approximately $500,000. An additional $170,000 would be obtained
from other sources.
5. Facilities

HEW's expenditures for facilities is anticipated to be $8,000,000

plus an additional $2,670,000 from other sources.

A summary of the benefits and costs associated with this program is

found in Table xX.
KIDNEY DISEASES RELATED TO HYPERTENSIVE VASCULAR DISEASES, HYPOTHETICAL PROGRAM
AT INTERMEDIATE HEW EXPENDITURE LEVEL, BASED ON THE CURRENT STATE OF THE ART

 

Short-Term Benefits

Long-Term Benefits

 

 

 

PICT
c

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reduction Reduction In
Expenditures Per Year In End-Stage Uremia
HEW Total
Program ($1,000) ($1,000) Mortality] Prevalence} Morbid Days | Per Year| Cumulative
I.A. Screening, diagnosis and treatment of
individuals 17 years of age and over
with known curable (non-essential)
hypertension and non-curable hyperten-
sion and individuals who would have had
undetected hypertension without the
initiation of the program component 948 4,740 y
1. Screening (57) (284)
~ — | 463,200
} 2. Diagnosis and treatment — (32,442 )
948 467,940
Sub-Total (57) (32,726)
8,000 10,670
B, Supportive education and administration (8,000) (10,670)
8,948 478,610
Sub-Total (8,057) (43, 396)
4,650 6,200
II. Research (4,650) (6,200)
500 670
Ill, Training (500) (670)
8,000 10,670
IV. Facilities (8,000) (10,670)
TOTAL 22,098 496,150 8,070 69,750 6,193,720
(21,207) (60,936) (2,270) (34,880) (2 ,056,820)) (4,820) | (95,300)
L/ Figures in parenthesis refer to statistics attributable to renal complications

 
152

Kidney Diseases Related to Hypertensive Vascular Diseases, Hypothetical
Program at Accelerated HEW Expenditure Level, Based on the Current State

of the Art ,

l. Introduction

This program has four components:

1) Screening,. diagnosis, treatment, and supportive education and

administration;

2) Research;

3) Training; and

4) Facilities.

The estimated total cost for this program is $566,700,000 ($75,441,000
for associated renal complications). HEW will account for $30,421,000 |
($28,639,000 for associated renal problems). “Figure ll illustrates the
total program expenditures by components. A discussion of these various
program components follows.

2. Screening, Diagnosis, Treatment, and Supportive Education and
Administration

With an accelerated program there is no expected change in the
target populations.
a. Relevant Population and Program Component Costs
The screening program for undetected hypertensive patients
will be accelerated so that rather than taking six years to reach
50% of the 43,500,000 individuals at risk, three years would be

sufficient to complete the task.

An average of 7,580,000 individuals are expected to be screened
119/
per year. Of these, 350,000 will have hypertension.

Screening costs are estimated at $1.25 per individual (as part of

a general screening program). Total screening cost is $9,480,000
Costs ($1,000, 000)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

150 —
100 —
75.4
Diagnosis
and
Treatment
(50.7)
50 —
28.6 F— Diagnosis and
Treatment (10.1) Research (7.3)
Trainin 1.9
Research (5.5) & ¢ )
Training (1.4) Facilities
Facilities (15.5)
(11.6)
HEW TOTAL
PROGRAM
Fig. 11. Kidney Diseases Related to Hypertensive Vascular Disease,

Hypothetical Program Costs at Accelerated HEW Expediture Level
Based on the Current State of the Art.
per year ($569,000 attributed to associated renal problems). HEW
will contribute to this program an estimated $1,896,000 ($114,000
for associated renal problems).

If 15% of the 350,000 patients with positive screening tests
have curable hypertension (i.e., 52,500 and if the yearly treat-
ment and confirming diagnosis cost per individual is $1,000, then
total treatment Costs for this group are $52,500,000 per year
(10% or $5,250,000 for associated renal complications).

If 85% of the 350,000 have currently non-curable hypertension
(i.e., 297,500), and if the estimated cost of treatment is $200 per
individual per year, total treatment costs for these individuals
are estimated at $59,500,000 per year ($3,570,000 for associated
renal disease).

Total costs for this component (and for all the surveyed popu-
lation) is now estimated at $528,680,000 ($37,421,000 for associated
renal complications). HEW's contribution is $1,896,000 ($114,000
for associated renal disease).

Financial support for education and administration in the
accelerated program is $10,000,000 to come from HEW with an additional
$3,330,000 anticipated from outside sources.

