Discussion of findings

was in contrast to the result from the descriptive analysis, where the death rate appeared to decrease after it reached a peak in 2012.

The age effect and period effect of ESRD deaths among UCS members were in accordance with those of RRT patients, since their trend lines in rate ratio graphs showed similar shapes. Rates started with sharp increases until 2009, followed by relatively stable trends until 2012. Both rates showed increasing trends from 2012.

The case fatality rate analysis suggested different findings, in particular during the period 2008‐2012. While calculated rates of the other two types were increasing in this period, case fatality rates were decreasing. However, in 2013 all types of rates increased.

6.4.3 Discussion of findings

The variation in trends in access to RRT services, and overall mortality of ESRD patients and patients who use RRT, may be explained by the introduction of the RRT programme, changes in the RRT policy, and environmental events.

Linking the timeline of the RRT programme with dialysis registration and mortality provided more explanations for their trends, Figure 6‐15. The opening of pilot PD centres may be a possible explanation for the declining death trend in 2007. After the RRT programme was fully implemented in 2008, both dialysis modalities could have high registration rates, resulting in an immediate effect of the new programme on patients who had never previously had RRT coverage. Consequently, the programme brought a large number of patients into all three RRT modalities and reduced the increasing death rate between 2008 and 2011.

After commencement of the RRT programme, the registration rate might have responded to the new policy since registration trends increased after each new reimbursement started. This was evident in 2009, when the NHSO started to reimburse erythropoietin²⁰ for PD users, effectively making the medication

20 for the treatment of anemia of ESRD patients

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cost‐free. This benefit is likely to have boosted the PD registration rate until 2010.

Deep drops in dialysis registration and transplantation in 2011 could be a consequence of flooding that affected major cities in 63 out of 77 provinces in Thailand. More than 600 public health facilities could not open as usual and many private clinics were temporarily closed down (The World Bank 2013).

The Nephrology Society of Thailand estimated that 30% or 12,000 dialysis patients²¹ resided in flooded areas. Hemodialysis patients were affected the most since they could not go to receive care at dialysis units. Peritoneal dialysis patients could perform home dialysis as the NHSO guaranteed home‐delivery of dialysis solution (The Nephrology Society of Thailand 2011). Although there was collaboration between various agencies to mitigate the situation,

registration rates of PD and HD went down in this period.

Increases in PD and HD registrations in late 2012‐ 2013 might be explained in a number of ways. The first explanation is the harmonisation of RRT benefits across the three public health insurance schemes, namely the Social Security Scheme, the UCS and the Civil Servant Medical Benefit scheme. The

harmonisation made for easier access to RRT services, since the three schemes agreed to use the same standard guidelines in taking on and caring for ESRD patients. Patients who changed their insurance schemes to another scheme had no barrier to continue RRT care in their transition phase. The RRT programme also benefited from the harmonised data management system, coherent and standard procedures, and standard validation processes. Consequently, data quality improved and timely information was available.

HD patients gained great advantages from the harmonisation. This is because within the other two schemes, the majority of dialysis users were HD. After the harmonisation, all three schemes had to allow new beneficiaries to retain their previous dialysis mode. Therefore, these HD patients could enter the UCS RRT programme without using the PD‐first policy. Additionally, in 2012 more

benefits were added to HD, for example free erythropoietin and exemption from

21 of all 3 public schemes and all over the country

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copayment. In addition to the harmonisation, UCS patients who were self‐

funding for hemodialysis might register to use free dialysis as they had more confidence in the quality of RRT services provided by the UCS.

2005 2006 2007 2008 2009 2010 2011 2012 2013

Year All-cause mortality

PD registration HD registration

Note: adjusted from the rate ratio graphs of registration into the RRT programme and mortality.

Y-axis is not the actual scale, UCS=universal coverage scheme, PD=peritoneal dialysis, HD=hemodialysis

The increase of the mortality rate during 2011‐2013 could be a combined effect of epidemiology of chronic renal disease, a disproportionate number of new registrations given increasing patients with ESRD, and loss of follow up while flooding. Given the fact that 90% of ESRD patients who do not receive proper dialysis will die within 3‐6 months (Tantivess, Werayingyong et al. 2013), these patients were sensitive to the change in the availability of the RRT benefit in 2008. As a result, patients who had ESRD before the programme started could prolong their life when they used dialysis. However, this effect was transient since dialysis could only slow the progress of kidney disease, not cure it. This is

Figure 6‐15 Comparison of registration rates and all‐cause mortality with RRT programme’s key events 

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a likely explanation for the increase in death rates after 2012. To support this account, we can look at an analysis of kidney function (eGFR: estimated

Glomerular Filtration Rate level) of patients first entering into the programme, Figure 6‐16 found that most patients in the RRT programme had a late start²². This means 70‐75% of these patients were likely to die within 3 years (Wright, Klausner et al. 2010).

