Elsa Novelia PDF

COST EFFECTIVENESS ANALYSIS ON CHRONIC DIALYSIS :
COMPARISON BETWEEN HAEMODIALYSIS AND CHRONIC

AMBULATORY PERITONEAL DIALYSIS
ELSA NOVELIA
BPJS Kesehatan
INA HEA, Jakarta 2015

BACKGROUND
LITERATURE REVIEW
FRAMEWORK CONSEPTS
METHODOLOGY
RESULT
DISCUSSION
CONCLUSION
INA HEA, Jakarta 2015 2

BACKGROUN
D Decreased renal function up with not being
able to work in maintaining the balance of
fluids/chemicals
(Sherwood 2001)
Damage of Renal > 3 months with

pathology abnormalities, glomerular
filtration rate < 60 ml/min
(Chonchol 2005)

CLASSIFICATION OF CKD
Penanda Tahapan CKD Kode CKD (ICD-9-CM)
eGFR ≥90 ml/min/1.73 m2, ACR ≥30 mg/g 585.1 Chronic kidney disease, Stage 1
eGFR 60–89, ACR ≥30 585.2 Chronic kidney disease, Stage 2 (mild)
eGFR 30–59 585.3 Chronic kidney disease, Stage 3 (moderate)
eGFR 15–29 585.4 Chronic kidney disease, Stage 4 (severe)
eGFR <15 585.5 Chronic kidney disease, Stage 5
Keterangan: ACR adalah Albumin/Creatinin Ratio
Source: National Health and Nutrition Examination Survey (2002)

Worldwide 7% or 488 million CKD
1,6 million ESRD/CKD stage 5
America 12,3 %, 36 million CKD
117 thousand ESRD
Indonesia 0,2% ESRD > 15 years old or 482
thousand inhabitant (Riskesdas 2013)

ESRD PATIENT AND VISIT TO
HOSPITAL
2010 2011 2012 2013
ESRD
Ratio /100.000 Ratio/100.000 Ratio/100.000 Ratio/ 100.000

number number number number
members members members members
Patient 26.455 159,8 23.261 141,1 24.362 148,7 25.975 160,9
Outpatient 28.546 172,4 52.614 319,2 54.512 332,7 54.092 335,2
Inpatient 12.533 75,7 23.911 145,1 26.703 162,9 28.829 178,6
Source: PT Askes Data (2013)

DM AND HYPERTENSION
TOTAL OF PATIENT
DIAGNOSIS
2010 2011 2012 2013
DM
414.906 348.518 371.243 380.887
HYPERTENSION
482.150 511.661 527.816 522.125
Sources: PT Askes Data (2013)

COST CONSEQUENCES OF ESRD TREATMENT
1 trillion USD in next 10

years
(World Kidney Day Organisation 2013)
32 billion USD/year
(Harvard Stem Cell Institute 2011)

COST OF ESRD
Cost of ESRD (Billion RP)
482,07
417,68
336,20
231,51
2010 2011 2012 2013

COST OF ESRD
Year Cost of ESRD Cost of Health Care % cost of ESRD compare to
cost of Health Care
2010 231,512,443,433.64 4,342,338,234,959 5,3%
2011 336,204,155,653.31 5,166,418,195,229 6,5%
2012 417,687,396,410.29 6,490,512,490,936 6,4%
2013 482,067,148,455.74 6,900,109,165,791 6,9%

COST OF RENAL REPLACEMENT
Transplant 172
Million (Rp) + HD 2 times a week, CAPD 53-70
immunosuppressant 5 hours, Million (Rp) +
drugs per year 68 54 – 72 (Rp) Million Catheter 10 Million
Million
Source: Karopadi (2013)

QUALITY OF LIFE
Chronic Disease Poor Quality of Life

(ESRD) Poor Mental Health

RENAL REPLACEMENT THERAPY
WORLDWIDE CAPD INDONESIA CAPD

120 THOUSAND (2009) 800 OR 10 % OF HD (2009)

HD VS CAPD
TREATMENT 2010 2011 2012 2013
HD 334,382 408,800 491,520 557,095
CAPD 6,571 6,464 7,497 8,645
Ratio CAPD/HD 2.0% 1.6% 1.5% 1.6%

OBJECTIVE
The aim of this study is to analize the cost effectiveness between HD and CAPD on ESRD
patients
HEMODIALISA
CAPD