The total cost for this program component is $542,010,000
($50,751,000 for associated renal complications), of which HEW will
contribute $11,896,000 ($10,114,000 for associated renal complica-
tions).

b. Short-Term Benefits

The following are estimated short-term benefits:
(1)

(2)

(3)

154

Newly Detected Potentially Curable (non-essential)
Hypertensives:

1)

2)

3)

A 60% decrease in the immediate mortality of the in-
dividuals with curable hypertension is anticipated.
From a base line of 290 nee! deaths occurring without
this health program, there would be 170 prevented
deaths (50% or approximately 90 reflect deaths avoided
in patients having associated renal problems).

A 60% reduction in prevalence of 31,500 from the base
line of 52,500 cases is expected (50%, or 15,750,

121/
with associated renal problems).

Morbid days are also expected to be reduced by 60%
122/
from a base line of 840,000 to 504,000 (252,000

attributed to associated renal disease).

Newly Detected Currently Non-Curable (essential)

 

Hypertensives:

1)

2)

An estimated 15% decrease in mortality from a base
line of 2,140 22" deaths to 320 (27% or 90 patients
having associated renal disease).

An estimated 20% reduction in the number of morbid
days is anticipated, i.e., a decrease of 952,000
from a base line of 4,760,000 (27% or 257,040 due

to associated renal problems).

All Surveyed Hypertensives:

Total short-term benefits for the surveyed high-risk groups

are 10,260 prevented deaths (2,370 with associated renal prob-

lems), a reduction in the number of cases by 85,500 (42,750

with associated renal problems), and a reduction in morbid days
toa

OT
ora

by 7,395,200 (2,311,340 in patients with associated renal
problems).
c. Long-Term Benefits
The following are estimated long-term benefits:
(1) Annual Long-Term Benefits

Under an accelerated program, there will be no change in
the number of currently undiagnosed hypertensives who can be
reached compared to the number reached in the intermediate
program. Therefore, the annual long-term benefits will be
identical with that group: an annual reduction of fatal end-
stage uremia by 330 in currently non-curable hypertensives.

Total annual long-term benefits for all the surveyed high
risk groups equal a reduction in fatal end-stage renal failure
by 4,820 each year.

(2) Cumulative Long-Term Benefits

No changes from the intermediate program are anticipated.
A reduction of 3,120 in the number of cases of fatal end-stape
uremia will occur.

Total cumulative long-term benefits for all of the surveyed
high-risk groups are 96,300 prevented cases of fatal end-stage
uremia.

3. Research

Under an accelerated HEW funding program, an additional increase in
the number of research projects is anticipated to encompass a total of
30 laboratory research study groups costing $40,000 per group, for a
total cost of $1,200,000. Thirty clinical research study groups costing

$50,000 per group will also be in progress yielding a total of $1,500,000.
ey
ay

Approximately $2,800,000 will be expended on 70 individual research
grants, averaging $40,000 per grant. Total HEW support for research is
expected to be $5,500,000. An additional $1,830,000 is anticipated
from outside sources.
4, Training

The training of physicians and allied medical personnel would cost
HEW approximately $1,425,000 with an additional $475,000 from other
sources.
5. Facilities

Under an accelerated HEW health program, $11,600,000 would be
expended on facilities. An additional $3,860,000 would come from other

sources.

A summary of the benefits and costs associated with this program is

found in Table XI.
Table XI

KIDNEY DISEASES RELATED TO HYPERTENSIVE VASCULAR DISEASES, HYPOTHETICAL PROGRAM
AT ACCELERATED HEW EXPENDITURE LEVEL, BASED ON THE CURRENT STATE OF THE ART

 

Short-Term Benefits

Long-Term Benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figures in parenthesis refer to statistics attributable to renal complications.

Reduction Reduction In
Expenditures Per Year In End-Stage Uremia
HEW Total
Program ($1,000) ($1,000) Mortality| Prevalence |Morbid Days }| Per Year /Cumulative
I.A. Screening, diagnosis and treatment of
individuals 17 years of age and over
with known curable (non-essential) hy-
pertension and non-curable hypertension
and individuals who would have had un-
detected hypertension without the ini-
tiation of the program component. 1,896 9,480 y
1. Screening (114) (569)
ao _ 519,200
ye 2. Diagnosis and treatment — (36,852)
q
1,896 528,680
Sub-Total (114) (37,421)
10,000 13,330
B, Education and administration for I.A,. (10,000) (13,330)
11,896 542,010
Sub-Total (10,114) (50,751)
Il. Research 5,500 7,330
TIT, Training 1,425 1,900
Iv. Facilities 11,600 15,460
30,421 566,700 10,260 85,500 7,395,220
TOTAL (28,639 (75,441) (2,380) (42,750) (2,311,340); (4,820) (96, 300)
L/

 
Kidney Diseases Related to Hypertensive Vascular Diseases, Hypothetical
Program for Fiscal Year 1975, at Accelerated HEW Expenditure Level,
Based on the Expected Advanced State of the Art in 1975

1. Introduction

This program has four components:

1)

2)
3)
4)

The

Screening, diagnosis, treatment and supportive education and
administration;

Research;

Training; and

Facilities.

estimated total cost for this program is $878,675,000

($101,438,000 for associated renal problems). HEW will account for

$37,899,

000 ($35,832,000 for associated renal problems).

