The search identified a total of 720 references (PubMed: 447, Embase: 245, Scopus: 22, Web of Science: 1, and CINAHL: 5). After reading the titles and abstracts, a total of 103 references were selected for the next step of full-text evaluation, to ensure that the articles met all the eligibility criteria. Finally, after identifying an article through cross references, 11 articles were included in this review: eight on comparison of effectiveness and three on cost (Fig. 1).

Figure 1.

Flow chart. ref: References.

(0.24MB).

All included studies on effectiveness have been conducted in the US. Three articles compared the effectiveness of organizations based on profitability, and included patients from the US Medicare Renal Registry cohort who received dialysis in 200318, 2005−200819 and 201020. The number of patients was 170,13018, 150,64219, and 366,01120, respectively, once different inclusion criteria were applied; of these, 9% received assistance in non-profit centers. Multivariate models showed that patients treated in for-profit centers had a higher relative rate of hospitalization, specifically, 15% (95% confidence interval [CI]: 13–18%; p < 0.001)19 (main causes: heart failure [37%] and volume overload [15%]) and days of hospitalization were increase by 17.5% in relation to those treated in non-profit centers (standard error 4.8; p < 0.001)18. In addition, Brunelli20 compared hospitalization and mortality rates, including 366,011 and 34,029 patients in for-profit and non-profit centers, respectively; and, it was found no significant differences in mortality (p = 0.64), nor in hospitalizations (p = 0.69).

On the other hand, there have been found four articles that compared the health outcomes of patients that received care in centers dependent on the Veterans Admnistration (VA) versus other external services. Thus, it has been possible to conclude that patients treated in VA centers showed a greater probability of receiving nephrological care prior to dialysis and having an AVF, although they had longer hospital admissions and longer durations and less access to kidney transplantation as comnpared to patients treated in outsourced centers21–24.

Erickson (2018)25 evaluated the association between competition in dialysis markets and levels of hospitalization and mortality in the US. Competition was measured using the Hirschman-Herfindahl (IHH) index, which ranges from 0 to 1, where a lower score represents a higher concentration of suppliers and, therefore, greater competition. A sample of 632,734 patients from 3379 dialysis centers between 2001 and 2011 was analyzed, with an average HHI index of 0.48. After adjusting for different variables, it was found that a reduction of 0.2 units in HHI was associated with a significant decrease in hospitalizations 2.9 per 100 patient/year, that is, an increase in competition between providers entails benefits for patients. patients. Competition that, however, was not associated with mortality (Table 1).

A report from the Agency for Health Technology Assessment of Andalusia analyzed the difference in costs between the modalities of hospital hemodialysis (HDH) (n = 256 patients) and concerted hemodialysis (HDC) (n = 226). The total annual cost, per patient and year, was 45,395.40 in HDH vs. 38,815.77 in HDC. This difference is mainly explained by the much more complex structure existing in the hospital compared to the centers where concerted dialysis is performed, and which represents an increase in direct costs of 6718.52 and 2573.03 in each of the modalities. Direct costs, for their part, are very similar in HDH and HDC, with 38,676.88 and 36,062.74, respectively3.

A multicenter cost study in two public owned and four subsidized, obtained an average cost of 40,136; ranging between 33,130 and 45,370 in the case of subsidized centers, and between 46,254 and 44,486 for public centers26. A similar distribution was found between the types of centers, except for spending on personnel, which was 37.3% of the total cost in public centers and 27.7% of the total in subsidized ones. By acontrast, other expenses (transport, management or maintenance) were higher in subsidized centers with 24.4% vs. 17.1% of those of public ownership.

In the study by Conde-Olasagasti27 it was estimated the cost of the dialysis program in Toledo during the years 2012 and 2013. The total cost of the treatment was 15,778,360, of which 40.1% corresponded to the dialysis treatment, 21.2% hospital charge (major outpatient surgery, outpatient consultations and emergency visits), 20.3% pharmacy, 10.1% transportation and 7.5% support (unscheduled HD sessions, PD training or unforeseen care at the day hospital). Thus, the cost per patient and year of HDH was 53,289 vs. the 44,971 of the HDC. The comparison of the different cost components reveals that the main cost difference between one modality and the other is in what is called the hospital charge, or expenses derived from direct medical care (HDH 9599 vs. HDC 6721), followed by of the cost of dialysis (HDH 27,289 vs. HDC 24,653). The part of the cost that transport, pharmacy or support represents in the total cost of each modality was not significantly different between hospital or subsidized HD (Table 1).

