|Year : 2018 | Volume
| Issue : 2 | Page : 54-59
Pharmacoeconomic evaluation of hemodialysis patients: A study of cost of illness
S Fathima1, Uday Venkat Mateti1, Malona Lilly Philip1, Janardhan Kamath2
1 Department of Pharmacy Practice, Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences, Nitte (Deemed to be University), Mangalore, Karnataka, India
2 Department of Nephrology, KS Hegde Medical Academy, Nitte (Deemed to be University), Justice KS Hegde Charitable Hospital, Mangalore, Karnataka, India
|Date of Web Publication||11-Oct-2018|
Dr. Uday Venkat Mateti
Department of Pharmacy Practice, Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences, Nitte (Deemed to be University), Deralakatte, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Objective: The objective of the study is to analyze the health-care costs of the hemodialysis (HD) patients in a charitable hospital. Subjects and Methods: A prospective observational study was carried out in an outpatient HD unit of nephrology department in a charitable hospital for a period of 8 months from August 2016 to March 2017. The collected direct medical and nonmedical cost data were analyzed for the median interquartile (Q3–Q1) cost incurred in treating the HD patients. Results: A total of 39 outpatients were included in the study. Of 39 patients, majority of the HD patients were males (66.2%) followed by females (33.8%). Most of the patients underwent HD for twice a week (89.7%) followed by thrice a week (10.3%). The median direct medical costs (85,999.2 Indian rupee [INR]) were found to be higher than direct nonmedical costs (14,437.1 INR). Conclusions: The study revealed that the total median direct cost was found to be uppermost for the age group of 41–60 years (1,12,438.8 INR) when compared to all other age groups, and it was also observed that the total median direct cost for males (1,07,522.4 INR) was higher than females (1,03,170.7 INR). The factors such as type of comorbidities, age, and number of HD per week may affect the cost of illness.
Keywords: Cost of illness, end-stage renal disease, hemodialysis
|How to cite this article:|
Fathima S, Mateti UV, Philip ML, Kamath J. Pharmacoeconomic evaluation of hemodialysis patients: A study of cost of illness. J Integr Nephrol Androl 2018;5:54-9
|How to cite this URL:|
Fathima S, Mateti UV, Philip ML, Kamath J. Pharmacoeconomic evaluation of hemodialysis patients: A study of cost of illness. J Integr Nephrol Androl [serial online] 2018 [cited 2018 Dec 19];5:54-9. Available from: http://www.journal-ina.com/text.asp?2018/5/2/54/243120
| Introduction|| |
Chronic kidney disease (CKD) includes different pathophysiologic processes associated with abnormal kidney function and a deterioration in glomerular filtration rate. CKD is a major health problem, which is one of the reasons for illness and financial burden on patients and even loss of life in the developing countries.,, The global prevalence of CKD ranges between 8% and 16%. It was found that 50 million patients around the world required treatment for CKD and that there were 3.78 million deaths in the year 1990 because of CKD which may increase to 7.73 million in the future.,
End-stage renal disease (ESRD) not only has increased in the prevalence but also has a major impact on the financial burden.,, The prevalence of ESRD has been on the rise since the past few years in India. If the prevalence of ESRD continues, the ESRD population will exceed 2 million patients by the year 2010. The only treatment option left is either hemodialysis (HD) or transplantation, and due to the unaffordable expenses, only HD can be opted by the Indian population.
HD and peritoneal dialysis continue to be the most extensively used treatment procedures due to least availability of kidney donors. As regular HD usually results in financial pressure in some population, it is necessary to evaluate the therapy by analyzing the treatment costs.
Since CKD is associated with the high economic burden on patients, it is necessary to obtain the exact details of expenditures of patients undergoing the HD. However, there is no literature available which contains details on the cost for HD in India. Therefore, the burden of disease can only be estimated by analyzing the cost. Hence, this study was conducted to estimate the direct costs of HD in a charitable hospital in Mangalore.
| Subjects and Methods|| |
A prospective observational study was carried out in an outpatient HD unit of nephrology department for a duration of 8 months (from August 2016 to March 2017). The study was approved by the institutional ethics committee (REF: INST. EC/EC/67/2016-17).
The sample size was calculated based on the similar study conducted by Suja et al. and subject to availability of patients in the HD unit. The minimum sample size required for this study was thirty patients. Outpatients undergoing maintenance HD with age more than 18 years and either gender were included in the study. The inpatients, patients not willing to participate in the study, patients with missing data, and pregnant women were excluded from the study.