MAIN CAUSE OF CHRONIC KIDNEY DISEASE IN THE UNITED STATES
(1995-1999)
Caused Incident
DM 44 %
Hypertension and vascular disease 27%
Glomerulonefritis 10%
Nefritis Insterstitialis 4%
Cyst and other congenital disease 3%
Systemic Disease (ex Lupus and Vasculitis) 2%
Neoplasma 2%
Source: Buku ajar Ilmu Penyakit Dalam (2006)

CAUSED OF RENAL FAILURE WHO UNDERGOING HEMODIALYSIS IN
INDONESIA
Caused Incident
Glomerulonefritis 46,39%
DM 18,6%
Obstruction and Infection 12,85%
Hypertension and Infection 8,46%
Others caused 13,65%
source: Buku ajar Ilmu Penyakit Dalam (2006)

RENAL REPLACEMENT THERAPY
No Renal Replacement
I Dialysis
A. Peritoneal Dialysis (DP)

B. Hemodialysis
II Renal Transplants
Life Donor
Funeral Donor
Source: Buku ajar Ilmu Penyakit Dalam (2006)

CAPD
HEMODIALYSIS

HEMODIALYSIS VS
PERITONEAL DIALYSIS
Hemodialysis Peritoneal Dialysis
Benefit Done by a team of health professionals Gives more freedom than HD

Be able to socialize with other hemodialysis patients who will Can be done at home, can be done at the time of travel,
provide emotional support while sleeping
Not be done alone as PD Can be done alone
Done in fewer days than the PD Does not take a lot of food and fluid restriction as in HD
It takes no needles
Loss Cause fatigue during the HD session The procedure is quite difficult as some people
Led to the emergence of problems such as low blood pressure, Increase the risk of infection peritonitis
blood clots during dialysis access
Increase the risk of bloodstream infection
Source: (WebMD 2011)

PD Utilization > 80%,
ESTIMATION COST OF HD AND CAPD Government Policy
Country Average cost of HD Average cost of CAPD HD Reimburstment CAPD Reimburstment

per month per month from Government from Government
Banglades 370 454,5 68% 0%
Cina 500 500 50-90% 50-90%
Hongkong 2,560 1,070 100% 100%
India 160-280 325 0% 0%
Indonesia 450-900 450 10-30% 40%
Jepang 3,480 3,200 100% 100%
Korea 1,160 1.100 80% 80%
Malaysia 520 315 40% 100%
Pakistan 300 800 70% 0%
Singapura 1,001 618 80% 80%
Sri Langka 324 700-800 60% 0%
Taiwan 1,615 1,032 100% 100%
INA HEA, Jakarta 2015
Source: Departement of Medicine and Therapeutics (2001) 21
COST COMPARISON BETWEEN HEMODIALYSIS
AND CAPD
Country HD CAPD
Swedia 99,084 74,880
USA In Center: 51,252 26,959

Satellite: 42,067
Self Care: 29,961
Hongkong 30,678 12,843
Turkey 22,759 22,350
Malaysia 8,853 8,325

Cost of PD less than HD, lower
Source: Departement of Medicine, Tung Wah Hospital, (2006) utillization, physician
incentives, main reason in
many countries
INA HEA, Jakarta 2015 (Kei Lo 2007) 22
QUALITY OF LIFE DIALYSIS PATIENT
According to (Coccossis, et al., 2008) renal failure patients who received
hemodialysis or peritoneal dialysis action / CAPD found to have a decreased
quality of life, with different areas.
Some studies showed that HD patients reported having better on physical

quality, sleep and sexual relationship. For some mental study found that
patients who commit acts of HD have more depressive symptoms compared
with PD. This can happen because the HD patients should be connected to
the machine during dialysis routinely. On the other hand the high rate of
suicide in patients with HD were reported due to the violation dietary cloud.

