The economic burden of end-stage renal disease in Canada
2007; Elsevier BV; Volume: 72; Issue: 9 Linguagem: Inglês
10.1038/sj.ki.5002459
ISSN1523-1755
Autores Tópico(s)Health Systems, Economic Evaluations, Quality of Life
ResumoEnd-stage renal disease (ESRD) is a serious illness with significant health consequences and high-cost treatment options. This study estimates direct and indirect cost associated with ESRD from a societal perspective. A prevalence-based approach was used to estimate direct health-care costs and productivity losses from short- and long-term disability. An incident-based human capital approach was used to estimate mortality costs as the sum of the discounted present value of current and future productivity losses from premature deaths. Less than 0.1% of Canadians have ESRD; however, the disease generated direct health-care costs of $1.3 billion in the year 2000. The amount of direct spending per person with ESRD is much more than the average spending per person for all health-care conditions. Adding indirect morbidity and mortality cost brings the total burden associated with ESRD to $1.9 billion. This economic impact is higher than that for skin or infectious diseases, about the same as for genitourinary or endocrine diseases, but lower than that for conditions such as cancer or stroke. This economic weight is borne by a relatively small number of individuals. With the rapid increase in the incidence of ESRD, these findings may be useful in setting priorities for research, prevention programs, and in the planning of treatments. A better understanding of the scope and magnitude of the total economic burden of ESRD would help to inform those making policy decisions. End-stage renal disease (ESRD) is a serious illness with significant health consequences and high-cost treatment options. This study estimates direct and indirect cost associated with ESRD from a societal perspective. A prevalence-based approach was used to estimate direct health-care costs and productivity losses from short- and long-term disability. An incident-based human capital approach was used to estimate mortality costs as the sum of the discounted present value of current and future productivity losses from premature deaths. Less than 0.1% of Canadians have ESRD; however, the disease generated direct health-care costs of $1.3 billion in the year 2000. The amount of direct spending per person with ESRD is much more than the average spending per person for all health-care conditions. Adding indirect morbidity and mortality cost brings the total burden associated with ESRD to $1.9 billion. This economic impact is higher than that for skin or infectious diseases, about the same as for genitourinary or endocrine diseases, but lower than that for conditions such as cancer or stroke. This economic weight is borne by a relatively small number of individuals. With the rapid increase in the incidence of ESRD, these findings may be useful in setting priorities for research, prevention programs, and in the planning of treatments. A better understanding of the scope and magnitude of the total economic burden of ESRD would help to inform those making policy decisions. About 10% of Canada's gross domestic product is spent on health services, but the economic burden of illness rises when the effects of morbidity and premature mortality are taken into account.1.Canadian Institute for Health Information National Health Expenditure Trends 1975–2003. CIHI, Ottawa2003Google Scholar,2.Policy Research Division of the Strategic Policy Directorate in the Population and Public Health Branch of Health Canada Economic Burden of Illness in Canada, 1998. Health Canada, Ottawa2002Google Scholar This is particularly true for chronic diseases where individuals live with the consequences of their disease for years or decades. End-stage renal disease (ESRD) exists when a person's original kidneys ‘are permanently impaired and can no longer function normally to maintain life’, often defined as functioning at less than 10% of their normal rate.3.Canadian Institute for Health Information 2001 Report: Dialysis and Renal Transplantation, Canadian Organ Replacement Register. Canadian Institute for Health Information, Ottawa2001Google Scholar Even with treatment, it is a serious illness that often leads to poorer than average health status and quality of life, significant financial consequences, and high health-care costs.4.Nissenson A.R. Rettig R.A. Medicare's end-stage renal disease program: current status future prospects.Health Aff. 1999; 18: 161-179Crossref PubMed Scopus (39) Google Scholar, 5.Van Manen J.G. Korevaar J.C. Dekker F.W. et al.How to adjust for comorbidity in survival studies in ESRD patients: a comparison of different indices.Am J Kidney Dis. 2002; 40: 82-89Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar, 6.Wight J.P. Edwards L. Brazier J. et al.The SF36 as an outcome measure of services for end stage renal failure.Qual Health Care. 1998; 7: 209-221Crossref PubMed Scopus (113) Google Scholar, 7.Belasco A.G. Sesso R. Burden and quality of life of caregivers for hemodialysis patients.Am J Kidney Dis. 2002; 39: 805-812Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 8.Molzahn A.E. Kikuchi J.F. Children and adolescents of parents undergoing dialysis therapy: their reported quality of life.ANNA J. 1998; 25: 411-417PubMed Google Scholar Previous researchers have estimated total health-care costs for ESRD in a few countries, but the additional impact of lost productivity on the cost of illness has rarely been studied.9.Lysaght M.J. Maintenance dialysis population dynamics: current trends and long-term implications.J Am Soc Nephrol. 