Anticipated advances in the state of the art include:

1)

2)

3)

4)

Advances in the knowledge concerning the underlying causes of
hypertension, e.g., an appreciation of the renin-angiotensin
mechanism;

Specific therapy directed toward the underlying causes cof hyper-
tension, e.g., an anti~renin substance in a situation in which
renin could be a cause of hypertension;

Improved diagnostic tests for detecting hypertension, e.B.y
advanced use of radio-isotopes, improved split renal function
tests, implementation of photo-electric methods for determining
high blood pressure, etc.; and

Advances in the art of treatment of surgically treatable hyper-

tension, e.g., improved vascular prostheses, etc.

Figure 12 illustrates the total program expenditures by components
Costs ($1,000,000)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

150 -
101.4 Jw
Diagnosis &
Treatment
(70)
50 =
35.8 fo -
Diagnosis &
Treatment
(11.7) Research
Research (12.0)
(9.5
(9.5) Training (4.0)
Training (3.0) .
Facilities
Facilities (15.4)
(11.6)
HEW TOTAL

Fig. 1

PROGRAM

Kidney Diseases Related to Hypertensive Vascular Diseases,
Hypothetical Program Costs for Fiscal Year 1975, at
Accelerated HEW Expenditure Level, Based on Expected
Advanced State of the Art in 1975.

L57a
258

including associated renal disease. A detailed discussion of the various

program components follows.

2. Screening, Diagnosis, Treatment, and Supportive Education and
Administration

In 1975, the accelerated program activity reflects changes in the
population. The ratio of the 1975 population of individuals 17 years of
age and over to that of 1966 is estimated at 1.16.22 No changes in the
number of target population groups are anticipated.

a. Relevant Population and Program Component Costs

It is estimated that there will be about 104,400 patients with
non-essential hypertension from among currently known hypertensives
receiving more adequate treatment. At an estimated cost of $1,000
per individual treated per year, a cost figure of $104,400,000 (102,
or $10,440,000, for those having associated renal disease) is arrived
at.

In 1975, there will be approximately 9,198,800 individuals with
essential hypertension among those currently knowto be hypertensives.
This accelerated program is designed to affect 20% of these individuals.
As a result of improved treatment programs and further advances in

the state of the art, it is estimated that the treatment costs for

these individuals per year is $300. | Assuming no additional expense
for screening, the cost for treatment and differential diagnosis for
the affected individuals is now estimated at $551,928,000 (6%, or
$31,116,000, attributed to associated renal problems).

In 1975, assuming no change in the current health services
system, there will be 50,460,000 individuals 17 years of age and

over who have not been seen by a physician in the previous year.
alk

Again, it is assumed that the program will be able to reach 50%

of these patients (26,390,000) over a three-year period. With an

accelerated program effort, approximately 33% (8,797,440) of these

persons will be reached each year. Screening costs per individual

per year remain at $1.25 (as part of a general screening program).

The total cost for screening is estimated at $10,997,000 ($660,000
127/

for associated renal dysfunction). HEW's share in this program

is estimated to be $2,199,000 ($132,000 for associated renal disease).

Of the anticipated 2,436,000 individuals who will have hyper-
tension detectable in these screening tests, it is assumed that 50%
will be detected over a period of three years; 406,000 will be
reached each year. Of this group, 15% or 60,900 individuals will
have non-essential hypertension. At a cost of $1,000 per year per
individual for treatment and differential diagnosis, the total cost
in this group is $60,900,000 (10% or $6,090,000 for patients with
associated renal problems).

Approximately 85% of the 406,000 hypertensive patients, or 345,100,
will have essential hypertension. At a cost of $300 per year per
individual for treatment, the total cost is estimated to be
$103,530,000 (6%, or $6,212,000, attributed to associated renal
diseases).

Total treatment costs for all groups are estimated at $820,758,000
($53,858,000 for associated renal problems). These costs are not
expected to be borne by HEW.

Total cost for this entire component (screening, diagnosis, and

treatment) is $831,755,000 ($54,518,000 for associated renal problems).

cry

CO
Ze

HEW will contribute $2,199,000 ($132,000 for associated renal

problems).