FRAMEWORK
Independent Variable Dependent Variable CONCEPTS
Age
Gender
Education
Job
Duration of HD Quality of life
Duration of CAPD
Disease before suffer from ESRD
Renal Replacement
Total cost of HD
Renal Replacement ACER
HD HD Patient Quality of life
ICER
Total cost of CAPD

Renal Replacement ACER
CAPD CAPD Patient Quality of life

HYPOTESIS
CAPD cost effective compare to HD

Location and
• Cross Sectional Time • Population:
• Direct medical cost (INA
• HD Patient :PMI
CBGs) • HD : RS PMI Bogor
• Indirect medical cost Bogor Hospital
• CAPD: Patient Home
(questionnaire) • CAPD Patient:
• Opportunity cost • April – May 2014 Fatmawati Hospital
(questionnaire)
• Quality of life (SF 36)
Population
and Sample
Research
Design

DIRECT MEDICAL COST : HEMODIALYSIS PACKET (TARIF RS TIPE
B, REGIONAL I) 2014
Variable Cost (Rp)
Cimino Operation 1.324.036,-
Hemodialysis packet
Rental Machines and room
Medical Fee
Consumable HD Set and Hemodialysis fluid
drugs and BMHP
Blood Transfusion
Laboratory
Diagnostic investigation
Other Cost
One Session of HD 982.650,-
Cost per year (2 times/week) 102.195.600,-

Cost per year (2 times/week) + Cimino Operation 103,519,636,-
DIRECT MEDICAL COST : HEMODIALYSIS PACKET
(TARIF RS TIPE A, REGIONAL I) 2014
Variabel Biaya (Rp)
Cimino Operation 3.063.114

Hemodialysis packet
Rental Machines and room
Assumptions calculation from new patients in 2012 Indonesian Renal Registry
Medical Fee (IRR) (19.621 patients), BPJS will be burdened Rp.2.031.158.777.956, - when
Consumable HD Set and Hemodialysis fluid patients get HD in Hospital type B and becomes
drugs and BMHP Rp. 2,877,294,899,682, - when patients received HD in Type A Hospital
Blood Transfusion
Laboratory
Diagnostic investigation
Other Cost
One Session of HD 1.380.582,-
Cost per year (2 times/week) 143.580.528,-
Cost per year (2 times/week) + Cimino Operation 146.643.642,-

CAPD DIRECT MEDICAL COST
(TARIF INA CBGS RSUP FATMAWATI)
Variable Cost (Rp)
Catheter 3.063.114
Routine CAPD Packet
Consumable CAPD Set include fluids for 30 days
- Dianeal 1,5% = 90
- Dianeal 2,5% = 90
- Minicap = 120 When compared with hemodialysis treatment, the direct medical care cost of
CAPD provide the difference in cost of Rp. 562 662 038 162, - lower or 28%
lower than hemodialysis in Type B Hospital and Rp.1.408.798.159.888, - in
Jasa Pengiriman CAPD Set Type A Hospital or 51 , 04% lower.
Medical fee
Sub Total Cost 5.940.000,-
Routine Packet per year (4 times per day) 71.280.000,-
Transfer set every 6 month depend on medical indication 250.000,-

Transfer set in one year 500.000,-
Cost per year + Transfer set per year 71.780.000,-
Total cost per year 74.843.114,-
DISTRIBUTION OF DIRECT NON MEDICAL COST
FOR HEMODIALYSIS PATIENT
Variable Min (Rp) Max Mean Median
(Rp) (Rp) (Rp)
Transportation 6.500 400.000 43.763 27.500
Food/Drink 5.000 90.000 14.859 2.500
HD Cost per session 11.500 490.000 58.622 30.000
Cost per month 103.500 4.410.000 468.976 240.000
(2 session per week)
Cost per year 1.236.000 52.920.000 5.627.712 3.120.000
These costs must be quite burden for patients whose income < Rp 500.000, -. Although the direct medical costs
not borne by the patient, direct non-medical costs alone is quite a burden for hemodialysis patients.

LOSS INCOME OF HD PATIENT’S
Variable Min Max Mean Median

(Rp) (Rp) (Rp)
Loss of income per month
Patient - 16.000.000 1.522.000 640.000
Family who are waiting during HD session - 450.000 280.000 280.000
Lost of income per month - 16.450.000 1.802.000 920.000
Lost of income per year 197.400.000 21.624.000 11.040.000
CAPD patients and their families do not have to lose time working for CAPD action. It can be concluded indirect
costs of the action CAPD is Rp.0

HD VS CAPD QUALITY OF LIFE
Variable Total Persentase (%)

Whole Sample
Less Quality 43 48,9
Good Quality 45 51,1
HD Patient
Less Quality 42 53,8
Good Quality 36 46,2
CAPD Patient
Less Quality 1 10
Good Quality 9 90

