Cost utility analysis of end stage renal disease treatment in Ministry of Health dialysis centres, Malaysia: Hemodialysis versus continuous ambulatory peritoneal dialysis

Autoři: Naren Kumar Surendra aff001;  Mohd Rizal Abdul Manaf aff001;  Lai Seong Hooi aff002;  Sunita Bavanandan aff003;  Fariz Safhan Mohamad Nor aff004;  Shahnaz Shah Firdaus Khan aff005;  Ong Loke Meng aff006;  Abdul Halim Abdul Gafor aff007
Působiště autorů: Department of Community Health, Faculty of Medicine, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia aff001;  Sultanah Aminah Hospital, Ministry of Health, Johor Bahru, Johor, Malaysia aff002;  Kuala Lumpur Hospital, Ministry of Health, Kuala Lumpur, Malaysia aff003;  Tengku Ampuan Afzan Hospital, Ministry of Health, Kuantan, Pahang, Malaysia aff004;  Tengku Ampuan Rahimah Hospital, Ministry of Health, Klang, Selangor, Malaysia aff005;  Pulau Pinang Hospital, Ministry of Health, Penang, Malaysia aff006;  Nephrology Unit, Faculty of Medicine, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia aff007
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0218422



In Malaysia, there is exponential growth of patients on dialysis. Dialysis treatment consumes a considerable portion of healthcare expenditure. Comparative assessment of their cost effectiveness can assist in providing a rational basis for preference of dialysis modalities.


A cost utility study of hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) was conducted from a Ministry of Health (MOH) perspective. A Markov model was also developed to investigate the cost effectiveness of increasing uptake of incident CAPD to 55% and 60% versus current practice of 40% CAPD in a five-year temporal horizon. A scenario with 30% CAPD was also measured. The costs and utilities were sourced from published data which were collected as part of this study. The transitional probabilities and survival estimates were obtained from the Malaysia Dialysis and Transplant Registry (MDTR). The outcome measures were cost per life year (LY), cost per quality adjusted LY (QALY) and incremental cost effectiveness ratio (ICER) for the Markov model. Sensitivity analyses were performed.


LYs saved for HD was 4.15 years and 3.70 years for CAPD. QALYs saved for HD was 3.544 years and 3.348 for CAPD. Cost per LY saved was RM39,791 for HD and RM37,576 for CAPD. The cost per QALY gained was RM46,595 for HD and RM41,527 for CAPD. The Markov model showed commencement of CAPD in 50% of ESRD patients as initial dialysis modality was very cost-effective versus current practice of 40% within MOH. Reduction in CAPD use was associated with higher costs and a small devaluation in QALYs.


These findings suggest provision of both modalities is fiscally feasible; increasing CAPD as initial dialysis modality would be more cost-effective.

Klíčová slova:

Cost-effectiveness analysis – Economic analysis – Chronic kidney disease – Malaysia – Markov models – Medical dialysis – Renal transplantation – Simulation and modeling


1. Rizal AM, Surendra NK, Abdul Gafor AH, Seong Hooi L, Bavanandan S. Dialysis provision and implications of health economics on peritoneal dialysis utilization: a review from a Malaysian perspective. Int J Nephrol. 2017;2017:5819629. doi: 10.1155/2017/5819629 29225970

2. Just PM, de Charro FT, Tschosik EA, Noe LL, Bhattacharyya SK, Riella MC. Reimbursement and economic factors influencing dialysis modality choice around the world. Nephrol Dial Transplant. 2008;23(7):2365–2373. doi: 10.1093/ndt/gfm939 18234844

3. Lameire N, Peeters P, Vanholder R, Van Biesen W. Peritoneal dialysis in Europe: an analysis of its rise and fall. Blood Purif. 2006;24(1):107–114. doi: 10.1159/000089446 16361850

4. Wauters JP, Uehlinger D. Non-medical factors influencing peritoneal dialysisutilization: the Swiss experience. Nephrol Dial Transplant. 2004;19(6):1363–1367. doi: 10.1093/ndt/gfh090 14993480

5. Arogundade FA, Ishola DA Jr, Sanusi AA, Akinsola A. An analysis of the effectiveness and benefits of peritoneal dialysis and hemodialsis using Nigerian made PD fluids. Afr J Med Sci. 2005;34(3):227–233.

