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Dialysis
notably PD, and probably also delays access to transplantation. In some PD patient population. Of note is that, in the 1980s, UK patients were
units in Belgium, many patients progressing towards ESRD are offered a more or less ‘forced’ into PD because the more expensive HD modality
structured pre-dialysis education programme (PDEP). The goals of such a was rarely available.
programme, based on both individualised information sessions given to
the patient and family by an experienced nurse, sometimes together with Since 2002, a new payment contract has been introduced in Germany
a psychologist and social worker, are to inform on all modalities of RRT that is more favourable for PD; one would thus expect a rapid increase in
in order to decrease anxiety and promote self-care RRT modalities. A high the PD population, but this could not be observed during the past three
percentage of patients exposed to such a structured PDEP start with a years. The reasons for this (so far) neutral impact on PD utilisation are
self-care RRT modality, including PD.
28
probably the still high number of HD units available, the unfamiliarity of
German nephrologists with PD and the lack of training of young fellows
As explained in our previous paper,
1
we believe that financial and in PD in academic institutions.
reimbursement issues are the most important non-medical determinants
of the choice of dialysis modalities in any given country. These issues are In central and eastern European countries, dramatic changes in the
partly related to the differences in healthcare structures in Europe and availability of RRT have occurred after their political and economic
their impact on reimbursement of dialysis. independence from the former Soviet Union. Many of these countries
have joined the EU and it may be hoped that their registries will become
part of the comprehensive European Renal Association–European Dialysis
and Transplant Association (ERA-EDTA) registry. The prevalence of PD in
In some countries, the prevalence of
these countries has been discussed before.
1
Recently, new data from
peritoneal dialysis has risen during the
Croatia and the Czech Republic have been published.
last few years; in other non-European
As of 31 December 2000, there were 76 patients on PD in Croatia, the
countries, a decline in its utilisation has prevalence of PD was 17 per million population (pmp) and
been observed.
the proportion of patients on PD was 2.7%.
33
By the end of 2004, the
number of patients on PD increased to 251, the proportion on PD was
7.0% and the prevalence of PD-treated patients was 57pmp. Between
2000 and 2004, 377 patients started PD. Total health expenditure per
Utilisation of Peritoneal Dialysis in capita in 2003 in Croatia was US$494. Reimbursement for RRT is
European Countries – Recent Data provided by the state insurance system (Croatian Institute for Health
As explained in detail in our previous paper,
1
major differences in PD Insurance [HZZO]). There are no restrictions on commencing RRT.
utilisation between countries, and even between regions in a given Costs of HD are US$26,000/patient/year and estimated expenses of
country, exist in Europe. We argued that most of these differences could CAPD are US$17,000/patient/year. Reimbursement for PD covers only
be explained by non-medical factors such as reimbursement issues, consumables and outpatient visits. Medical professionals are
organisation of the public healthcare systems in different countries and remunerated by a salaried system. A fee-for-service payment system is
lack of attention to PD in the training curricula in many academic centres. used for HD, as reimbursement is profitable for facilities, and the
In France, patients can be assisted in performing their PD exchanges at global trend toward privatisation is in action. At the end of 2004, 10%
home by a nurse working in the private system. This possibility allows of HD patients were treated in two private units and since then the
French nephrologists to treat elderly patients or those with poor social number of private dialysis centres has been increasing. Nephrologists
support, performing home dialysis therapy with PD.
29
Despite this are not motivated by remuneration to select any of the dialytic
advantageous system, PD is underused in France compared with other methods. Organising and running a PD facility is not encouraged by
countries. In 2003, 8.9% of prevalent ESRD patients were treated with the healthcare administration agencies.
PD,
30
but 44.6% of the 11,557 patients who started PD over the past
decade were on assisted PD (unpublished data extracted from the French In the Czech Republic, modern PD using state-of-the-art equipment
Registry of Peritoneal Dialysis [RDPLF]).
31
The paradox of low PD could be performed only after 1991, when it became available in three
penetration in France in the presence of an assisted PD programme can centres. To date, 59 centres have been set up. The prevalence of PD in
be explained by the French healthcare system. This system, which also the Czech Republic is currently 7.5%. However, the total number of PD
has many positive characteristics, has been instrumental in helping to set patients is rising at a much slower pace compared with the number of
up an important network of outpatient HD units throughout the country. centres.
34
A host of medical and non-medical factors affecting PD
In addition, it has recently facilitated an increase in the number of utilisation in the Czech Republic have been identified. One limitation of
inpatient HD machines. Thus, access to HD has become easier and the widespread acceptance of PD as a self-care method of dialysis may
unrestricted. Paradoxically, despite the possibility of access to home- have been the absence of patient involvement in making decisions about
based assisted PD, no real financial incentive exists for prescribing PD.
32
their health or the care they receive. There is little doubt that
reimbursement for PD covered virtually only material costs until 1996,
In contrast, the decline in PD in the UK can be easily explained by a but reimbursement has increased since 1997, making PD procedures a
substantial increase in low care satellite haemodialysis centres (from 842 slightly profitable business. This is reflected in an increase in PD
in 1998 to 1,431 in 2002) and, to a lesser extent, by an increase in penetration in private and (partially) in state-run PD centres while, in
hospital haemodialysis facilities (from 1,376 dialysis posts in 1998 to contrast, PD penetration in academic centres has not changed
1,621 in 2002). This, of course, has had a negative impact on the total appreciably over the last few years.
60 EUROPEAN RENAL DISEASE 2007