The educational and administrative support for this program

component is estimated to cost $15,460,000 of which $11,600,000

would come from HEW and an anticipated $3,860,000 would come from

other sources.

Total cost for the entire program component is $847,215,000

($69,978,000 for associated renal problems). HEW's contribution

is $13,799,000 ($11,732,000 for associated renal problems).

128/

b. Short-Term Benefits

The following are estimated short-term benefits:

(1) Known Hypertensives with Potentially Curable (non-essential)
Hypertension:

1)

2)

3)

A 654 reduction in immediate mortality is expected from a
base line of 660 expected deaths (i.e., 430 prevented
deaths of which 220 have associated renal problems).
About 5 of the 65%, or 30 (20 from renal involvement),
can be attributed to the advanced state of the art;

A reduction of 65% in prevalence is anticipated, or
67,860, from a base line of 104,400 (33,930 with renal
problems). About 5 of the 65% or 5,220 prevented cases
can be attributed to advances in the state of the art
(2,610 with renal problems); and

A 65% reduction in the number of morbid days from a

base line of 1,670,400, or a reduction of 1,085,760 days
(542,880 of the reduction in morbid days would have
associated renal problems). About 5 of the 65% reduction

in morbid days, or 83,520, is attributed to advances in
-61

the state of the art (41,760 are in patients with renal

problems).

(2) Known Hypertensives with Essential Hypertension

1)

2)

3)

Mortality will be reduced by 554, or by 31,860, from a
base line of 57,930 (8,600 with associated renal problems).
Forty of the 55% decrease, or 23,170, is attributed to
advances in the state of the art (6,260 represent patients
with associated renal problems);

It is estimated that a 40% reduction of 735,900 in the
number of cases from a base line of 1,133,760 will occur
(198,690 with renal complications) all of which is attribu-
ted to advances in the state of the art; and

A 50% reduction in morbid days, or 14,718,050, is
anticipated from a base line of 29,436,160 (3,973,880

in patients with associated renal problems). Thirty of

the 50% reduction, or 8,830,850 days are attributed to

the advances in the state of the art (2,384,330 in

patients with associated renal disease).

(3) Undiagnosed Individuals with Non-Essential Hypertension

1)

2)

An estimated reduction in immediate mortality by 65%, or
by 220, from a base line of 340 (110 with associated renal
problems). About 5 of the 65% reduction, or 20, is
attributed to advances in the state of the art (10
represent patients with associated renal problems) ;

A 65% reduction, 39,590, in prevalence is also anticipated
3)

262

from a base line of 60,900 (19,800 are patients with
associated renal problems). About 5 of the 65%
reduction, or 3,050 controlled cases are attributable
to advances in the state of the art (1,530 of these
would have had associated renal problems); and

Morbid days will be reduced by 65%, or 633,360, from a
base line of 974,400 (316,680 of these in patients with
associated renal problems). Five of the 65% reduction,
or 48,720 days are attributable to advances in the
state of the art (24,360 in patients with associated

renal problems).

(4) Undiagnosed Individuals with Essential Hypertension

1)

2)

3)

A 55% reduction in immediate mortality, or 1,360, is
anticipated from a base line of 2,480 deaths (370 of the
prevented deaths would have been associated with renal
failure). Forty of the 55% reduction, or 990 deaths
avoided are attributed to advances in the state of

the art (270 in patients with associated renal problems) ;
Prevalence will decrease by 40%, or by 138,040, cases,
from a base line of 345,100 (37,270 would be cases

with associated renal disorders) all of which is
attributable to advances in the state of the art; and

A 50% reduction in morbid days, or 2,760,800, is
anticipated from a base line of 5,521,600 (745,420 in
patients with associated renal problems). Thirty of the
50% reduction, or 1,656,480 morbid days avoided may be

attributed to advances in the state of the art (447,250
(5)

163

of these in patients with associated renal disease).

