End-of-life healthcare utilisation and costs of older patients on kidney replacement therapy - analysis of Dutch health insurance claims data

Background: Patients on kidney replacement therapy (KRT) face high symptom and treatment burden, especially at end of life. Yet insights into end-of-life healthcare utilisation and costs remain limited. We aimed to describe healthcare utilisation and costs during the last year of life across KRT modalities. Methods: We used Dutch health insurance claims data to identify incident and prevalent patients aged ≥ 65 years, treated with KRT during the year preceding death, and who deceased between June 2016 and December 2021. Healthcare utilisation and costs in the last year of life were analysed for different KRT modalities and compared with controls without kidney disease-related claims, with controls being matched on sex, age, socio-economic status, and year of death. Results: We identified 7279 patients on KRT (4614 haemodialysis [HD] patients, 766 peritoneal dialysis [PD] patients and 1899 kidney transplant [KTx] recipients) and 14,558 controls. During their last year of life, 85% of patients on KRT experienced ≥ 1 hospital admission, with 27% requiring intensive care - representing to 2.6- and 3.5-fold higher proportions than in their controls, with minimal variation across KRT modalities. Similar differences were observed for emergency department visits, outpatient visits, and long-term care use. Healthcare utilisation significantly increased in the last three months preceding death, more markedly among patients on KRT than controls (p < 0.001). Average healthcare costs were 5.9, 5.5 and 3.0 times higher for patients on HD (€117,520), PD (€108.294), and KTx recipients (€59,489), respectively, compared to controls (€19,820). KRT-unrelated costs, encompassing 40% to 74% of total costs, were 2.2 to 2.6 times higher in patients on KRT compared to controls, with specialist hospital care costs being three times higher. Conclusion: In the last year of life, healthcare utilisation is higher for patients on KRT compared to controls, with a further increase towards end-of-life, along with higher KRT-unrelated costs.