Table 2 shows the public prices for dialysis services in the different Autonomous Communities28–46, observing a wide difference in the time of the publication dates of the prices between June 2011, in Castilla y León, and March 2011. 2019, in Murcia. The public price ranged from 393.42 per hemodialysis session in La Rioja to 132.5 for the hemodialysis session in Andalusia (2015). In addition to the variability between the rates of the different regions, once the amounts are updated to 2020 using the Consumer Price Index (CPI), a notable diversity is observed in the name of the concept and type of dialysis, with a wide range of therapeutic options ranging from the "HD session" of the Basque Country or Castilla y León, to the detail of five different types of HD published by Aragon.

It should be noted that there were found two systematic reviews that evaluated the quality of health care in a multitude of services in centers dependent of VA. These two reviews conclude that, in general, care at VA-operated facilities (eg, Medicare, Medicaid) is good or better than care provided by non-VA-operated or outsourced facilities50,51.

In terms safety of care, no article was found that evaluated differences in different areas of dialysis provision. In a 2017 study52, carried out in a Spanish hospital, all HD sessions were reviewed in two months (2149 in the hospital unit and 2125 in the peripheral center), detecting 11.8% of adverse events (AEs) in the hospital unit (12.9% high severity) vs. 9.2% in the peripheral center (1% high severity). The most frequent AEs were hypotension, in both cases, followed by extracorporeal circuit coagulation and AVF problems (hospital unit) and problems related to AVF puncture and extracorporeal circuit coagulation (in the peripheral center).

Roderick et al.6 asked the nursing staff the incidence of AEs observed in the last six weeks in 368 CHD patients. A 37.5% of patients did not have major adverse events, and of the 551 adverse events identified, the most frequent were: hypotension (48.8%), others (32.1%) and access problems (15.3%). These results are in line with the study by Arenas53 which found a proportion of adverse events in a CHD unit of 25.8%, the most frequent being hypertension (42.7%) and hypotension (27, 5%).

Balhara54 conducted a survey of 906 US nephrologists on the time they spent educating their CKD stage 4 patients. It was estimated at 20 min, the ideal time devoted to patient education on kidney transplantation. One of the results found that only 43% of professionals claimed to invest that time. In addition, it was found that those for-profit centers statistically showed less time dedicated to education (relative risk [RR] = 0.89) counseling (RR = 0.58), discussion about transplantation (RR = 0.58), family involvement (RR = 0.57), as compared to those without profit. This result is especially relevant, since patient training is a key element for patient autonomy and self-care55 and directly affects the results of the techniques and patient satisfaction.

Two studies were found In relation to the patient satisfaction according to the care received6,56. In both, greater satisfaction was found among HD patients in subsidized centers, being significantly higher in those aspects related to food, the appearance of the center, and the information received by health personnel.

Equity and continuity of care are shown to be key elements to obtain the maximum health results for dialysis patients; it is essential an appropriate coordination between subsidized centers and their reference hospitals, this allows standardizing the criteria for action, portfolio of services or techniques, procedures, etc.8.

In Spain, there are still no systematic and independent evaluations of the different forms of management, that could serve as a guide for future organization and management strategies57. It should be noted that the promotion of competition between centers (regardless of the legal form of management) could result in improvements25. Such a competition cannot arise spontaneously, given the quasi-monopoly characteristics that health centers have in their areas of influence, therefore it but must be generated by the request for services (in the case of private management) and by comparing results of efficiency and quality of care provided by the different centers57. Thus, the health outcomes of dialysis patients should not be conditioned by the ownership (public or private) of the health centers.

The great variability between the prices of the Autonomous Communities could be explained by the differences in the concepts included or different methodologies for their calculation, and also because they are not reflecting the real costs of the treatment58. A study carried out in Galicia concluded that HD concerts generated added value (economic growth and jobs) for the healthcare area, much higher than PD concerts59. This result highlights the need to carry out a more exhaustive evaluation that includes different dimensions and perspectives, using a multi-criteria decision analysis as a novel methodology that allows to perform and evaluation with a more holistic and transparent perspective.

The treatment of kidney disease has a high impact on health systems; the percentage of healthcare spending ranged between 1.3 and 3% of total healthcare cost, and it is higher in countries with lower incomes. These patients representing only 0.02−0.03% of the general population1,60. In 20 years, it is estimated that a third of the population will be ≥65 years of age, which could be translated into an increase in the prevalence of patients on RRT of 41% in the next two decades61. All of this highlights the need to use strategies that manage to reduce the economic burden of CKD, through programs to prevent the progression of the disease, together with the promotion of PD62. Thus, the coexistence in Spain of public and subsidized centers, the variability in the provision of dialysis techniques and the scant evidence on whether the outsourcing of RRT is an adequate plan to reduce treatment costs, illustrate the need to dedicate efforts and means to perform comparative investigation of results for the application of strategies that result in an improvement of care for chronic kidney disease, within the strategies of chronic diseases63–65.