All Surveyed Hypertensive Patients

1)

2)

3)

Immediate mortality will be reduced by 33,870 cases
(9,300 would have been patients with associated renal
problems). Approximately 24,210 of these are attributed
to advances in the state of the art (6,560 of these
would have been patients with associated renal problems);
Prevalence will be reduced by 981,390 cases (289,690
with associated renal problems). 882,210 of the total
reduction in prevalence is attributed to advances in the
state of the art (240,100 would have been patients with
associated renal problems) ; and

Morbid days will be reduced by 19,198,000 (5,578,860 in
patients with associated renal problems). Approximately
10,619,570 of the total reduction is attributed to
advances in the state of the art (2,897,700 in patients

with associated renal problems).
129/

Long-Term Benefits

(1)

Annual Long-Term Benefits

It is anticipated that 3,690 out of 5,680 individuals with

known non-essential hypertension (who would normally progress

to renal failure), can be prevented from developing end-stage

kidney failure each year. Approximately 5 of this 65% reduction

(a reduction of 280 cases/year) is attributed to advances in the

state of the art.
264

For the group of known patients with essential hypertension,
it is expected that 4,830, or 30% of 16,100 individuals (who
would develop renal failure), can be prevented from progressing
to end-stage renal failure each year. About 20 of the 30%
reduction (a reduction of 3,220 cases/year is attributed to
advances in the state of the art.

In the group of individuals with undetected non-essential
hypertension it is anticipated that a 65% reduction in end-
stage uremia will occur from the base line of 640 (420 such
cases averted each year). About 5 of the 65% reduction, or
30 cases of prevented end-stage uremia per year are attributed
to advances in the state of the art.

In the group of individuals with undetected essential
hypertension it is anticipated that a 30% reduction (540 cases)
in end-stage uremia will occur from a base line of 1,810 cases
of renal failure which would normally occur each year. About
20 of the 30% reduction, or 360 cases averted can be attributed
to advances in the state of the art.

For all surveyed hypertensive groups the reduction in end-
stage uremia is estimated at 9,480 per year. Approximately
3,890 of these cases are attributed to advances in the state
of the art.

(2) Cumulative Long-Term Benefits

In the group of patients with known non-essential hypertension

a 65% reduction in cumulative long-term cases of end-stage uremia

is anticipated. This will amount to a reduction of 73,890
765

cases from a base line of 113,680. Approximately 5 of the 65%
reduction, or a reduction of 5,680 cases of end-stage uremia
can be attributed to advances in the state of the art.

in the group of patients with known essential hypertension
a 30% reduction in cumulative long-term end-stage uremia is
anticipated. This amounts to 96,590 cases avoided from a
base line of 321,960. About 20 of the 30% reduction, or 64,390
cases of end-stage uremia avoided, are attributed to advances
in the state of the art.

In the group of individuals with undetected non-essential
hypertension it is estimated that a 65% reduction in end-stage
uremia will occur. This will amount to 8,310 cases avoided
from a base line of 12,790 (5 of the 63% reduction, or a reduc-
tion of 640 cases, is attributed to advances in the state of the
art).

In the group of individuals with undetected essential hyper-
tension it is anticipated that a 30% reduction of 10,870 in
the number of cases of end-stage uremia will occur from a
base line of 36,240. About 20 of the 30% reduction, ora
reduction of 7,250 cases is attributed to advances in the
state of the art.

Total cumulative long-term benefits for all groups surveyed
are the prevention of 189,660 cases of end-stage uremia, 77,960
of which are attributable to advances in the state of the art.

3. Research
It is anticipated that in this hypothetical situation an estimated

$9,500,000 would be required from HEW and an additional $2,500,000 from
26

other institutions to support the various research programs.
4. Training

With the advanced state of the art, it is anticipated that there
will be an additional requirement for the training of physicians and
allied medical personnel requiring increased financial support amounting
to $3,000,000 from HEW with an additional $1,000,000 to come from other

agencies.
5. Facilities
Expenditures for facilities are estimated to be $15,460,000 of which

$11,600,000 will come from HEW and an additional $3,860,000 will come

from other sources.

A benefit-cost summary associated with this program is presented in

ible XII.

130/
6. Estimated Benefits Dependent on Research and Development

Advances in the state of the art would produce a further 5% decrease
in short-term mortality, prevalence, and morbid days for known patients
with non-essential hypertension. A 5% long-term reduction in end-stage
uremia is also anticipated.

A further 40% decrease in immediate mortality and prevalence is
estimated for the group of patients with known essential hypertension.
Also anticipated is an additional 30% decrease in morbid days and an
additional 20% reduction in end-stage renal failure.