2002; 13: S37-S40Crossref PubMed Scopus (41) Google Scholar, 10.Kaitelidou D. Ziroyanis P.N. Maniadakis N. et al.Economic evaluation of hemodialysis: implications for technology assessment in Greece.Int J Technol Assess Health Care. 2005; 21: 40-46Crossref PubMed Scopus (36) Google Scholar, 11.de Wit G.A. Ramsteijn P.G. de Charro F.T. Economic evaluation of end stage renal disease treatment.Health Policy. 1998; 44: 215-232Abstract Full Text Full Text PDF PubMed Scopus (176) Google Scholar, 12.Eggers P.W. Health care policies/economics of the geriatric renal population.Am J Kidney Dis. 1990; 16: 384-391Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 13.Hornberger J.C. Garber A.M. Jeffery J.R. Mortality, hospital admissions, and medical costs of end-stage renal disease in the United States and Manitoba, Canada.Med Care. 1997; 35: 686-700Crossref PubMed Scopus (11) Google Scholar, 14.Hamer R.A. El Nahas A.M. The burden of chronic kidney disease is rising rapidly worldwide.BMJ. 2006; 332: 563-564Crossref PubMed Scopus (141) Google Scholar Since the early 1980s, the number of Canadians with ESRD has risen rapidly,3.Canadian Institute for Health Information 2001 Report: Dialysis and Renal Transplantation, Canadian Organ Replacement Register. Canadian Institute for Health Information, Ottawa2001Google Scholar leading to questions about the current and future impact of the disease on public health, quality of life, and health spending. This increase reflects growth in both incidence (e.g. 181% more patients were diagnosed with ESRD in 2000 than in 1985) and survival.15.Canadian Organ Replacement Register/Canadian Institute for Health Information Preliminary Report for Dialysis Transplantation: Preliminary Statistics on Renal Failure Solid Organ Transplantation in Canada 2002 (Includes Data 1981–2000). Canadian Institute for Health Information, Ottawa2002Google Scholar This study measures the economic burden of ESRD in Canada in 2000 in terms of direct spending on health care (e.g. dialysis and hospital care), as well as indirect costs, such as productivity losses due to premature death and short- and long-term disability. The intent is to provide a broader understanding of the effects of ESRD and how they compare with other health conditions. The McMaster University Research Ethics Board approved this study. By the end of 2000, an estimated 24 921 Canadians were living with ESRD.15.Canadian Organ Replacement Register/Canadian Institute for Health Information Preliminary Report for Dialysis Transplantation: Preliminary Statistics on Renal Failure Solid Organ Transplantation in Canada 2002 (Includes Data 1981–2000). Canadian Institute for Health Information, Ottawa2002Google Scholar That year, renal centers cared for approximately 4515 new ESRD cases and there were 2675 deaths. The total economic burden of ESRD in Canada in 2000 was $1.9 billion (see Tables 1 and 2). Direct costs account for most of the total (69%), reflecting the high health-care costs for ESRD and the fact that many of those affected are past their peak earning years. Indirect costs are also significant, however, both for mortality (23%) and morbidity (8%). Indirect costs are higher for patients on dialysis than for those with transplants, reflecting the significant effect that being on dialysis often has on an individual's ability to work, as well as on life more generally.Table 1Direct health-care costs of end-stage renal disease in Canada in 2000CategorynInflation-adjusted cost per capita in 2000Baseline estimateDirect health-care costs Living kidney donorsaIncludes health-care costs for care of living donors only. Costs of transplantation and aftercare for recipients are included in the relevant entries.389$5890$2 million Cadaveric kidney retrieval (donors)470$5850$3 million Transplant care (year of transplant)1105$96 040$106 million Functioning transplant care (later years)9249$31 222$289 million Center hemodialysis9752$66 259$646 million Self/home hemodialysis1568$50 982$80 million Peritoneal dialysis3247$45 400$147 millionTotal direct costs$1273 milliona Includes health-care costs for care of living donors only. Costs of transplantation and aftercare for recipients are included in the