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Assisted peritoneal dialysis (aPD) was 'invented' in France in 1977 and was immediately very well reimbursed. This has since helped to maintain a high French peritoneal dialysis (PD) penetration rate among elderly dependent patients who might enjoy a better quality of life by remaining in their own environment. The aim of this study was to investigate the present status of aPD funding in European countries through a questionnaire sent in 2006 to health authorities and commercial PD providers asking about reimbursement modalities (in euro ([euro]) per patient per year) for nurse aPD. Specific funding for aPD only exists in Belgium, Denmark, France, Switzerland, and one region of Spain (Canary Islands). Germany and the United Kingdom are testing pilot schemes. Compared to France, all other countries exhibit significant differences in reimbursement for similar services (performing bag exchanges or disconnections from/to a cycler, exit site care, monitoring weight as well as blood pressure and ultrafiltration, and also including transportation costs) both for continuous ambulatory peritoneal dialysis (CAPD) (23 400 vs 7280 \[euro] per patient per year in Spain) and automated peritoneal dialysis (APD) (18 200 vs 5356 euro per patient per year in Belgium); these differences are difficult to understand and might reflect disparities in cost of living, national health-care budget, and/or mean nurses' salaries. Also, there is no correlation between these rates and the reimbursement for PD therapy itself. Only France and Belgium differentiate assisted CAPD and APD, but these differences do not reflect the time really spent at the patient's home. It is concluded that high reimbursement rates for assistance add significant extra cost to PD, but allow granting many dependent patients all the advantages of home therapy, instead of treating them with in-center hemodialysis which in any case still remains more expensive for our societies.

Background: In healthcare economics, the cost factor plays a leading role, particularly for chronic diseases such as end-stage renal disease because of the growing number of patients., Objectives: An international comparison was made of the costs and reimbursement/funding of a selection of key dialysis modalities--centre haemodialysis (CHD), limited care haemodialysis (LCHD), home haemodialysis (home HD), continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD)--in various industrial countries. The focus was on treatment costs plus erythropoietin medication and reimbursement of transportation costs., Results: Reimbursement/funding of dialysis is different from country to country, with some healthcare system-specific commonalities: in 'public' systems, the funding is based more on global budgets, whereas in mixed public and private countries it is based mainly on reimbursement rates per treatment. Only in the 'private system' of the US is there one DRG (diagnostic-related group)-type rate for dialysis. By comparing the costs (in public countries) or reimbursements (in mixed countries) of treatment modalities within each country, we could see similar curves: the costs were the highest for public CHD, followed by private CHD. They were lower on LCHD and the lowest for home HD and CAPD, which were at nearly the same level. The cost level for APD was almost the same as that of LCHD. The reimbursements followed the cost pattern. Some countries introduced increases for CAPD and APD with the intention of increasing the share of home care. The costs and reimbursement patterns in the majority of countries (except the US and Japan) were very similar and therefore did not explain the different distribution of modalities in these countries. One explanation could be, however, the difference in microeconomics, CHD being a treatment with high fixed costs (personnel and structure) and CAPD being a treatment with low fixed costs, but high variable costs (supplies) and a low need for investments., Discussion: The choice of treatment modality seems to be influenced strongly by the provider's perspective, being either public with limited HD capacity or private having invested in HD capacity. For public providers (and healthcare payers), CAPD is less expensive than CHD and offers a number of potential savings. In many countries, two CAPD patients could be treated for the same costs as one CHD patient. The microeconomics of private centres, however, are meant to use the investments maximally for CHD. Only if capacity limits are reached, is PD, with mainly supply costs, interesting. The future with constantly increasing numbers of patients and growing cost constraints will force all providers to make the best use of their resources by also offering home therapies such as PD to patients. The latter are cost efficient and offer comparable survival and quality of life.