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and costs are no always lower than in HD&#46; One treatment or the other are considered more efficient depending on the costs of other treatment components &#40;transport for HD&#44; accesses for dialysis and their complications&#44; drugs&#44; emergency care&#44; hospitalisations&#41; which vary between different hospitals&#46; This is why it is important to consider prescriptions in PD and rigorously estimate costs in future studies&#44; which should be publicly financed and include participation by a representative number of medical centres in order to eliminate biases inherent to the &#34;centre effect&#34;&#46;</p><p class="elsevierStylePara">We agree that all costs to nephrology departments incurred by patients being treated in an outsourced centre must be calculated&#44; but we must distinguish between care for issues that are common to both techniques and complications that are directly related to one treatment regimen or the other&#46;</p><p class="elsevierStylePara">We do not have the data regarding the percentage of patients undergoing more than 3 weekly HD sessions in an outsourced centre&#46; The cited S&#46;E&#46;N&#46; data are based on a record of daily HD sessions&#44;<span class="elsevierStyleSup">3</span> which only included 70&#37; of prevalent patients on HD&#46;<span class="elsevierStyleSup">4</span> Of them&#44; 3&#46;5&#37; underwent 3&#46;5 or 4 weekly sessions and only 1&#46;5&#37; underwent 5 or more sessions&#46; If we extrapolate these data to our study&#44; the results do not change significantly&#46; High-flux membranes and special techniques do not affect HD outsourcing costs in our region because mark-ups associated with them do not enter into the equation&#59; these materials are used according to the provider&#8217;s best judgement and at the provider&#39;s expense&#46;</p><p class="elsevierStylePara">We do agree that we should have included value-added tax &#40;VAT&#41; when we calculated the difference between the outsourced service costs and the consumable materials&#46; But if we consider this as a reimbursement passed on to the Treasury&#44; we should also count VAT paid for outsourced HD services for the purchase of monitors&#44; materials and other services&#44; and the personal income tax on participants in both outsourced services&#46; With regard to personnel hired by companies providing PD&#44; it is similar to staff providing dialysis material in outsourced HD centres and it is already included in the cost of the service&#46;</p><p class="elsevierStylePara">In conclusion&#44; we also believe that PD is underused&#44; but we would not say that economic concerns are the best reason for promoting this treatment regimen due to discrepancies listed in our article&#46; Rather&#44; we feel that equal access to all types of dialysis in all nephrology departments should be guaranteed&#44; and that the process of selecting the technique should revolve around the patient&#39;s situation&#44; the patient being free to choose an option after being properly informed&#46;</p><p class="elsevierStylePara">We trust that further multi-centre studies that receive public funding and evaluate all of the factors in play will aid in clarifying the questions that have been raised&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare potential conflicts of interest&#58;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Grants</span>&#58; 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Costs of haemodialysis and peritoneal dialysis outsourcing agreements
Costes de los conciertos de hemodiálisis y diálisis peritoneal
José M. Lamas-Barreiroa, Mario Alonso-Suáreza, Jesús Á. Saavedra-Alonsoa, Argimiro Gándara-Martíneza
a Servicio de Nefrología, Hospital Universitario de Vigo, Vigo, Pontevedra,
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and costs are no always lower than in HD&#46; One treatment or the other are considered more efficient depending on the costs of other treatment components &#40;transport for HD&#44; accesses for dialysis and their complications&#44; drugs&#44; emergency care&#44; hospitalisations&#41; which vary between different hospitals&#46; This is why it is important to consider prescriptions in PD and rigorously estimate costs in future studies&#44; which should be publicly financed and include participation by a representative number of medical centres in order to eliminate biases inherent to the &#34;centre effect&#34;&#46;</p><p class="elsevierStylePara">We agree that all costs to nephrology departments incurred by patients being treated in an outsourced centre must be calculated&#44; but we must distinguish between care for issues that are common to both techniques and complications that are directly related to one treatment regimen or the other&#46;</p><p class="elsevierStylePara">We do not have the data regarding the percentage of patients undergoing more than 3 weekly HD sessions in an outsourced centre&#46; The cited S&#46;E&#46;N&#46; data are based on a record of daily HD sessions&#44;<span class="elsevierStyleSup">3</span> which only included 70&#37; of prevalent patients on HD&#46;<span class="elsevierStyleSup">4</span> Of them&#44; 3&#46;5&#37; underwent 3&#46;5 or 4 weekly sessions and only 1&#46;5&#37; underwent 5 or more sessions&#46; If we extrapolate these data to our study&#44; the results do not change significantly&#46; High-flux membranes and special techniques do not affect HD outsourcing costs in our region because mark-ups associated with them do not enter into the equation&#59; these materials are used according to the provider&#8217;s best judgement and at the provider&#39;s expense&#46;</p><p class="elsevierStylePara">We do agree that we should have included value-added tax &#40;VAT&#41; when we calculated the difference between the outsourced service costs and the consumable materials&#46; But if we consider this as a reimbursement passed on to the Treasury&#44; we should also count VAT paid for outsourced HD services for the purchase of monitors&#44; materials and other services&#44; and the personal income tax on participants in both outsourced services&#46; With regard to personnel hired by companies providing PD&#44; it is similar to staff providing dialysis material in outsourced HD centres and it is already included in the cost of the service&#46;</p><p class="elsevierStylePara">In conclusion&#44; we also believe that PD is underused&#44; but we would not say that economic concerns are the best reason for promoting this treatment regimen due to discrepancies listed in our article&#46; Rather&#44; we feel that equal access to all types of dialysis in all nephrology departments should be guaranteed&#44; and that the process of selecting the technique should revolve around the patient&#39;s situation&#44; the patient being free to choose an option after being properly informed&#46;</p><p class="elsevierStylePara">We trust that further multi-centre studies that receive public funding and evaluate all of the factors in play will aid in clarifying the questions that have been raised&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare potential conflicts of interest&#58;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Grants</span>&#58; the authors receive funds for different research projects from <span class="elsevierStyleItalic">Instituto Reina Sof&#237;a de Investigaci&#243;n </span>research centre&#44; which belongs to the <span class="elsevierStyleItalic">Fundaci&#243;n Renal &#205;&#241;igo &#193;lvarez de Toledo </span>&#40;&#205;&#241;igo &#193;lvarez de Toledo Kidney Foundation&#41;&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Travel</span><span class="elsevierStyleBold">expenses</span>&#58; the authors receive funding for different continuous training activities from the firms Baxter&#44; Fresenius&#44; Hospal and Gambro&#46;</p>"
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