CONECTION BETWEEN INDEPENDENT VARIABLE WITH DEPENDENT
VARIABLE
(*) : statistical significant
Variable Quality of life OR P-Value
Leer Quality Good Quality (95% CI)
Renal Replacement
HD 42 (53,8%) 36 (46,2%) 10,5 (1,269-86,901) 0,015*
CAPD 1 (10,0%) 9 (90,0%)
Age
< 45 year 17 (54,8%) 14 (45,2%) 1,448 (0,601-3,486) 0,546
>= 45 year 26 (45,6%) 31 (54,4%)
Gender
Man 26 (53,1%) 23 (46,9%) 1,463 (0,628-3,408) 0,504
Women 17 (43,6%) 22 (56,4%)
Working
no 35 (57,4%) 26 (42,6%) 3,197 (1,213-8,429) 0,030*
Working 8 (29,6%) 19 (70,4%)
Education
Low 6 (54,5%) 5 (45,5%) 1,297 (0,365-4,611) 0,936
High 37 (48,1%) 40 (51,9%)
Duration of HD/ CAPD
< 4 year 29 (46,0%) 34 (54,0%) 0,670 (0,264-1,702) 0,544
>= 4 year 14 (56,0%) 11 (44,0%)

QUALITY OF LIFE
DIMENSION
QoL Dimension Variable N Mean SD T (t-test) P-value
General Health
CAPD 10 257,500 73,645 -1,257 0,212
Haemodialisa 78 298,718 100,072

Physical Function
CAPD 10 540,000 177,638 0,285 0.777
Haemodialisa 78 514,103 279,830

Physical Role
CAPD 10 300,000 169,967 4,464

<0.001*
Haemodialisa 78 98,718 129,427
Role of Emotions
CAPD 10 270,000 94,868 4,701 <0.001*
Haemodialisa 78 111,538 135,781

QUALITY OF LIFE
DIMENSION
QoL Dimension Variable N Mean SD T (t-test) P-value
Pain
CAPD 10 182,000 20,709 6,218 <0.001*

Energy
CAPD 10 324,000 18,378 4,220 <0.001*

Social Function
CAPD 10 180,000 10,540 7,165 <0.001*

Mental Health
CAPD 10 420,000 24,944 4,758 <0.001*

NON PARAMETRIK TEST
Uji statistik Kualitas hidup per dimensi Mann-Whitney U-Test
Uji statistik Kualitas hidup per dimensi Kolmogorov-Smirnov

CRONBACH’S ALPHA IF ITEM
DELETED
No Dimension Cronbach’s Alpha if Item Deleted

1 Emotional Role 0,655
2 Physical Function 0,669
3 Mental Health 0,683
4 Energy 0,708
5 Pain 0,724
6 Social Function 0,726
TOTAL HD
COST
min max mean median
HD
INA CBGs 102,195,600 143,850,528 102,195,600 102,195,600
OOP - 25,440,000 3,949,380 1,440,000
Direct Medical Cost 102,195,600 169,290,528 106,144,980 103,635,600
Direct Non Medical Cost 1,236,000 52,920,000 5,627,712 3,120,000
Indirect Cost - 197,400,000 21,624,000 11,040,000
Total 103,431,600 419,610,528 133,396,692 117,795,600
CAPD
Paket CAPD 71,780,000 71,780,000 71,780,000 71,780,000
OOP 600,000 24,000,000 9,900,000 9,999,996
Direct Medical Cost 72,380,000 95,780,000 81,680,000 81,779,996
Direct Non Medical Cost - - - -
Indirect Cost - - - -
Total 72,380,000 95,780,000 81,680,000 81,779,996
Data dalam Rp

EMOSIONAL ROLE CEA
ANALYSIS
Renal Per year Emotional ACER
Replacement Role
HD 133.396.692 41,61 Rp 133.396.692/41,61 = 3.205.881,-
per emotional role
CAPD 81.680.000 67,05 Rp 81.680.000/67,05 = 1.218.195,-
per emotional role
ICER CAPD vs HD Dominant for cost and emotional role*

CAPD vs HD (Rp 81.680.000 - 133.396.692) / 67,05 –
41,61) = Rp 2.032.889,-
per extra emotional role
*CE(Cost Effectiveness) Plan

