Outcomes and Trade-offs of Thailand's 2022 Patient-Choice Dialysis Policy Reform.

Introduction: In February 2022, Thailand transitioned from a 14-year "peritoneal dialysis (PD)-first" policy to a "patient-choice" model, allowing unrestricted modality selection. This study evaluated the patient- and system-level impacts of this policy change on access, providers, expenditure, and outcomes. Methods: We linked nationwide administrative datasets (2018-2024). System-level trends in dialysis prevalence, incidence, and mortality were evaluated using interrupted time-series analysis. We further examined the program expenditure and shifts in care provision between the public and private sectors. For incident patients, we compared demographics, unplanned initiations, and hemodialysis (HD) vascular access use. All-cause mortality was modelled using multivariable Cox proportional hazards models, adjusting for key covariates. Results: Following the policy shift, dialysis utilization expanded rapidly; HD replaced PD as the dominant modality, driving increased incidence. Provision shifted to private providers, accompanied by more unplanned starts and prolonged use of temporary catheters. Expenditure increased by 74% from 2018, reaching USD 452 million in 2024. This accounted for 9.3% of the national health budget in a country with a GDP per capita of USD 7350. All-cause mortality increased, particularly within the first 90 days of treatment. Postpolicy initiation was associated with higher mortality, as were unplanned initiation, older age, and comorbidities. Conclusion: The reform resulted in rapid service expansion, requiring a substantially higher proportion of public funding and correlating with increased mortality. These findings underscore the importance of refining policy implementation strategies, including appropriate patient selection and implementing robust safeguards to ensure the integrity and sustainability of the national health system.