A SRIRAVINDRARAJAH1, SS KOTWAL2,3, S SEN1,4, S MCDONALD5,6, A CASS7, M GALLAGHER1,2,4
1Concord Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales; 2The George Institute for Global Health, Sydney, New South Wales; 3Prince of Wales Hospital, Sydney, New South Wales; 4Concord Repatriation General Hospital, Sydney, New South Wales; 5University of Adelaide, Adelaide, South Australia; 6Royal Adelaide Hospital, Adelaide, South Australia; 7Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory
Aim: To understand the impact of private health insurance upon dialysis modality in Australia.
Background: Re-imbursement systems have been associated with differences in treatment modalities for patients receiving renal replacement therapy (RRT).
Methods: All adult patients who commenced RRT in NSW between 2000-2010 were identified using the Australia and New Zealand Dialysis and Transplant Registry. Data were linked to the state hospitalisation dataset to obtain insurance status, health service use, and mortality. Dialysis modality in the first year after starting RRT, dialysis access type, health service utilisation and mortality were compared between privately insured (PI) and public patients using appropriate statistical techniques.
Results: PI patients were 38% (n=2152) of the 5737 patients in the study cohort. After adjustment for differences in baseline characteristics, PI patients were more likely to initiate RRT with in-centre haemodialysis (OR 1.22, 95% CI 1.01-1.46, P=0.03) and less likely to start with peritoneal dialysis (OR 0.81, 95% CI 0.67-0.98, P=0.03). At one-year after RRT initiation, PI patients were more likely to be receiving home haemodialysis (OR 1.38, 95% CI 1.01-1.88, P=0.04) or to have been transplanted (OR 1.71, 95% CI 1.22-2.40, P=0.002). PI patients were more likely to start haemodialysis with an arteriovenous fistula or graft (OR 1.91, 95% CI 1.50-2.43, P=<0.001), used 15% fewer bed days in the first year after RRT commencement (IRR 0.85, 95% CI 0.74-0.96, P=0.01) and had a lower mortality (HR 0.84, 95% CI 0.74-0.95, P=0.01).
Conclusions: Private health insurance in Australia is associated with higher use of home haemodialysis and transplantation at one year post RRT initiation. Sizeable differences in health service usage and outcomes in this group represent an equity challenge to renal services.