A summary of the short-term benefits dependent on research and

development follows:
Table XIT

KIDNEY DISEASES RELATED TO HYPERTENSIVE VASCULAR DISEASES, HYPOTHETICAL PROGRAM FOR FISCAL YEAR 1975
AT ACCELERATED HEW EXPENDITURE LEVEL, BASED ON EXPECTED ADVANCED STATE OF THE ART IN 1975

 

 

 

 

eQgy

 

 

 

 

 

 

 

 

 

 

 

 

Short-Term Benefits Long-Term Benefits
Reduction Reduction In
Expenditures Per Year In End~Stage Uremia
HEW Total
Program ($1,000) ($1,000) Mortality |Prevalence|Morbid Days |Per Year |Cumulative
I.A. Screening, Diagnosis and treatment of
individuals 17 years of age and over
with known curable (non-essential)
hypertension and non-curable hyperten-
sion and individuals who would have
had undetected hypertension without the
initiation of the program component 2,199 i 10,997
1, Screening (132)= (660)
— 820,758
2. Diagnosis and treatment — (53,858)
2,199 831,755
Sub-Total (132) (54,518)
11,600 15,460
B. Supportive education and administrtion (11,600) (15,460)
13,799 847,215
Sub-Total (11,732) (69,978)
9,500 12,000
IL. Research (9,500) (12,000)
3,000 4,000
IIL, Training (3,000) (4,000)
11,600 15,460
Iv. Facilities (11,600) (15,460)
37,899 878,675 33,870 981,390 19,198,000
TOTAL (35,332) | (101,438) (9,300) |(289,690) (5,578,860) (9,480) (189,660)

 

 

 

 

 

 

 

L/ Figures in nareninesis refer ta ctaticris
1)

2)

3)

267

24,210 prevented deaths (6,560 in patients with associated renal
problems) ;

A reduction in prevalence by 882,210 (240,100 cases with
associated renal problems); and

A reduction in morbid days by 10,619,570 (2,897,700 in patients

with renal problems).

A summary of the long-term benefits includes:

1)

2)

An annual reduction in cases of end-stage kidney disease of
3,890; and
A cumulative reduction in the cases of end-stage kidney disease

of approximately 77,960.

All of these benefits have been based on the projected 1975 population

of individuals 17 years of age and over, which is estimated to be 16%

greater than the 1966 population. Disregarding the effects of population

changes, it is estimated that the following short-term benefits are the

result of research and development advances (using 1966 population figures):

1)

2)

3)

Approximately 20,870 prevented deaths (5,660 in patients with
associated renal problems);

A reduction in prevalence by 760,530 (206,980 cases with associated
renal problems); and

A reduction in morbid days by 9,154,800 (2,498,020 in patients

with associated renal problems).

Long-term benefits dependent on research and development are estimated

as follows:

1)

2)

An annual reduction in the cases of end-stage kidney disease of
3,350; and

A cumulative reduction in the cases of end-stage kidney disease of

67,210.
V. END-STAGE KIDNEY DISEASE
A. Introduction

This section describes programs which are concerned with alleviating the
effects of end-stage kidney disease--the result of a natural progression of
the infectious, hypersensitivity, hypertensive, and other kidney disease
processes. End-stage kidney disease is currently treated by two procedures,
chronic intermittent hemodialysis and kidney transplantation.

Approximately 50,000 people die as a result of uremia each year .t3l/

Of these 50,000 about 79% are in the age group above 55, about 19% are in

the age group 15-54, and about 2% are in the age group 0-14. It has been
estimated that of the 50,000 annual end-stage uremia victims, about 8,000232/
are ideally suited for dialysis therapy. While published estimates of
transplant candidates are not available, it is assumed for the purposes of
this report that about 6,000 of the ideal dialysis candidates are also ideal
transplant candidates. It is also assumed that an additional 2,000 persons
would be suited for transplantation but not for chronic dialysis .233/ Most
patients suitable for either procedure are within the 15-54 age group.

A schematic representing the progression of a patient into a hemodialysis
and/or transplant program is presented in Figure 13. With the development of
end-stage uremia, the patient becomes a candidate for chronic intermittent
dialysis or renal transplantation. Following the transplant procedure
(especially if a cadaver kidney has been used), the patient may require
temporary dialysis until the transplanted kidney is functioning normally.

If the transplant has been successful, the patient exits from the program.

If the transplant is unsuccessful, the patient is returned to the chronic
 

 

Infections of
the Kidney

 

 

Hypertensive
Kidney Disease

 

 

Hypersensitivity
Kidney Disease

Other Kidney or
Urinary System

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disease
”
oo
a
End-Stage Uremia
Chronic
Intermittent Transplantation
Dialysis
rN
Temporary
Dialysis
unsuccessful ‘J Successful
transplant Transplant
Fig. 13. Schematic of Transplant and Dialysis Patients.

168a
269

intermittent dialysis program either for life or to await a second attempt
of transplantation. Certain patients undergoing chronic intermittent
dialysis therapy are suitable for transplantation and may be dialysed
only until a matching donor kidney is available. Death, of course, can
occur at any stage in the schematic.

Benefits attributable to the various dialysis progrems presented in this
section are measured in terms of reduction in mortality (lives prolonged) for
the year in which the program is active.

