attendees on learning about HD since the late 1990s. Although the total number of attendees at the PD course has been quite substantial, the content and duration of the meetings has not been sufficient to produce reliable and skillful PD nurses. The overall situation has led to a self-limiting cycle: Hospital and personnel incentives for PD are limited, leading to limited support from hospitals and limitations in the government reimbursement policy. With fewer PD units in operation, fewer personnel are trained or have the opportunity to increase their competence, and therefore fewer CME refresher courses are held. Inadequate PD skills from a lack of ongoing training mean that a high rate of PD complications (that is, peritonitis) eventually prevails. Thereafter, staff and patient confidence in PD treatment decline, leading to a drop in the popularity of PD. A recent survey of nephrologists (Tungsanga K. Unpublished data) that asked about reasons given by patients who did not choose PD as their mode of RRT indicated that nearly half of all patients (47%) mentioned lack of confidence in the maintenance of proper PD care, and more than one quarter (29%) mentioned the lack of experienced personnel (Table 5). Generally, the patient s decision depends not only on information received from caring doctors, but also on knowledgeable persuasion. In the United States, studies indicate that 70% 75% of maintenance HD patients were not offered PD as an RRT option (11,12). Moreover, the rate of PD utilization significantly correlated with presentation of PD as a treatment option during pre-rrt counseling (13). When Thai nephrologists (n = 130) were asked about their practice of pre-dialysis counseling (Tungsanga K. Unpublished data), about 35% of those who worked at government hospitals said that they delivered most of the counseling themselves, and 65% said that other personnel also delivered it (Table 6). In contrast, 83% of nephrologists in private hospitals said that they delivered the counseling themselves, and fewer than 20% delivered joint counseling with other personnel. Given that knowledge, skills, and financial gain favor HD, it is conceivable that Thai ESRD patients receiving care at private hospitals have been under-informed about PD option by physicians and renal nurses. Thus, their decisions seem to trend more toward HD than toward PD. A further survey of patients concerning their opinion and perception of PD as an RRT option is needed. Commitment to PD by nephrologists is also crucial to PD utilization. Commitment reflects their willingness and S56
PDI JUNE 2008 VOL. 28, SUPPL 3 PROCEEDINGS OF THE 3RD ASIAN CHAPTER MEETING OF THE ISPD TABLE 5 Reasons Given by Patients to Thai Nephrologists (n = 153) for Not Choosing Peritoneal Dialysis(PD) as the Initial Mode of Renal Replacement Therapy A Survey Reason (n) (%) 1. Fear of PD-associated peritonitis 101 66 2. Fear of creating a future burden to family members 98 64 3. Medical contraindications 78 51 4. Lack of confidence in ability to maintain proper PD self-care 72 47 5. Financial constraints (inability to receive full reimbursement, for example) 54 35 6. Previous PD complications (peritonitis, for example) 49 32 7. Lack of personnel experienced in PD 44 29 8. Others 15 10 TABLE 6 Pre Renal Replacement Therapy (RRT) Counseling Methods Used by Thai nephrologists A Survey Method of pre-rrt counseling a determination to pursue PD as a RRT option. In the survey discussed earlier, 57% of Thai nephrologists said that they would prefer PD as a personal choice if they themselves developed ESRD and needed RRT. About 85% said that they had confidence in their own centers to deliver PD services. However, when asked about the reasons why PD was underutilized at their hospitals, Thai nephrologists mentioned lack of qualified personnel (40%) and inadequate experience in PD (30%). Those reasons contradict the confidence earlier expressed, reflecting inconsistency in commitment to PD. Patient and Societal Perspectives: Patient and societal perspectives on PD are complex, and many of the factors are non-medical. The impression of the complications of PD that is, peritonitis and the agonizing abdominal pain and fever that can result are quite scary and threatening to patients. The Asian view of social values, which emphasizes the virtue of group or family interest above individual interest, can sometimes make patients feel uneasy about PD care. They do not want to burden their family. Lastly, Thai ESRD patients tend to be more comfortable in letting health personnel and high-tech machines cure disease in hospital than in handling fluid bags themselves at home. When Thai nephrologists (n = Nephrologists (n=153) working at Government hospitals Private hospitals (n) (%) (n) (%) Mostly done by nephrologists themselves 42 35 91 83 Also done by non physician personnel 78 65 19 17 a Defined as at least one meeting before commencement of RRT. Patients must be informed about modes of RRT, either peritoneal dialysis, hemodialysis, or both. 153) were asked about reasons given by patients who did not choose PD as their mode of RRT, the 4 of the 5 most frequent reasons given were non medical in nature (Table 5), specifically: Fear of peritonitis (66%) Fear of creating a future burden