6. Teerawattananon Y, Mugford M, Tangcharoensathien V. Economic evaluation of palliative management versus peritoneal dialysis and hemodialysis for end-stage renal disease: evidence for coverage decisions in Thailand. Value Health. 2007;10(1):61–72. doi: 10.1111/j.1524-4733.2006.00145.x 17261117

7. Liu FX, Quock TP, Burkart J, Noe LL, Inglese G. Economic evaluations of peritoneal dialysis and hemodialysis: 2004–2012. F1000 Research. 2013;2(273):1–13,

8. Karopadi AN, Mason G, Rettore E, Ronco C. Cost of peritoneal dialysis and hemodialsis across the world. Nephrol Dial Transplant. 2013;28(10): 2553–2569. doi: 10.1093/ndt/gft214 23737482

9. Grapsa E. Is the underutilization of peritoneal dialysis in relation to hemodialysis, as renal replacement therapy, justifiable worldwide? Yes or No. Hippokratia. 2011;15(1): 13–15.

10. Lim TO, Goh A, Lim YN, Mohamad Zaher ZM, Suleiman AB. How public and private reforms dramatically improved access to dialysis therapy in Malaysia. Health Aff (Millwood). 2010;29(12):2214–2222.

11. Wong HS, Goh BL (eds) 24th Report of the Malaysian Dialysis and Transplant Registry 2016, Kuala Lumpur 2018,

12. Levey AS, Atkins R, Coresh J, Cohen EP, Collins AJ, Eckardt KU, et al. Chronic kidney disease as a global public health problem: approaches and initiatives—a position statement from Kidney Disease Improving Global Outcomes. Kidney Int. 2007;72(3):247–259. doi: 10.1038/ 17568785

13. Bujang MA, Adnan TH, Hashim NH, Mohan K, Kim Liong A, Ahmad G, et al. Forecasting the incidence and prevalence of patients with end-stage renal disease in Malaysia up to the Year 2040. Int J Nephrol. 2017;2017:2735296. doi: 10.1155/2017/2735296 28348890

14. Surendra NK, Rizal AM, Hooi LS, Bavanandan S, Mohamad Nor FS, Shah Firdaus Khan S, Ong LM, et al. The cost of dialysis in Malaysia: hemodialysis and continuous ambulatory peritoneal dialysis. Malaysian Journal of Public Health Medicine 2018;18(Suppl 2): 70–81.

15. Surendra NK, Rizal AM, Hooi LS, Bavanandan S, Mohamad Nor FS, Shah Firdaus Khan S, Ong LM, et al. Health related quality of life of dialysis patients in Malaysia: Hemodialysis versus continuous ambulatory peritoneal dialysis. BMC Nephrol. 2019; 30;20(1):151. doi: 10.1186/s12882-019-1326-x 31039745

16. Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ, Stoddart GL. Methods for the Economic Evaluation of Health Care Programmes (4rd ed). Oxford. New York: Oxford University Press: 2015.

17. Villa G, Fernández-Ortiz L, Cuervo J, Rebollo P, Selgas R, González T et al. Cost-effectiveness analysis of the Spanish renal replacement therapy program. Perit Dial Int. 2012;32(2):192–199. doi: 10.3747/pdi.2011.00037 21965620

18. Marseille E, Larson B, Kazi D, Kahn J, Rosen S. WHO thresholds for the cost–effectiveness of interventions: alternative approaches. Bull World Health Organ. 2015;93:118–124. doi: 10.2471/BLT.14.138206 25883405

19. International Monetary Fund.2017. Available from

20. Hooi LS, Lim TO, Goh A, Wong HS, Tan CC, Ahmad G, et al. Economic evaluation of centre hemodialysis and continuous ambulatory peritoneal dialysis in Ministry of Health hospitals, Malaysia. Nephrology. 2005;10:25–32. doi: 10.1111/j.1440-1797.2005.00360.x 15705178

21. Karopadi AN, Mason G, Rettore E, Ronco C. Cost of peritoneal dialysis and hemodialsis across the world. Nephrol Dial Transplant. 2013;28(10):2553–69. doi: 10.1093/ndt/gft214 23737482

22. Li PK, Chow KM. The cost barrier to peritoneal dialysis in the developing world—an Asian perspective. Periton Dialysis Int. 2001;21(3):S307–313.

23. Liu FX, Quock TP, Burkart J, Noe LL, Inglese G. Economic evaluations of peritoneal dialysis and hemodialysis: 2004–2012. F1000 Research. 2013; 2 (273):1–13.

24. Karopadi AN, Mason G, Rettore R, Ronco C. The role of economies of scale in the cost of dialysis across the world: a macroeconomic perspective. Nephrol Dial Transplant. 2014; 29(4): 885–892. doi: 10.1093/ndt/gft528 24516226

25. Chang YT, Hwang JS, Hung SY, Tsai MS, Wu JL, Sung JM, et al. Cost-effectiveness of hemodialysis and peritoneal dialysis: A national cohort study with 14 years follow-up and matched for comorbidities and propensity score. Sci Rep. 2016;21(8):669–677.

