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PD, nocturnal home hemodialysis show lowest costs in study
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The medical and societal cost for treating patients on PD and nocturnal home hemodialysis was lower compared to patients treated with in-center dialysis care, a study from Hong Kong shows.
The analysis looked at the economic burden of ESRD in the first and second years after patients initiated PD, hospital-based hemodialysis (HD) or nocturnal home HD at three different health care centers. Health care and societal costs – defined as direct medical and in-direct nonmedical expenses – were calculated for patients using the three modality options.
Hong Kong established a “PD first” approach to ESRD treatment more than 25 years ago, making it the preferred modality for new patients.
“As the first-line dialysis modality, PD is offered to incident dialysis patients unless they have medical contraindications for PD or are willing to pay for HD,” wrote Carlos K.H. Wong, MD, from the University of Hong Kong, and colleagues from the Princess Margaret Hospital and TungWah Hospital.
Use of PD in the study showed the lowest health care and societal cost. Nocturnal dialysis at home had the lowest cost in the second year of treatment from the societal perspective. Hospital-based HD had the highest total annual costs in the initial year and second year for both health care and societal costs.
The authors acknowledged that hospital-based patients in the study “were likely to be more complicated medically, which could contribute to a higher treatment and complication costs” compared to the other modalities.
Patients selected for the study (n = 402) were at least 18 years old, had started dialysis on or before 2015 and were either using hospital-based HD, nocturnal home HD or PD for at least 1 year.
For the PD group, the mean number of sessions were 14.40 per week. The hospital-based HD group had a mean of 2.19 sessions per week. The nocturnal HD group had a mean of 3.70 sessions per week.
For the study, the researchers defined costs from a societal perspective to include self-prescribed medication and transportation costs, and indirect costs that included caregivers’ time and patients’ productivity loss due to morbidity and mortality. Health care costs included the number of treatment sessions per week, duration of each dialysis treatment, general and specialist outpatient visits, length of hospital stays, emergency visits, drug use, treatment associated adverse events and dialysis-related complications. “The unit costs of surgical items, such as the insertion and removal of PD catheter, catheter placement and arteriovenostomy for HD and renal transplantation, were applied according to the best available evidence,” the authors wrote. “The unit costs of dialysis training, re-training after peritonitis and post-transplant follow-up in initial and subsequent years were estimated by nephrologists” and included in the analysis.
“Results from this cost analysis facilitate economic evaluation in Hong Kong for health services and management targeted at ESRD patients,” the authors concluded. “Future studies are warranted to assess the patient/carer-reported quality of life outcomes and cost effectiveness of having HD units in subacute or convalescent hospitals and community [in-center] HD units.”
Disclosures: The authors report no relevant financial disclosures. This study was supported by the Health and Medical Research Fund (grant number 13142451), Food and Health Bureau, Government of the Hong Kong SAR.
Perspective
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Brent W. Miller, MD
Dialysis treatments remain perhaps the most expensive chronic therapies in medicine, both for the comorbid complications of kidney failure and the actual cost of the dialysis therapy itself, multiplied by its prevalence. A successful business model providing dialysis services has subsequently developed. Thus, many have thought that behavioral economic theory has driven how dialysis is performed more than the primacy of patient outcomes.
Wong and colleagues in this study address the costs of various dialysis modalities. This study has numerous limitations that limit its wide-spread applicability, but it furthers the conversation about relative costs. Contrasted to the generally accepted view in the United States, a home-based hemodialysis treatment — in this case home nocturnal hemodialysis — has a lower cost at 2 years than center-based dialysis and less societal cost in year 2 than either center-based hemodialysis or peritoneal dialysis.
Within the dataset are interesting nuggets that deserve better study. For example, caregivers spend equal amount of time on center-based dialysis as home dialysis. More men undergo home hemodialysis than women. And clearly, transportation time is significantly less for home therapies. And perhaps most strikingly, the relative economic benefits of home therapies become more dramatic as time goes on: The reduction in cost in the second year for center-based HD, peritoneal dialysis and nocturnal home hemodialysis was 9%, 20% and 56%, respectively.
This finding alone about nocturnal HD – particularly in a country that has embraced a “PD first” approach for more than 2 decades - is so dramatic that it likely has broad applicability. It shows the value of both home modalities as effective in terms of reduced costs and societal benefits. Perhaps patient retention on home therapies is key to economic success in home dialysis therapies. Payors developing quality incentives and businesses honing their care delivery models should take note.
clinical chief of nephrology
Indiana University School of Medicine
Indianapolis
Nephrology News and Issues Editorial Advisory Board Member
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