Data collection form was designed as per the study requirements. The details such as age, gender, diagnosis, number of HD per week, number of visits to HD, comorbid conditions, and number of medicines per prescription were obtained from the patient medical records. The pharmacoeconomic-related direct medical costs (medicines, HD, laboratory investigations, consultations, hospitalization, and miscellaneous costs) and nonmedical costs (transportation to visit HD unit and food expenses during HD) were collected from the patient records, medical bills, hospital accounts section, and interviewing the patients or patient parties. From the data obtained, the total cost of HD for 6 months was calculated.
The collected data were analyzed for the median interquartile (Q3–Q1) cost incurred in treating the HD patients and were calculated based on the total amount spent by the patients to that of a total number of patients. Details of direct medical and nonmedical costs were analyzed. The direct costs are the sum of the direct medical and nonmedical costs. The data of all the costs in Indian rupee (INR) were converted into the United States dollar (USD), i.e., 1 INR = 64.62 USD.
The normally distributed continuous variables were presented as mean ± standard deviation, and skewed distribution variables were presented as median and interquartile range (Q3–Q1). The categorical variables were presented as frequency and percentage. All the data were analyzed using the SPSS Statistics for Windows, Version 20.0. (IBM Corp., Armonk, NY, United States of America).
| Results|| |
A total of 39 HD patients were included in the study, of which 66.2% and 33.8% were males and females, respectively. Baseline characteristics of patients such as age, comorbid conditions, occupation status, educational status, and other details are specified in [Table 1]. In the present study, most of the patients belonged to the age group of 41–60 years, i.e., 18 (46.2%), and the mean age of the HD patients was found to be 51 ± 12.7 years. Majority of HD patients had normal BMI (n = 25, 64%) with the mean BMI of 21.7 ± 3.7 kg/m2.
It was observed that most of the HD patients had completed their high school certificate (30.8%) followed by patients who were illiterate (23.1%). Of these, the majority of them were not working (53.8%) and only a few patients had the history of smoking (15.4%) and drinking alcohol (10.3%). In the study, most of the patients were found to have a duration of HD for less than a year (31%) as depicted in [Table 1].
In the present study, the maximum number of medications prescribed to HD patients ranged from 6 to 9 medications (79.5%), and the median number of medications prescribed per HD patients was found to be 9 (11–7) as summarized in [Table 1]. Higher incidence of various comorbidities among HD patients was hypertension (46.2%) and hypertension with diabetes mellitus (25.6%) as is depicted in [Table 1].
The median direct medical costs (85,999.2 INR) were found to be higher than that of direct nonmedical costs (14,437.1 INR) as summarized in [Table 2]. The median cost per patient for each session of HD was 980 INR (1100–900 INR). Among the various direct medical cost components, the median cost was found to be highest for HD sessions (44,000 INR) followed by medication charges (30,507 INR). In this study, the median cost for the transportation of patients to visit the HD unit was 9600 INR, and food cost during HD was 3720 INR.
Costs were also categorized based on the age groups, where it was observed that the total median direct cost was found to be highest for the age group of 41–60 years (1, 12, 438.8 INR) when compared to all other age groups. It was because these patients were traveling from distant places, so they had to spend more on traveling and food during HD sessions as presented in [Table 3]. It was also observed that the total median direct cost for males (1,07,522.4 INR) was higher than females (1,03,170.7 INR) as presented in [Table 4].
|Table 3: Categorization of costs based on the age of hemodialysis patients|
Click here to view
|Table 4: Categorization of costs based on the gender of hemodialysis patients|
Click here to view
Among the HD patients, 89.7% underwent twice a week and 10.3% thrice a week. It was also found that the total median direct costs were highest in patients on thrice-weekly HD sessions (1,27,682.4 INR) when compared to patients on twice-weekly HD sessions which lead to increase in expenses on transportation, food, HD sessions, and medications as described in [Table 5]. In this study, most of the HD patients were under various schemes and few without schemes, of which the median (Q3–Q1) direct medical cost was found to be highest in patients with MED scheme (95,674.3 INR). In case of the median, the direct nonmedical cost was highest in patients with group scheme (31,892.9 INR). The overall median direct cost was found to be highest in patients who were not on schemes (1, 12, 438.8 INR) as described in [Table 6]. The direct medical cost was high in the case of MED scheme because patients availed reimbursements; hence, they preferred high-end treatments as there are no monitory implications for them. Therefore, their medical costs would be higher when compared to those patients who received no such reimbursements. The total median cost was high in patients without scheme as they were not getting any concessions and they had to spend more on transportation to the hospital.
|Table 5: Categorization of costs based on number of hemodialysis per week|
Click here to view
| Discussion|| |
ESRD is a condition where there is irreversible loss of normal kidney function, and it has a greater impact on health economics. The role of HD is to treat ESRD, which remains one of the most intensive and expensive therapeutic interventions. Thus, this study was conducted to assess the expenditure of HD patients to get the detailed information on their direct medical and nonmedical costs in a charitable hospital.