relevant entries. Open table in a new tab Table 2Economic burden of end-stage renal disease in Canada in 2000CategoryBaseline estimate% of totalDirect costs$1273 million69Mortality costs$434 million23Morbidity costs$149 million8Total$1857 million100 Open table in a new tab ESRD generated direct health-care expenditures of $1.3 billion in 2000. This includes $2 million for hospital costs, physician surgery fees, and aftercare for living kidney donors; $3 million for hospital and physician costs for cadaveric kidney retrieval; $106 million for pretransplant care, transplantation procedures, and ESRD care after transplantation in the year of transplant; $289 million for functioning kidney transplant care in subsequent years; $646 million for center hemodialysis and associated care; $80 million for self/home hemodialysis and related services; and $147 million for ESRD care for peritoneal dialysis patients. More than two-thirds of direct health-care expenditures related to ESRD (69%) were for persons on dialysis, although they accounted for 58% of persons with ESRD. Consistent with previous international research, center-based hemodialysis is more expensive than other methods.16.de Vecchi A.F. Dratwa M. Wiedemann M.E. Healthcare systems and end-stage renal disease (ESRD) therapies—an international review: costs and reimbursement/funding of ESRD therapies.Nephrol Dial Transplant. 1999; 6: 31-41Crossref Scopus (198) Google Scholar,17.Peeters P. Rublee D. Just P.M. et al.Analysis and interpretation of cost data in dialysis: review of the Western European literature.Health Policy. 2000; 54: 209-227Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar In Canada, it accounts for half of all ESRD care costs. Care for those on this type of therapy costs more than twice that for someone with a functioning transplant. The amount spent on ESRD care represents about 1.3% of Canada's total health-care spending or just over 2% of what provincial/territorial governments spent on health services in 2000.18.Canadian Institute for Health Information National Health Expenditure Trends 1975–2002. CIHI, Ottawa2002Google Scholar On a per capita basis, about $51 099 was spent on ESRD care for each person with the disease (congruent with methods used in similar studies,2.Policy Research Division of the Strategic Policy Directorate in the Population and Public Health Branch of Health Canada Economic Burden of Illness in Canada, 1998. Health Canada, Ottawa2002Google Scholar this total does not include costs of care for unrelated conditions received by these patients), significantly more than the average per person to care for all conditions ($3183). Over 2000 persons with ESRD died in 2000. The discounted present value of future production lost due to their premature deaths is estimated at $434 million. This is higher than the totals Health Canada calculated for conditions such as blood, musculoskeletal, and skin and related diseases ($19–126 million in 1998), but lower than those for major causes of death such as cancer ($10 622 million) and cardiovascular disease ($8250 million).2.Policy Research Division of the Strategic Policy Directorate in the Population and Public Health Branch of Health Canada Economic Burden of Illness in Canada, 1998. Health Canada, Ottawa2002Google Scholar As for many other diseases, while most deaths occur in older age groups, deaths among younger persons with ESRD contribute disproportionately to the value of lost production due to premature mortality. About 30% of those who died were under the age of 65 but they accounted for 68% of mortality costs. Additional analyses (see Table 3) show that ESRD economic burden estimates are more sensitive to changes in assumptions regarding discount rates than to those related to labor productivity growth. For example, a 3–7% variation in the discount rate leads to a $153 million difference in the present value of lost production due to premature mortality. However, neither set of assumptions had a substantial effect on the total economic burden of illness.Table 3Sensitivity of estimates of the economic burden of ESRD in Canada in 2000 to changing assumptions ($ millions)VariableChange from baseline assumptionsResulting estimate of the economic burden of ESRDBaselineNA$1857Discount rate applied to the value of future production7–3%$1792–$1945Labor productivity growth-0.3 to 2.8%$1812–$1925Lost productivity related to morbidity and mortalityInclude paid labor market earnings only (e.g. exclude value of unpaid work)$1509Disability weights (extent of impact of ESRD on productivity)Somewhat lower loss (increase baseline weights by 0.1) to somewhat higher loss (decrease baseline weights by 0.1)$1820–$1895Recovery time for living organ donors14–64 days off work$1856–$1857Recovery time for transplant recipients3–10 weeks to resume regular activities$1856–$1858ESRD, end-stage renal disease; NA, not applicable. Open table in a new tab ESRD, end-stage