PHYSICAL ROLE CEA ANALYSIS
Renal Replacement Per Year Physical ACER
Role
HD 133.396.692 41,20 Rp 133.396.692/41,20 = 3.237.784,-
per physical role
CAPD 81.680.000 70,25 Rp 81.680.000/70,25 = 1.162.705,-
per physical role
ICER CAPD vs HD Dominant for cost and physical role *

CAPD vs HD (Rp 81.680.000 - 133.396.692) / (70,25 -
41,20) =
Rp 1.780.265,- per extra physical role
*CE(Cost Effectiveness) Plan

CE PLAN
Cost Differences (+)
Effect Diferences (-) Effect Differences (+)
Dominant
Cost Differences (-)

Cost of Renal Replacement
Cost of CAPD 39% lower than HD (Peeters P 2000) cost analysis HD
This is in accordance with (Philip and CAPD in 25 studies
2001), PD 10-40% lower than HD CAPD provide a cost advantage
in worldwide compared with hemodialysis

Statistics Significant : Quality of Life HD vs CAPD
(Albert W Wu 2004) peritoneal dialysis have a better quality of life compared with (Peeters P 2000) HD and CAPD cost analysis on 25 studies.
hemodialysis CAPD provide a cost advantage compared to hemodialsa
(Thong and Adrian a Kaptein 2008) Research using a questionnaire developed by the experts mentioned that dialysis peritoneal
dialysis patients score higher than hemodialysis patients on aspects of family life, independence, spiritual condition, energy level, and
living conditions
(Noshad, et al. 2009), peritoneal dialysis had a statistically significantly better quality of life compared to hemodialysis in patients with
diabetes and non-diabetes. Peritoneal dialysis patients have a higher value for all aspects.
The positive thing of peritoneal dialysis is due to the addition of energy for feeling alive and well, able to do therapy at home, can do
therapy during sleep, and feel independent. Patients in this study also feel good because it can perform CAPD own without requiring
the assistance of the medical team
Another study in 16 755 patients with hemodialysis and peritoneal dialysis 1,260 patients found that peritoneal dialysis patients had
higher scores on the mental dimension compared with hemodialysis patients, using a questionnaire SF 36 (Thong and Adrian a Kaptein
2008)
(Coccossis, et al. 2008) Hemodialysis patients have more experience in terms of anxiety and sleep disorders that
affect the patient's emotions and feel overwhelmed with the strict provisions of the action routine hemodialysis
Peritoneal dialysis patients in the 65 analysis meta studies showed that peritoneal dialysis patients have better
characteristics and stress less than hemodialysis patients (Thong and Adrian a Kaptein 2008)
Hemodialysis patient dissatisfaction can be caused by stress facing dialysis procedure, the high frequency of
visits to the hospital, waiting time in hemodialysis units and treatment of medical personnel at the hospital.
Hemodialysis patients have symptoms of depression are higher and tend to commit suicide besides having
depressive symptomatology
ROLE OF PHYSICAL
CAPD patient satisfaction

increased as the opportunity 2/3 patients receiving dialysis CAPD patients allowed to
to do a better recreation in therapy never return to travel every day, can work to
terms of transportation, the normal activities or work, and earn more and dialysis can be
opportunity to obtain many patients lose their jobs done anywhere
information, better life and
the opportunity to gain new (Nurchayati 2010) (Coccossis, et al. 2008).
skills . (Coccossis et al. 2008).

CONCLUSION
1. CAPD costs 39% lower than HD
2. Patients receiving hemodialysis measures 10.5 times more likely to have less quality of life compared
with patients receiving CAPD
3. CAPD patient's quality of life is better compared with hemodialysis patients in the physical dimensions
of the role, the role of emotions, pain, energy, social functioning and mental health (proven
statistically)
4. CAPD action is more cost effective than hemodialysis

ADVICE FOR PATIENT
Looking for information related to kidney disease
Finding the advantages and disadvantages of every

kind of renal replacement therapy
Choosing CAPD if there are no complications to walk

on CAPD
ADVICE FOR
HOSPITAL
The team of doctors at the hospital are expected to assist the patient in deciding the type of renal
replacement therapy in accordance with the patient and provide more benefits for patient
Provide a complete and detailed description of hemodialysis and CAPD before the patient decides the
selected action either directly to patients or in health seminars forums
Ensuring Patient CAPD fluid available from distributors and delivered directly to the patient's home.
Do not take additional cost from patient if all of its services has been included in the package hemodialysis
or CAPD
Communicate with doctors, not prescribed expensive drugs, because patients take medications regularly

