Authors’ view: Hemodialysis Cost in India -Dr. Raja Ramachandran
This month, we are introducing a new feature to our blog- Author’s view-a blog post by the author of the publication. This is an attempt to understand author’s view on their research. In this post, Dr. Raja Ramachandran (@raja_1980) writes about the paper published in Clinical Kidney Journal last month. He is an Assistant Professor Department of Nephrology, PGIMER, Chandigarh, INDIA.
Cost of hemodialysis in a public sector tertiary hospital of India
India is witnessing a rise in end-stage renal disease (ESRD) patients every year, which calls for an additional demand of 34 million dialysis sessions annually. Majority of costs for the provision of dialysis are borne by the health system in the developed countries. Conversely, in developing countries like India, this economic burden is manifested as out of pocket expenditures (OOPE) endured by the patients; at times leading to catastrophic expenditures that may push them below the poverty line. Taking cognizance of this rising disease and economic burden, the Government of India has announced a National Dialysis Programme to provide free dialysis in public hospitals. However, the primary choice of method of dialysis to be included- hemodialysis (HD) or peritoneal dialysis (PD) is debatable. Further, evidence on Indian estimates of health system costs is lacking.
In our study, we have tried to address this gap and estimated the average cost of performing HD in a tertiary care hospital from the health system- and patient-perspective. Second, we assessed the catastrophic impact of out-of-pocket expenditures (OOPEs) for HD on households and its determinants. This study was undertaken in an exclusive 24-station dialysis unit at a public-sector tertiary care hospital. Emergency dialysis, continuous ambulatory peritoneal dialysis (CAPD) and kidney transplantation facilities are also delivered at the institute but were not included in this study. Bottom-up costing approach was used to estimate the resource use from April 2015 to March 2016 in the provision of HD. These resources were identified, measured and valued under capital and recurrent resources. Capital included buildings, medical and non-medical equipment and any other item with a lifetime more than for 1 year. Recurrent resources were salaries of staff, drugs and consumables and overhead. We annualized capital costs after accounting for their useful life and discounted at 3% for future years. We undertook sensitivity analyses to determine the effect of variation in the input prices on the annual health system cost. Further, we also estimated the unit cost at 100% bed occupancy rate from a provider perspective. We undertook a primary survey to capture OOPEs from 108 patients undergoing HD in the study hospital. In addition, the prevalence of catastrophic health expenditures (CHEs) was computed per threshold of 40% of non-food expenditures.
The average cost incurred by the health system per HD session was INR 4,148 (US $64) and mean OOPE per patient on HD was estimated as INR 2,838 (US$44; 95% confidence interval US$34–55). The expenditure on erythropoiesis-stimulating agents and dialyzer reuse were included under OOPE. However, we would like to mention that we did not collect detailed information on the clinical profile of the patients. Also, we did not collect information on productivity losses of patient/caregiver due to dialysis. Nevertheless, we comprehensively assessed health system costs and our estimates may be useful in the context of planning and setting up provider payment rates for hemodialysis under several government-funded insurance schemes. Moreover, we encourage on undertaking further cost-effectiveness analysis to guide on future resource allocation decisions.
Dr. Raja Ramachandran,
Department of Nephrology, PGIMER, Chandigarh, India.