Apel Christian, Hornig Carsten, Maddux Frank W, Ketchersid Terry, Yeung Julianna, Guinsburg Adrian
Health Economics and Market Access EMEA, Fresenius Medical Care, Bad Homburg, Germany.
Global Medical Office, Fresenius Medical Care, Waltham, MA, USA.
Clin Kidney J. 2021 Dec 27;14(Suppl 4):i98-i113. doi: 10.1093/ckj/sfab193. eCollection 2021 Dec.
As the prevalence of chronic kidney disease is expected to rise worldwide over the next decades, provision of renal replacement therapy (RRT), will further challenge budgets of all healthcare systems. Most patients today requiring RRT are treated with haemodialysis (HD) therapy and are elderly. This article demonstrates the interdependence of clinical and sustainability criteria that need to be considered to prepare for the future challenges of delivering dialysis to all patients in need. Newer, more sustainable models of high-value care need to be devised, whereby delivery of dialysis is based on value-based healthcare (VBHC) principles, i.e. improving patient outcomes while restricting costs. Essentially, this entails maximizing patient outcomes per amount of money spent or available. To bring such a meaningful change, revised strategies having the involvement of multiple stakeholders (i.e. patients, providers, payers and policymakers) need to be adopted. Although each stakeholder has a vested interest in the value agenda often with conflicting expectations and motivations (or motives) between each other, progress is only achieved if the multiple blocs of the delivery system are advanced as mutually reinforcing entities. Clinical considerations of delivery of dialysis need to be based on the entire patient disease pathway and evidence-based medicine, while the non-clinical sustainability criteria entail, in addition to economics, the societal and ecological implications of HD therapy. We discuss how selection of appropriate modes and features of delivery of HD (e.g. treatment modalities and schedules, selection of consumables, product life cycle assessment) could positively impact decision-making towards value-based renal care. Although the delivery of HD therapy is multifactorial and complex, applying cost-effectiveness analyses for the different HD modalities (conventional in-centre and home HD) can support in guiding payability (balance between clinical value and costs) for health systems. For a resource intensive therapy like HD, concerted and fully integrated care strategies need to be urgently implemented to cope with the global demand and burden of HD therapy.
预计在未来几十年里，慢性肾脏病在全球的患病率将会上升，提供肾脏替代治疗（RRT）将给所有医疗保健系统的预算带来更大挑战。如今，大多数需要RRT的患者接受血液透析（HD）治疗，且患者多为老年人。本文阐述了临床标准与可持续性标准之间的相互依存关系，在为未来向所有有需要的患者提供透析治疗的挑战做准备时，需要考虑这些标准。需要设计更新颖、更具可持续性的高价值护理模式，即基于价值医疗（VBHC）原则进行透析治疗，也就是在控制成本的同时改善患者预后。从本质上讲，这需要在所花费或可获得的资金量上实现患者预后最大化。为实现这一有意义的变革，需要采用涉及多个利益相关者（即患者、提供者、付款人和政策制定者）的修订策略。尽管每个利益相关者在价值议程中都有既得利益，且彼此之间的期望和动机（或目的）往往相互冲突，但只有将透析治疗系统的多个部分作为相互促进的实体来推进，才能取得进展。透析治疗的临床考量需要基于患者的整个疾病过程和循证医学，而非临床的可持续性标准除了经济因素外，还包括HD治疗的社会和生态影响。我们讨论了如何选择HD治疗的合适模式和特点（如治疗方式和时间表、耗材选择、产品生命周期评估），这可能会对基于价值的肾脏护理决策产生积极影响。尽管HD治疗的实施是多因素且复杂的，但对不同HD模式（传统的中心血液透析和家庭血液透析）进行成本效益分析，有助于指导卫生系统的支付能力（临床价值与成本之间的平衡）。对于像HD这样资源密集型的治疗，迫切需要实施协调一致且全面整合的护理策略，以应对全球对HD治疗的需求和负担。
