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4 Strategies to Reduce Costs in Publicly Funded Renal/Kidney Program

I spent 7 years (2011-2018) as medical director of the renal program in the Fraser Health Authority, BC, Canada.

I quickly learned that reducing healthcare expenses is key in order to keep up with patient care needs in the Canadian healthcare context.

Here are some strategies we explored to reduce costs while also improving patient care.

Unfortunately, I was not successful in executing all these strategies. The biggest challenge encountered was the siloing of healthcare budgets and struggles to collaborate across services & programs.

Eg. spending more on surgical services might reduce dialysis costs while spending more on dialysis staffing might reduce critical care's supply costs. Since these budgets are held by different individuals, there is often no incentive to collaborate.

    1. Growing home dialysis vs facility-based hemodialysis (HD)

    ~50% of patients have a preference for home dialysis over facility HD, yet <30% are on home dialysis.

    Mortality rates with peritoneal dialysis are similar in-centre hemodialysis, and PD may offer other advantages, such as improved quality of life, higher patient satisfaction, maintenance of independence, ability to travel and improved hemodynamic stability

    2003 data shows a cost differential of ~$39K per patient per year for PD over HD. Difference likely much larger now in absolute dollars.

    Chu et al. AJKD 2013, 61 (1): 104-11

    https://linkinghub.elsevier.com/retrieve/pii/S0272-6386(12)01019-0

    Canada has about 24K patients on dialysis (https://www.cihi.ca/en/trends-in-end-stage-kidney-disease-in-canada-2020-infographic)

    Growing home dialysis by just 3% (absolute), translates into savings of approximately $28 million/year; growing by 6% would yield $56 million in savings. Moreover, reducing HD growth avoids/delays capital investment in new HD facilities.

    For a program with 1000 patients on dialysis (such as FHA), 3% growth would yield $1.2 million in annual savings.

    2. Shortening surgical wait times for PD catheter insertion

    Surgical wait times will likely always exist, as the healthcare system trades dollars for surgical results. The budget is capped so we have capacity limits.

    However, some surgeries provides better results at LOWER total costs. Surgical PD catheter insertion is one example.

    If patients on HD are waiting for a surgical PD tube and they wait ~4 months for surgery, and we know that PD saves $39k per year, that surgical delay costs the system approximately $13k. By doing surgical PD tubes within 1-2 weeks of referral, we could save ~$12k per case.

    Imagine earning $12K for ones hospital for every surgery performed!

    Most patients waiting on HD for a PD tube have a CVC for their dialysis access. Those patients have much higher costs than those with an AVF, so the net savings are likely even larger.

    3. Transitioning critical care dialysis from CRRT to SLED

    For critically ill patients on dialysis, dialysis options include CRRT and SLED.

    Clinical outcomes are similar yet costs are strikingly lower for SLED. Why don't we see more programs switching from CRRT to SLED?

    References: https://journals.lww.com/ccejournal/fulltext/2021/05000/comparing_renal_replacement_therapy_modalities_i.3.aspx

    https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-015-0123-4

    https://linkinghub.elsevier.com/retrieve/pii/S0085-2538(15)52045-0

    4. Ensuring more patients on hemodialysis avoid a central line for dialysis

    When patients do hemodialysis, they can use a central venous catheter (CVC) or a surgically created blood access (either an arteriovenous fistula or graft).

    CVCs are associated with worse outcomes and the highest annual access-related costs, largely attributable to the high frequency of hospitalizations due to catheter-related bacteremia.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5698057/

    5. Utilizing Volunteers

    Utilizing volunteers can be an effective way to reduce costs. By recruiting volunteers to provide support services such as transportation, research assistance, and administrative tasks, the program can reduce its expenditure on labor and use the savings to focus on patient care. Additionally, volunteers can provide a valuable source of support and guidance for patients, which can improve outcomes and reduce costs in the long run.

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