In contrast to transplantation, which--if successful--is a one-time
treatment, chronic dialysis is an ongoing type of treatment. All patients
on dialysis who survive the first year must be treated in successive years.
Thus, if during year x, there are 1,000 patients who are being maintained
on hemodialysis, all of these patients less those dying during the year
must be treated in subsequent years. If the mortality rate among these
1,000 dialysis patients is 20%, only facilities for some 200 new patients
would be available for the 8,000 ideal dialysis candidates who will develop
end-stage uremia during the next year. This situation is further compli-
cated by the addition of those persons with unsuccessful transplants who
require subsequently chronic dialysis treatment in order to survive.

The benefits attributed to transplantation are measured in terms of a
reduction in mortality (patients eured). As is shown in Figure 14, the
patient undergoing transplantation may, as 4 result of the procedure, a) be
cured, b) die, or c) have an unsuccessful transplant subsequently he will
enter a chronic dialysis program or be retransplanted. The benefits, as
measured here take into account only those who are cured by the transplant
procedure. Those persons not successfully transplanted who survive will,
of course, become part of the chronic dialysis patient population or will

be retransplanted.
Four specific programs have been postulated in this analysis. (See
Chapter 4, Research Methodology.) ‘These are described in detail in the

following sections.

B. End-Stage Uremia Program, Hypothetical Program at Current HEW Expenditure
Level, Based on Current State of the Art

1. Introduction

This program has five components consisting of:

1) Treatment by dialysis,

2) Treatment by transplantation,

3) Research,

4) Training, and

5) Facilities.
HEW costs and total costs of this program are presented in Figure 1.
As can be seen, total program costs are about $33,000,000 with HEW
expenditures at approximately $21,000,000. This hypothetical program is
essentially a reflection of the current allocation of funds for end-stage

uremia programs. A discussion of the various components of the program

follows.
2. Dialysis Treatment
As was indicated earlier, with the present operational state, only
about 8,000 of the 50,000 annual uremic victims are ideal candidates for
life-long chronic hemodialysis. Of these 8,000 annual dialysis candi-
dates about 750134/ are currently receiving treatment. Treatment costs
for some 225 of these treated patients can be attributed to HEW funding, 232/
about 175, to the Veterans Administration/30/ and the remainder to other

sourcese
Costs ($1,000,000)

150 r-

100 —

32.9

20.8

 

Treatment (17.8)

 

Treatment (7.2)

 

 

 

 

Research (12.1) Research (12.8)
Training (1.0

Faeilities (0.5

 

 

1-3).

Facilities ¢

 

 

 

Fig. 14.

HEW TOTAL
PROGRAM

End-Stage Uremia, Hypothetical Program Casts at Current HEW
Expenditure Level, Based on the Current State of the Art.

170a
171

The present cost of chronic dialysis is approximately $15,000 per
year per patient.232/ The cost of dialysis as used here is derived from
the cost in organized hospital dialysis centers supported by Government
funds. If such a treatment were to be undertaken independently, private
eosts would run considerably higher. It has been estimated for the
purposes of this study that the cost of private dialysis is on the order
of $20,000 per year per patient. Current total expenditures for chronic
dialysis therapy for the year are approximately $13,000,000 of which
about $3,400,000 can be attributed to wEw.238/

In determining the benefits associated with this dialysis program,
(see Section A above), it 4s assumed that treated patients suffer an
annual 20% overall mortality 232/ Approximately 600 lives are saved
due to the total current program efforts. Of these, about 180 lives
saved can be attributed to HEW funding.

3. Transplantation Treatment ,

As indicated above, approximately 8,000 individuals of the 50,000
who die annually from end-stage uremia are ideally suited for trans-
plantation. Of these, approximately 300 patients per year are now being
treated by transplantation. About 2ho of these can be attributed to
HEW punding 240/ Those individuals who are not cured by transplantation
and who survive, usually must revert to chronic intermittent dialysis in
order to survive.

The cost of transplantation is estimated to be approximately $16,000
per patient per year 2t/ A total of $4,800,000 is spent in transplant

treatments of which about $3,800,000 can be attributed to wow 22/
212

Benefits associated with this transplant program are measured in
terms of a reduction in mortality (patients cured, see Section A above).
The average mortality rate among patients undergoing transplantation
(with kidneys from living donors or utilizing "cadaver kidneys”) is
estimated to be about nog. 23/ Among the 60% who survive, about one-half
are curea Ltt/ The remainder must revert to chronic hemodialysis
therapy or adjunctive dialysis pending retransplantation. The mmber
of patients cured as a result of the total program was found to be
90 of which 72 can be attributed to HEW funding.