BPJS KESEHATAN
Approach to the hospital in order to make CAPD as first choice
Encourage the patient to take hemodialysis in lower type hospital if the patient is not
allowed to take CAPD
CAPD action socializing through BPJS Center officer in hospital and through seminars
Monitor and coordinate with the hospital to make sure there is no additional costs are
charged to the patient's with hemodialysis and CAPD

THE GOVERNMENT
Increase the number of hospitals that are able to provide services CAPD
Ensuring CAPD fluid supply imported from abroad are available and controlling costs so that the liquid is not too high
Analyze the possibility of CAPD fluid produced in Indonesia when there will be increasing number of CAPD patients in the
future
CAPD campaigning as the first choice of renal replacement therapy for patients with ESRD
Evaluate the hospital that still take additional costs from HD and CAPD
Evaluate the INA CBGs rates for dialysis procedures

THANK YOU

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COST EFFECTIVENESS ANALYSIS ON CHRONIC DIALYSIS :

COMPARISON BETWEEN HAEMODIALYSIS AND CHRONIC

INA HEA, Jakarta 2015

INA HEA, Jakarta 2015 2

Damage of Renal > 3 months with

INA HEA, Jakarta 2015 3

Source: National Health and Nutrition Examination Survey (2002)

INA HEA, Jakarta 2015 4

INA HEA, Jakarta 2015 5

Ratio /100.000 Ratio/100.000 Ratio/100.000 Ratio/ 100.000

Patient 26.455 159,8 23.261 141,1 24.362 148,7 25.975 160,9

Outpatient 28.546 172,4 52.614 319,2 54.512 332,7 54.092 335,2

Inpatient 12.533 75,7 23.911 145,1 26.703 162,9 28.829 178,6

Source: PT Askes Data (2013)

INA HEA, Jakarta 2015 6

Sources: PT Askes Data (2013)

INA HEA, Jakarta 2015 7

1 trillion USD in next 10

INA HEA, Jakarta 2015 8

2010 2011 2012 2013

Source: PT Askes Data (2013)

INA HEA, Jakarta 2015 9

2010 231,512,443,433.64 4,342,338,234,959 5,3%

2011 336,204,155,653.31 5,166,418,195,229 6,5%

2012 417,687,396,410.29 6,490,512,490,936 6,4%

2013 482,067,148,455.74 6,900,109,165,791 6,9%

Source: PT Askes Data (2013)

INA HEA, Jakarta 2015 10

Source: Karopadi (2013)

INA HEA, Jakarta 2015 11

Chronic Disease Poor Quality of Life

INA HEA, Jakarta 2015 12

WORLDWIDE CAPD INDONESIA CAPD

INA HEA, Jakarta 2015 13

HD 334,382 408,800 491,520 557,095

CAPD 6,571 6,464 7,497 8,645

Ratio CAPD/HD 2.0% 1.6% 1.5% 1.6%

Source: PT Askes Data (2013)

INA HEA, Jakarta 2015 14

INA HEA, Jakarta 2015 15

Source: Buku ajar Ilmu Penyakit Dalam (2006)

Obstruction and Infection 12,85%

Hypertension and Infection 8,46%

Others caused 13,65%

source: Buku ajar Ilmu Penyakit Dalam (2006)

INA HEA, Jakarta 2015 17

A. Peritoneal Dialysis (DP)

Source: Buku ajar Ilmu Penyakit Dalam (2006)

INA HEA, Jakarta 2015 19

Benefit Done by a team of health professionals Gives more freedom than HD

Source: (WebMD 2011)

Country Average cost of HD Average cost of CAPD HD Reimburstment CAPD Reimburstment

Swedia 99,084 74,880

USA In Center: 51,252 26,959

Turkey 22,759 22,350

Malaysia 8,853 8,325

Some studies showed that HD patients reported having better on physical

INA HEA, Jakarta 2015 23

Total cost of CAPD

INA HEA, Jakarta 2015 24

CAPD cost effective compare to HD

INA HEA, Jakarta 2015 25

INA HEA, Jakarta 2015 26