Economic studies of chronic kidney disease
Approximately 9% of the global population has chronic kidney disease (CKD). Patients with end-stage renal disease (ESRD), the most advanced form of CKD, comprise 0.15% of the global population but consume 2-4% healthcare budgets. While the impact of CKD and ESRD are experienced most immediately by people with these diseases, the impact extends beyond them to include the healthcare system and wider society in terms of, for example, the costs and legal framework that are required to ensure good governance around organ donation. These impacts vary between countries, depending, inter alia, on access to resources and societal attitudes. It is important to investigate and compare impacts across contexts in order to improve our understanding. This PhD examined distinct aspects of these impacts across contexts using a variety of analytic approaches. Chapter 2 examined the relationship between health-related quality of life (HRQoL) and CKD severity, and the consequent economic impact due to reduced HRQoL among a representative sample of community dwelling adults in the United Kingdom. The evident decline in HRQoL among people even with milder stages of CKD underscored the importance of primary prevention, early diagnosis and secondary prevention in reducing the impact of CKD. As ESRD is expensive and access to renal replacement therapies (RRTs) is limited in many circumstances, there is considerable potential for disparities to occur in relation to the management of ESRD. Chapter 3 examined disparities among ESRD inpatients taking into account changes in the policy context in the United States of America. Significant racial disparities regarding recorded anaemia, a modifiable and common complication of CKD, were observed. Not only did Native Americans as a group experience the worst outcomes but their relative position declined after changes to policy. Chapter 3 underlined unintended consequences of policy changes that may have been preventable. Complementing global efforts to address organ shortage, Chapter 4 examined attitudes (conceptualised in terms of passive support) and behaviours (conceptualised in terms of active support) related to tissue donation after death among citizens from 27 European countries. Here, a mismatch and unobserved heterogeneity between passive and active support for tissue donation, was observed which underscored the importance of examining both types of support together in order to attain a more complete understanding about attitudes and how, potentially, they shape behaviours. Chapter 4 found the potential of incorporating both selfless and selfish motivations to translate latent passive into active support for donation. Finally, despite the evident medical benefits of living donor kidney transplantation (LDKT), there is limited information about the economic impact of LDKT in the UK. The final chapter reviewed the evolution of the LDKT program in Northern Ireland, which currently leads the world in terms of living donor rate, and considered the implications of the program’s evolution for future cost-effectiveness studies. Using the linked data provided by the Belfast Health and Social Care (HSC) Trust and the Northern Ireland HSC Business Service Organization, Chapter 5 demonstrated the superiority of LDKT over deceased donor kidney transplantations in terms of survival outcomes. Furthermore, it demonstrated how this superiority persisted, despite the increasing complexity of case mix over time. The chapter concluded by presenting a road map for a subsequent full economic evaluation of the LDKT program. In summary, the PhD thesis identified a number of economic aspects of CKD and ESRD including economic impact, equity in care, potential approaches to address the organ shortage crisis and the implication of program evolution for cost-effectiveness analyses.
chronic kidney disease, end-stage renal disease, health economics, living donor kidney transplantation, health-related quality of life, policy impact, support for donation
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