renal disease; NA, not applicable. Analyses were also conducted to test the sensitivity of estimates of the economic burden of ESRD to the inclusion of earnings from sources outside the labor market. Given that sources of income such as the Canada/Quebec Pension Plans, worker's compensation, and unemployment insurance effectively represent transfers, some argue that they should not be included in estimates of the societal burden of illness since they shift resources between individuals but do not change society's overall resources.19.Brouwer W.B. Koopmanschap M.A. Rutten F.F. Productivity costs measurement through quality of life? A response to the recommendation of the Washington panel.Health Econ. 1997; 6: 253-259Crossref PubMed Scopus (132) Google Scholar,20.Choi B.K. Pak A.W. A method for comparing and combining cost-of-illness studies: an example from cardiovascular disease.Chronic Dis Can. 2002; 23: 47-57PubMed Google Scholar Others contend that they represent an approximation of the indirect cost of illness due to disability.2.Policy Research Division of the Strategic Policy Directorate in the Population and Public Health Branch of Health Canada Economic Burden of Illness in Canada, 1998. Health Canada, Ottawa2002Google Scholar,21.Chan B. Coyte P. Heick C. Economic impact of cardiovascular disease in Canada.Can J Cardiol. 1996; 12: 1000-1006PubMed Google Scholar Removing them caused estimates of mortality costs related to ESRD to fall only slightly. Simultaneously dropping the value of unpaid labor had a more significant effect, particularly for women and older persons. The total mortality ‘cost’ based only on lost future paid labor market earnings was $132 million, rather than $434 million. For the almost 25 000 Canadians who had ESRD in 2000,15.Canadian Organ Replacement Register/Canadian Institute for Health Information Preliminary Report for Dialysis Transplantation: Preliminary Statistics on Renal Failure Solid Organ Transplantation in Canada 2002 (Includes Data 1981–2000). Canadian Institute for Health Information, Ottawa2002Google Scholar the disease had a significant impact on their lives. This translated into $149 million in estimated production losses for paid and unpaid work. Notably, this figure is about the same as Health Canada's2.Policy Research Division of the Strategic Policy Directorate in the Population and Public Health Branch of Health Canada Economic Burden of Illness in Canada, 1998. Health Canada, Ottawa2002Google Scholar estimates for much more common conditions, such as hip problems ($174 million in 1998) and chronic obstructive pulmonary disease ($161 million), reflecting the degree to which ESRD affects individuals' lives. The morbidity-related economic burden was much higher for dialysis patients than for those with transplants. This is because more people receive dialysis and they tend to experience higher productivity losses. In 2000, an estimated $113 million in productivity was lost due to morbidity for patients on hemodialysis. A further $33 million was attributed to peritoneal dialysis patients. The difference between the two primarily reflects the number of patients receiving each therapy. Both estimates are highly sensitive to assumptions about productivity weights, but the impact on the total economic burden of ESRD is modest (see Table 3). Kidney transplant donors and recipients accrued a further $3.3 million in short-term productivity losses in 2000. The majority of these losses were attributed to transplant recipients, mostly because of their larger numbers. For the same reason, the sensitivity analyses that varied recovery time for transplant patients had more effect than those that varied the time that living donors spent off work. In both cases, however, the changes had little impact on overall estimates of the economic burden of ESRD. Until relatively recently, communicable diseases, deaths in childbirth, and trauma were leading causes of death, and policies to improve health often focused on preventing the spread of disease. Summary measures derived from vital statistics, such as mortality rates and life expectancy, helped to inform these decisions.22.Committee on Summary Measures of Population Health of the Institute of Medicine Summarizing Population Health: Directions for the Development and Application of Population Metrics. National Academy Press, Washington1998Google Scholar As average life expectancy lengthens, however, interest in promoting health throughout the lifespan and in managing health-care costs has increased. Estimates of the economic burden of illness attempt to provide information needed to support this policy focus. They explicitly combine both spending on health care and productivity losses related to morbidity and premature mortality. Results have been used for a variety of purposes, including informing policy and research priorities and decisions, estimating the relative societal impact of different health