4, Research

Expenditures in dialysis and transplant research totaled about
$12,800,000 of which $12,100,000 was expended by HEW. Current HEW
programs include intra- and extramural laboratory and clinical research
and demonstration grants involving about 188 projects Lte/

5. Training

It-is estimated that about $1,000,000 is being expended by HEW in

the area of training and education of personnel to work in dialysis and

transplant operations and related research programs. This value also

reflects total U. S. training expenditures 16/

6. Facilities

Expenditures for facility construction, expansion and remodeling
are estimated to be about $1, 300,000, 2#1/ of which $500,000 is being
expended by HEW,

No benefits were estimated for research, training and facility expend-~

itures although quite obviously these funds will provide long-term
benefits.
7. Summary
HEW expenditures for this program are about $21,000,000 with total

program expenditures estimated at about $33,000,000. Total benefits
derived from these expenditures are about 690 lives saved of which

about 250 can be attributed to HEW.

A summary of benefits and costs attributed to this program are presented

in Table XIII.
RPCLT

END-STAGE UREMIA, HYPOTHETICAL PROGRAM

Table XIII

AT CURRENT HEW EXPENDITURE LEVEL, BASED ON THE CURRENT STATE OF THE ART

 

Short-Term Benefits

 

 

 

 

 

 

 

Expenditures Reduction in Mortality for 1966
HEW Total HEW Program Total Program
Programs ($ 1,000) ($ 1,000) (No. of Lives) (No. of Lives)
Dialysis 3,400 13,025 180 600
Transplant 3,840 4,800 72 90,
Research 12,100 12,800
Training 1,000 1,000
Facilities 500 1,300
Totals 20,840 32,925 252 690

 

 

 

 

 
,@

174

End-Stage Uremia, Hypothetical Program at Intermediate HEW
Expenditure Level, Based on Current State of the Art

1. Introduction

This program describes what could be accomplished in an end-stage
uremia program with an "4 ntermediate” funding level (i.e., two to
three times greater than the current level), and no change in the
current state of the art. There are five components in this program
including: |

1) Dialysis treatment,

2) Transplantation treatment,

3) Research,

4) Training, and

5) Facilities.

The total cost of this intermediate program would be about
$70,500,000 of which HEW would contribute about $56,000,000. Figure 15
graphically presents the expenditures under this program. A description
of the program components follows.

2, Dialysis Treatment

There are now a total of 1,430 persons undergoing chronic dialysis
therapy due to the increase in fundssupporting treatment. Of these,
about 880 can be attributed to HEW support. It is estimated that
because of the general availability of HEW funds, the VA will have about
200 chronic dialysis patients (an increase of 25 over the current level

program), and that there will still be about 350 patients being treated
through other resources.

It is anticipated that the annual cost of chronic dialysis will-

‘remain at about $15,000 per year for patients supported by HEW and VA

funds, and that treatment by private resources will remain at about

$20,000. A total of $21,000,000 will be expended for dialysis treatment.
Costs ($1,000,000)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

150 —
100 -—
70.5
56 |
50 LL
Treatment
(43)
Treatment
(30)
Research Research
(18) (18.7)
Training (5.5) Training (5.5)
TMacilities (2.3) Facilities (3.3)
HEW TOTAL

PROGRAM

Fig. 15. End-Stage Uremia, Hypothetical Program Costs at Intermediate.
HEW Expenditure Level, Based on the Current State of the Art.

174a
175

It is assumed that there is no change in the 20% annual overall
mortality rate associated with chronic dialysis therapy. Total
penefits derived from this program are about 1,144 lives prolonged

of which about 704 can be attributed to HEW funding.

3. Transplant Treatment

This program provides financial support for 1,387 persons undergoing
kidney transplantations on an annual pasis. Of these, about 1,187 can
ve attributed to HEW funding. It is assumed that the cost of trans-
plantation will remain at $16,000, which as indicated previously,
ineludes the actual transplant procedure and pre- and post-operative
supportive therapy. The total cost of the transplant program is about
$22,200,000 of which HEW contributes about $19,000,000.

The benefits associated with this program are measured in terms of
a reduction in mortality (patients cured). It is assumed that the
general increase in funding has not markedly affected either the

mortality rate associated with this procedure ( about 40%) or the cure

rate among surviving transplantees (about 50%). About 416 patients

are cured as a result of this program of which 356 can be attributed

to HEW funding.

4. Research

It is anticipated that research expenditures will increase to about

$18,000,000. While no specific research plans for dialysis and trans-

plantation will be outlined, it is anticipated that the existing 188

intra- and extramural research projects (please see previous program)

will increase in number and in some instances, in scope. Research