26. Heaf JG, Wehberg S. Relative survival of peritoneal dialysis and hemodialsis patients: effect of cohort and mode of dialysis initiation. PLoS ONE. 2014;9(3):e90119. doi: 10.1371/journal.pone.0090119 24614569

27. Kim H, Kim KH, Park K, Kang SW, Yoo TH, Ahn SV, et al. A population-based approach indicates an overall higher patient mortality with peritoneal dialysis compared to hemodialysis in Korea. Kidney Int. 2014;86(5):991–1000. doi: 10.1038/ki.2014.163 24805104

28. Liem YS, Wong JB, Hunink MG, de Charro FT, Winkelmayer WC. Comparison of hemodialysis and peritoneal dialysis survival in The Netherlands. Kidney Int 2007;71(Suppl 2):153–158.

29. Yang F, Khin LW, Lau T, Chua HR, Vathsala A, Lee E, et al. Hemodialysis versus peritoneal dialysis: a comparison of survival outcomes in South-East Asian patients with end-stage renal disease. PLoS ONE. 2015;10(10):e0140195. doi: 10.1371/journal.pone.0140195 26444003

30. Weinhandl ED, Foley RN, Gilbertson DT, Ameson T J, Snyder JJ, Collins AJ. Propensity-matched mortality comparison of incident hemodialysis and peritoneal dialysis patients. J Am Soc Nephrol. 2010;21:499–506. doi: 10.1681/ASN.2009060635 20133483

31. Briggs AH, Ades AE, Price MJ. Probabilistic sensitivity analysis for decision trees with multiple branches: use of the Dirichlet distribution in a Bayesian framework. Med Decis Making. 2003;23(4):341–50. doi: 10.1177/0272989X03255922 12926584

32. Treharne C, Liu FX, Arici M, Crowe L, Farooqui U. Peritoneal dialysis and in-centre hemodialysis: a cost-utility analysis from a UK payer perspective. Appl Health Econ Health Policy. 2014;12:409–420. doi: 10.1007/s40258-014-0108-7 25017433

33. Howard K, Salkeld G, White S, McDonald S, Chadban S, Craig JC, et al. The cost-effectiveness of increasing kidney transplantation and home-based dialysis. Nephrology (Carlton, Vic). 2009;14(1): 123–132. doi: 10.1111/j.1440-1797.2008.01073.x 19207859

34. Haller M, Gutjahr G, Kramar R, Harnoncourt F, Oberbauer R. Cost-effectiveness analysis of renal replacement therapy in Austria. Nephrol Dial Transplant. 2011;26(9):2988–2995. doi: 10.1093/ndt/gfq780 21310740

35. Pikea E, Hamidia V, Ringerikea T, Wisloffa T, Klempa M. More use of peritoneal dialysis gives significant savings: a systematic review and health economic decision model. J Clin Med Res. 2017;9(2):104–116. doi: 10.14740/jocmr2817w 28090226

36. Afiatin Khoe LC, Kristin E, Masytoh LS, Herlinawaty E, Werayingyong P, Nadjib M, et al. Economic evaluation of policy options for dialysis in end-stage renal disease patients under the universal health coverage Indonesia. PLoS ONE. 2017;12(5), e0177436. doi: 10.1371/journal.pone.0177436 28545094

37. Bavanandan S, Ahmad G, Teo AH, Chen L, Liu FX. Budget impact analysis of peritoneal dialysis versus conventional in-center hemodialysis in Malaysia. Value Health Reg Issues. 2016;9:8–14. doi: 10.1016/j.vhri.2015.06.003 27881266

38. Ong LM, Ch'ng CC, Wee HC, Supramaniam P, Zainal H, Goh BL, et al. Risk of Peritoneal Dialysis-Related Peritonitis in a Multi-Racial Asian Population. Periton Dialysis Int. 2017;37(1):35–43.

39. Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Periton Dialysis Int. 2010; 30(4):393–423.

40. Chaudhary K, Sangha H, Khanna R. Peritoneal dialysis first: rationale. Clin J Am Soc Nephrol. 2011;6(2):447–456. doi: 10.2215/CJN.07920910 21115629

41. Shafie AA, Lim YW, Chua GN, Hassali MA. Exploring the willingness to pay for a quality-adjusted life-year in the state of Penang, Malaysia. Clinicoecon Outcomes Res. 2014;6: 473–481. doi: 10.2147/CEOR.S67375 25364267

Článek vyšel v časopise


2019 Číslo 10