on family members (64%) Lack of confidence in the ability to maintain proper PD care (47%) Financial constraints, that is, the inability to receive full reimbursement of PD costs (35%). Clearly, had these non medical factors been corrected, PD utilization would have been higher. Government Policy: Government policy also impedes PD utilization. Because of a previously high peritonitis rate with the older single-bag system [about 1 episode in every 18 patient months (13)], the Royal Thai government felt reluctant to fully support PD. No stringent PD first policy was declared. Reimbursement of PD costs for civil servants was not as complete as it was for HD. No reimbursement was provided for the PD catheter, connecting tube, and advanced but efficient medical supplies such as the double-bag system and automated PD machines. More S57
PROCEEDINGS OF THE 3RD ASIAN CHAPTER MEETING OF THE ISPD JUNE 2008 VOL. 28, SUPPL 3 PDI importantly, the incentive to health personnel delivering PD was not set as high as it was for personnel delivering HD. Fortunately, in January 2008, the Royal Thai government announced a PD first policy as a pilot project to support this form of RRT in certain parts of the nation. The expectation is that PD will have good prospects soon in Thailand. CONCLUSIONS With the rising demand for RRT, PD penetration in Thailand (Table 7) needs to improve. The proposals that follow (7,14) should help to make that change: The cost of PD must be lowered. One method would be to facilitate local production of high-quality PD fluid. The double-bag or Y-connect system and other advanced dialysis tools that help to minimize peritonitis should be fully reimbursable. The PD first policy should be strongly endorsed and implemented. Incentives could be provided to health care personnel and hospitals, quality improvements in aseptic PD care could be enhanced, and high-quality PD training and CME courses could be expanded. And last, but not least, confidence and faith inpd could be strengthened with a cautious and proper approach that emphasizes a high quality of care rather than simply a larger number of PD cases or a high PD growth rate. To meet this goal, strictly TABLE 7 Strategies Proposed to Improve Peritoneal Dialysis (PD) Utilization in Thailand 1. Facilitate production of high-quality PD fluid. 2. Provide full reimbursement for double-bag systems and other advanced and efficient dialysis tools. 3. Begin a PD first policy. (announced in January 2008 by the royal Thai government) 4. Facilitate PD utilization: Provide incentives to health care providers and hospitals. Continuously improve the quality of aseptic PD care. Encourage PD nurse training and continuing medical education courses. 5. Build up confidence in PD: Encourage strictly aseptic protocols. Use the double-bag system. Use the fixed PD nurse system. aseptic protocol, the double-bag system,and a fixed PD nursing system will have to be integrated into nationwide PD care in the future. REFERENCES 1. Cheng IK. Peritoneal dialysis in Asia. Perit Dial Int 1996; 16(Suppl 1):S381 5. 2. Zhao LJ, Wang T. Attitudes of Chinese chief nephrologists toward dialysis modality selection. Adv Perit Dial 2003; 19:155 8. 3. Kawaguchi Y. Status of peritoneal dialysis in Japan. Perit Dial Int 2006; 26:133 5. 4. Blake PG. Peritoneal dialysis in Asia: an external perspective. Perit Dial Int 2002; 22:258 64. 5. United States Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Division of Kidney, Urologic, and Hematologic Diseases. USRDS 2007 annual data report. Atlas of end-stage renal disease in the United States. Bethesda: United States Renal Data System; 2007. 6. Lo WK. Peritoneal dialysis utilization and outcome: what are we facing? Perit Dial Int 2007; 27(Suppl 2):S42 7. 7. Lo WK. What factors contribute to differences in the practice of peritoneal dialysis between Asian countries and the West? Perit Dial Int 2002; 22:249 57. 8. Yu AWY, Chau KF, Ho YW, Li PKT. Development of the peritoneal dialysis first model in Hong Kong. Perit Dial Int 2007; 27(Suppl 2):S53 5. 9. Tangcharoensathien V, Kasemsup V, Mukem S. Lowincome citizens and their access to renal replacement therapy in Thailand (Thai). J Nephrol Soc Thailand 2000; 6:72 80. 10. Teerawattananon Y, Mugford M, Tangcharoensathien V. Economic evaluation of palliative management versus peritoneal or hemodialysis for end-stage renal disease: evidence for coverage decisions in Thailand. Value Health 2007;10:61 72. 11. United States Renal Data System (USRDS). The USRDS Dialysis Morbidity and Mortality Study: Wave 2. Am J Kidney Dis 1997; 30(Suppl 1):S67 85. 12. Mehrotra R, Marsh D, Vonesh E, Peters V, Nissenson A. Patient education and access of ESRD patients to renal replacement therapies beyond in-center hemodialysis. Kidney Int 2005; 68:378 90. 13. Sirivongs D, Wittayajunyapong S, Seetaso K, Homnan N. Catheter-related infection in CAPD patients (Thai). J Nephrol Soc Thailand 2003; 9:251 5. 14. Li PK, Lui SL, Leung CB, Yu AW, Lee E, Just PM, et al. on behalf of the participants of the Roundtable Discussion on Dialysis Economics in Asia. Increased utilization of peritoneal dialysis to cope with mounting demand for renal replacement therapy perspectives from Asian countries. Perit Dial Int 2007; 27(Suppl 2):S59 61. S58