conditions, and providing frameworks for program evaluation.23.Rice D.P. Cost of illness studies: what is good about them?.Inj Prev. 2000; 6: 177-179Crossref PubMed Scopus (183) Google Scholar In the case of ESRD, the economic burden is substantial: approximately $1.9 billion in Canada in 2000. While health services account for most of these costs, ESRD-related morbidity and premature mortality also impose a considerable burden on society. That said, without spending on ESRD care, individuals with the disease would die, thereby increasing premature mortality ‘costs’. This balance is particularly evident for transplants. The surgery generates relatively high short-term direct costs but tends to reduce both health-care costs and indirect productivity losses in the longer term.6.Wight J.P. Edwards L. Brazier J. et al.The SF36 as an outcome measure of services for end stage renal failure.Qual Health Care. 1998; 7: 209-221Crossref PubMed Scopus (113) Google Scholar The magnitude of these trade-offs depends largely on the method used to value productivity losses due to premature mortality and morbidity. The human capital approach used here is common in cost of illness studies, with results often interpreted as conservative estimates of the total societal welfare loss.2.Policy Research Division of the Strategic Policy Directorate in the Population and Public Health Branch of Health Canada Economic Burden of Illness in Canada, 1998. Health Canada, Ottawa2002Google Scholar Limitations of this method include the failure to value intangibles (e.g. pain and suffering) except as they lead to productivity losses, the difficulty of projecting earnings potential over long periods, the inherent bias toward diseases that tend to affect higher income earners, concerns about whether lost actual and imputed earnings are the best measure of production and/or welfare loss, and questions about the extent to which absenteeism or death reduces long-term economic production.23.Rice D.P. Cost of illness studies: what is good about them?.Inj Prev. 2000; 6: 177-179Crossref PubMed Scopus (183) Google Scholar, 24.National Health Strategy of the Department for Health Housing and Community Services Cost of Illness Studies Their strengths and limitations.in: Nutbeam D. Pathways to Better Health. Commonwealth of Australia, Canberra1993Google Scholar, 25.Drummond M. O'Brien B. Stoddart G. et al.Methods for Economic Evaluation of Health Care Programs. 2nd edn. Oxford University Press, Oxford1997Google Scholar, 26.Donaldson C. Narayan K.M. The cost of diabetes. A useful statistic?.Diabetes Care. 1998; 21: 1370-1371Crossref PubMed Scopus (11) Google Scholar A variety of alternatives have been proposed, each with strengths and limitations. For example, the willingness to pay method values human life based on how much people would be willing to spend to reduce the probability of having the consequences associated with a particular disease.27.Rice D.P. Cost-of-illness studies: fact or fiction?.Lancet. 1994; 344: 1519-1520Abstract PubMed Scopus (151) Google Scholar This approach tends to produce much larger estimates of indirect cost, although estimates often differ depending on the group consulted, over time, and by estimation method used.2.Policy Research Division of the Strategic Policy Directorate in the Population and Public Health Branch of Health Canada Economic Burden of Illness in Canada, 1998. Health Canada, Ottawa2002Google Scholar On the other hand, the friction cost method tends to produce much lower estimates of indirect costs. It assumes that unemployed workers can be recruited to replace those who are disabled or die.28.Koopmanschap M.A. Rutten F.F. van Ineveld B.M. et al.The friction cost method for measuring indirect costs of disease.J Health Econ. 1995; 14: 171-189Crossref PubMed Scopus (797) Google Scholar Productivity costs are therefore limited to losses in output during a defined friction period while a new worker is sought (e.g. 3 months), recruitment and training costs, and any medium-term macroeconomic impact resulting from labor market adjustments. Critics dispute the assumptions on which this method is based and argue that it does not consider full societal costs, depends heavily on the economy's unemployment level, and takes into account neither the lost value of the recruited employee's leisure time nor intangibles (e.g. pain and suffering).29.Johannesson M. Karlsson G. The friction cost method: a comment.J Health Econ. 1997; 16 (discussion 257–249): 249-255Crossref PubMed Scopus (127) Google Scholar,30.Pritchard C. Schulper M. Productivity Costs: Principles and Practice in Economic Evaluation. Office of Health Economics, London, England2002Google Scholar While alternative valuation methods would change the precise cost estimates, much of the value of cost of illness studies is in assessing the relative burden of different health conditions. As this study demonstrates, the total economic burden