The cost of renal replacement therapy in Brazil and the story of the short blanket

Correspondence to: Mario Abbud Filho. Faculdade de Medicina de São José do Rio Preto. Av. Brigadeiro Faria Lima, no 5416, São José do Rio Preto, SP, Brazil. CEP: 15090-000 E-mail: mabbud@terra.com.br Properly and effectively allocating public resources to promote health in a society is a controversial subject in public policy, since is required from the person in charge to manage the health resources to take in account the broad spectrum of diseases, from those that can be prevented to those that require more sophisticated and expensive treatments. Therefore, analyzes that evaluate cost-effectiveness, costutility and cost-benefit are of extreme importance to help in the allocation of resources to the different areas of health. Unfortunately, these studies are still rare in Brazilian nephrology, as evidenced by a recent review of 83 national cost-effectiveness studies, where only two studies were related to the use of immunosuppressive agents in transplants and one referring to the treatment of renal replacement therapy.1 Thus, the study of Gouveia et al.,2 “Analyzing the economic impact of renal replacement therapy,” published in this issue of BJN, can be very useful for public health managers, nephrologists, and transplant physicians. The authors analyzed the financial impact of the dialysis treatment (hemodialysis and peritoneal dialysis) and renal transplantation (Tx) in the Brazilian Unified Health System (SUS) and Supplementary Health (SS) in the city of Curitiba. The results showed that in the 1st year the mean cost for Tx recipients, treated with cyclosporine or with tacrolimus, was higher than that of patients maintained on hemodialysis, decreasing significantly in the second year while hemodialysis treatment remained practically unchanged. The cost of renal replacement therapy in Brazil and the story of the short blanket

Properly and effectively allocating public resources to promote health in a society is a controversial subject in public policy, since is required from the person in charge to manage the health resources to take in account the broad spectrum of diseases, from those that can be prevented to those that require more sophisticated and expensive treatments.Therefore, analyzes that evaluate cost-effectiveness, costutility and cost-benefit are of extreme importance to help in the allocation of resources to the different areas of health.
Unfortunately, these studies are still rare in Brazilian nephrology, as evidenced by a recent review of 83 national cost-effectiveness studies, where only two studies were related to the use of immunosuppressive agents in transplants and one referring to the treatment of renal replacement therapy. 1 Thus, the study of Gouveia et al., 2 "Analyzing the economic impact of renal replacement therapy," published in this issue of BJN, can be very useful for public health managers, nephrologists, and transplant physicians.
The authors analyzed the financial impact of the dialysis treatment (hemodialysis and peritoneal dialysis) and renal transplantation (Tx) in the Brazilian Unified Health System (SUS) and Supplementary Health (SS) in the city of Curitiba.The results showed that in the 1 st year the mean cost for Tx recipients, treated with cyclosporine or with tacrolimus, was higher than that of patients maintained on hemodialysis, decreasing significantly in the second year while hemodialysis treatment remained practically unchanged.

The cost of renal replacement therapy in Brazil and the story of the short blanket
O custo da terapia renal substitutiva no Brasil e a história do cobertor curto DOI: 10.5935/0101-2800.20170026 The results of Gouveia et al. corroborate international and national results, 3 showing that renal Tx, although more expensive in the 1 st year, becomes significantly less expensive after the 2 nd year and therefore is more cost-effective when compared to dialysis treatment.
However, as the authors themselves acknowledge at the end of the discussion, there are important limitations to this type of study among them is the fact that the authors did not calculate the actual medical-hospital cost, that is, all expenditure related to the consumption of resources for patient care, and inferred various expenses related to procedures.
However the study is an important example for elaboration of further studies of this type, where a correct detailing of the real cost and the cost-benefit of each procedure is sought.It is also commendable that the authors have shown the discrepancy between the SS compensation costs when compared to the SUS, for the different treatments: the SS pays by Tx half of the amount paid by the SUS while the dialysis reimbursement amount is twice the SUS value.This fact, which occurs almost all regions of the country, shows the distortion of remuneration by the two paying sources, the Tx by the SS and the dialysis by the SUS and again shows the urgent need for studies that show the real cost of these procedures.
Moreover, this study serves as a reflexive mathematical exercise in order we can have, at least, some idea of what and how much the expenses with renal replacement therapy represents in a country with serious healthcare budgetary limitations.As an example, the Ministry of Health reported that the SUS spent on transplantation hospital procedures (SIH), ambulatory care (SIA), preservation fluid and immunosuppressive drugs, around R$ 720 million in 2008 and R$ 1.3 billion in 2015 (http://portalquivos.saude.gov.br/images/pdf/2016/abril/04/Valores-gastos.pdf).
Considering that renal Tx accounts for about 70% of total Tx of solid organs performed in Brazil, the costs with this procedure, in the same years, increased 80%, from R$ 504 million (2008) to R$ 910 million (2015).In the same period, ABTO's Brazilian Registry of Transplants shows that the number of renal Tx increased only 45% (n = 3823 in 2008, n = 5556 in 2015; http://www.abto.org.br/abtov03/Upload/file/RBT/2015/anualrbt.pdf).These figures, although simplistic, show us that there is a serious and growing disproportion between the expenses reported by SUS and the number of renal Tx performed in the country and we are not convinced of the assuredness of these numbers.Therefore, governors might be tempted to make projections for the future and draw unrealistic and erroneous conclusions about cost estimates of Tx.
Certainly, in order to justify their decisions they will take advantage of the old story of the short blanket that when pulled to cover the ears, discovers the feet and vice-versa.