Figure 6‐16  eGFR levels at registration into the RRT programme of  PD patients between 2007 and 2014 

eGFR: estimated Glomerular Filtration Rate

From the decreasing trend of case fatality rates (CFR), we can infer that those who have ESRD were more likely to survive with the introduction of the RRT programme. However, this finding contrasted with the ESRD mortality rate which showed a reverse sign. The percentage of new ESRD patients per UCS population is a possible explanation as to why the results of the mortality rate

and CFR were different. Figures in Table 6‐15 suggest that there were growing numbers of new patients with ESRD diagnoses relative to the UCS population 2010‐2012. Calculations of the ESRD death rate among UCS population²³ and

22 eGFR levels lower than 10ml/min/1.73m²

23 ESRD mortality rate= (Number of deaths from all causes among patients with ESRD x 100)/ Number of mid-year UCS members

0204060%Patient

2007 2008 2009 2010 2011 2012 2013 2014 Registration Year

0-5 6-10 11-15

15-29

>29 eGFR ml/min/1.73m2

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CFR²⁴ employed same numerators but different denominators. When the denominators of CFR increased, the calculated figures of CFR decreased.

Moreover, looking at the share of new patients with an ESRD diagnosis in the UCS population (Table 6‐15), there were growing numbers of patients with ESRD, in particular, among the elderly population (65 years old and above), who have a high risk of mortality. However, lower numbers of elderly patients were registered with the RRT programme. These figures may account for the high CFR in elderly ESRD patients between 2010 and 2012.

Table 6‐15  Percentages of new ESRD diagnoses and overall UCS population,  2008‐2013 

Age 2008 2009 2010 2011 2012 2013

20-24 0.01% 0.01% 0.01% 0.01% 0.01% 0.01%

25-29 0.02% 0.01% 0.02% 0.02% 0.01% 0.01%

30-34 0.03% 0.01% 0.02% 0.02% 0.02% 0.01%

35-39 0.03% 0.01% 0.02% 0.03% 0.02% 0.01%

40-44 0.05% 0.02% 0.03% 0.04% 0.03% 0.02%

45-49 0.07% 0.03% 0.05% 0.06% 0.05% 0.03%

50-54 0.13% 0.05% 0.09% 0.09% 0.08% 0.05%

55-59 0.18% 0.07% 0.13% 0.14% 0.14% 0.09%

60-64 0.25% 0.10% 0.19% 0.20% 0.19% 0.12%

65-69 0.32% 0.13% 0.25% 0.28% 0.27% 0.17%

70-74 0.40% 0.16% 0.32% 0.37% 0.35% 0.20%

75-79 0.46% 0.19% 0.39% 0.44% 0.42% 0.26%

80-84 0.42% 0.19% 0.40% 0.45% 0.48% 0.29%

85-89 0.31% 0.18% 0.36% 0.41% 0.46% 0.27%

Total 0.11% 0.05% 0.09% 0.11% 0.10% 0.06%

Note: bold figures represented relatively high percentages of elderly in comparison to overall UCS population, 2010-2012

Further comparison of new RRT registrations and numbers of patients with an ESRD diagnosis is shown in Table 6‐16. Proportions of most age groups were increasing, with slight drops in 2010‐2011. Despite rapidly growing

proportions of new RRT registrations among young patients, less than half of patients aged 65 years and older enrolled in the RRT programme. This situation might explain the increase in all types of death rates in 2013.

24 CFR= Number of deaths from all causes among patients with ESRD x 100/ Number of all patients with ESRD

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Table 6‐16  Proportions of new RRT registrations as percentage of new  ESRD diagnoses by year and age group 

Age 2008 2009 2010 2011 2012 2013

20-24 51.0% 145.2% 83.8% 78.9% 100.0% 100.0%

25-29 36.5% 61.8% 46.8% 45.8% 60.7% 88.5%

30-34 32.3% 48.9% 46.4% 39.9% 54.4% 92.4%

35-39 32.1% 53.4% 41.9% 44.3% 49.6% 85.2%

40-44 31.1% 52.7% 42.5% 38.8% 50.0% 79.1%

45-49 28.7% 50.0% 39.6% 38.6% 49.8% 73.3%

50-54 27.1% 45.3% 35.3% 36.0% 43.0% 68.2%

55-59 24.7% 39.7% 32.7% 33.7% 37.8% 63.6%

60-64 23.1% 33.6% 28.4% 29.3% 33.7% 55.3%

65-69 21.0% 23.6% 20.9% 22.8% 25.7% 41.7%

70-74 16.8% 14.4% 15.7% 15.5% 16.8% 31.8%

75-79 13.1% 9.0% 8.4% 10.2% 10.8% 18.8%

80-84 11.3% 5.2% 5.8% 6.7% 7.2% 9.0%

85-89 8.8% 2.6% 4.2% 4.4% 4.2% 4.8%

Total 22.8% 31.7% 25.1% 25.3% 28.8% 47.3%

Note: bold figures represented relatively constant or low increasing percentages of elderly in comparison to overall UCS population, 2010-2012