of ESRD in Canada is higher than that for conditions such as skin and infectious diseases, about the same as for genitourinary and endocrine disease, and lower than for diseases such as cancer and stroke.2.Policy Research Division of the Strategic Policy Directorate in the Population and Public Health Branch of Health Canada Economic Burden of Illness in Canada, 1998. Health Canada, Ottawa2002Google Scholar This weight is, however, borne by a relatively small number of individuals. As a result, the economic burden of ESRD is much higher per person affected than for many other diseases. This is consistent with the results of international research.9.Lysaght M.J. Maintenance dialysis population dynamics: current trends and long-term implications.J Am Soc Nephrol. 2002; 13: S37-S40Crossref PubMed Scopus (41) Google Scholar In Canada, ESRD treatment costs alone are estimated to be more than 16 times what was spent on average per person to care for all health conditions. Given the rapid rise in the number of persons living with ESRD, this has important implications for planning and policy design. This study measures the direct and indirect economic burden of ESRD in Canada in 2000. The calculations take a societal perspective, quantifying costs regardless of whether they fall on individuals, employers, governments, or others. In order to facilitate comparison with other diseases, the methods used parallel those employed for a recent broad-based Canadian burden of illness study,2.Policy Research Division of the Strategic Policy Directorate in the Population and Public Health Branch of Health Canada Economic Burden of Illness in Canada, 1998. Health Canada, Ottawa2002Google Scholar which in turn drew on protocols developed by a Task Force of the US Public Health Service.31.Rice D.P. Estimating the Cost-of-Illness. Department of Health, Education, and Welfare, Rockville, MD, USA1966Google Scholar,32.Rice D.P. Hodgson T.A. Kopstein A.N. The economic costs of illness: a replication and update.Health Care Financ Rev. 1985; 7: 61-80PubMed Google Scholar A prevalence-based approach is used to estimate all direct health-care costs and indirect morbidity costs related to ESRD. Thus totals include costs incurred in 2000, regardless of the time of disease onset. Mortality cost estimates are based on the discounted present value of current and future production losses related to premature deaths among those with ESRD in 2000, quantified using an incidence-based human capital approach. This method sees individuals as producing a stream of output over the years valued at their earnings. Morbidity and mortality reduce or eliminate this production.31.Rice D.P. Estimating the Cost-of-Illness. Department of Health, Education, and Welfare, Rockville, MD, USA1966Google Scholar,32.Rice D.P. Hodgson T.A. Kopstein A.N. The economic costs of illness: a replication and update.Health Care Financ Rev. 1985; 7: 61-80PubMed Google Scholar The direct and indirect cost calculations draw on many data sources. The data cluster around the year 2000, the period for which costs are calculated. Data from other years were adjusted to year 2000 dollars using a total health-care implicit price index18.Canadian Institute for Health Information National Health Expenditure Trends 1975–2002. CIHI, Ottawa2002Google Scholar for health-care costs or the consumer price index.33.Statistics Canada Consumer Price Index Historical Summary. Statistics Canada, Ottawa2005Google Scholar Direct health-care costs represent the value of goods and services used to prevent and/or treat illness that cannot, as a result, be put to other uses. This study captures costs for organ retrieval, transplant surgery and aftercare, and dialysis patients. Data on the number of persons with ESRD by treatment modality in 2000 were obtained from the Canadian Organ Replacement Register. Total costs were calculated by multiplying the average cost per procedure or course of treatment by the numbers who received each type of care. Consistent with methods used in similar cost of illness studies, to the extent possible, costs related to ESRD are isolated, rather than including health care received by patients with ESRD for unrelated health problems.2.Policy Research Division of the Strategic Policy Directorate in the Population and Public Health Branch of Health Canada Economic Burden of Illness in Canada, 1998. Health Canada, Ottawa2002Google Scholar This calculation sums the cost of services related to ESRD, thereby excluding, for example, costs related to a broken leg for an individual with a functioning transplant. This approach avoids double counting (e.g. attributing dialysis costs to both ESRD and hepatitis, which may be an underlying risk factor), and hence facilitates cross-disease comparisons. Cost estimates were obtained from comprehensive national sources or, when not possible, from individual provinces
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