A total of 39 HD patients were selected for the study, of which majority of them belonged to the age group of 41–60 years (46.2%). The mean age of HD patients was found to be 51 ± 12.7 years which is comparable with the study results obtained by Suja et al., where it was reported that majority of the patients belonged to the age group of 51–60 years, and the mean age of the patients was 49.72 ± 13.2 years.
Of 39 patients, the majority were males (66.2%) followed by females (33.8%). Similar results were found in the studies of Al Saran et al., Mateti et al., Al-Shdaifat et al., where it was reported that majority were males (60%, 80.7% and 53.6%) followed by females (40%, 19.3% and 46.4% ).,,
In this study, it was observed that hypertension (46.2%) and hypertension with diabetes (25.6%) were the major comorbid conditions. Similar results were also found in the studies conducted by Suja et al., Mushtaq et al., and Shyamala et al., where diabetes and hypertension were the leading causes in HD patients compared to other disease states.,,
In this study, most of the patients were found to have HD sessions for less than a year (31%). The median duration of HD sessions was 2 (5–1) years. Similar results were obtained in a study conducted by Suja et al., where it was reported that the mean duration of HD was 2.8 years. In the present study, the median number of medications prescribed in our study was 9 (11–7), and in the study conducted by Mateti et al., the mean number of medications prescribed was 13.10 ± 4.86.,
Patients undergo HD either twice or thrice weekly depending on the severity of their disease state and affordability. Of the total number of 39 HD patients, majority of the patients underwent HD for twice a week (89.7%) followed by thrice a week (10.3%). Similar results were observed in the study by Abreu et al., where they selected patients undergoing maintenance HD (2–3 HD sessions per week).
In this study, the median direct medical costs (85,999.2 INR) were found to be higher than direct nonmedical costs (14,437.1 INR). Similar study results were reported by Mateti et al., who reported that the median direct medical costs of HD patients were higher (573.11 INR) than direct nonmedical costs (67.50 INR).
Among the various direct medical cost components, the median cost was found to be highest for HD sessions (44,000 INR) followed by medication charges (30,507 INR). Similar results were reported by Lorenzo et al., which stated that major expenditure was from HD sessions (51%) followed by medications (27%). In this study, the median cost of hematopoietic agents (55.1%) was highest followed by phosphate binders (22.9%), which was similar to the results obtained from the study carried out by Lorenzo et al., where it was reported that 68% of total pharmaceutical cost was contributed by hematopoietic agents.
Proportional allocation of costs in our study was as follows: HD sessions (50%), medications (35%), diagnosis (6%), hospitalization (5%), laboratory investigations (3%), and miscellaneous (1%). This was similar to the results obtained by Lorenzo et al., where it was reported that proportional allocation of costs in their study was HD sessions (51%), pharmacy (27%), hospitalization (17%), transportation (3%), and ambulatory care (2%). The median cost for each session of HD was 980 INR (1100–900 INR) which was similar to the results obtained by Khanna et al., where it was reported that the cost per each session of HD in South India was 1100 INR.
In our study, it was observed that the total median direct cost was highest for the age group of 41–60 years (1, 12, 438.8 INR) when compared to all other age groups. In contrast, the study conducted by Kao et al. concluded that the total cost per life year of patients was found to be highest for the age group of ≥65 years (23,664 USD).
In the present study, it was observed that the total median direct cost for males (1,07,522.4 INR) was highest followed by females (1,03,170.7 INR). In case of median direct medical cost, it was found that cost for female patients (85,999.2 INR) was higher than male patients (85,415.9 INR). Similar results were reported in the study conducted by Roggeri et al., where it was found that the total costs for male patients (53,945€/year/patient ± 14,884€) were highest followed by female patients (53,467€/year/patient ± 14,356€).
| Conclusions|| |
This study gives an insight on the direct costs and the impact of economic burden on the HD patients. The most commonly prescribed medication was found to be hematopoietic agents, which consumes the highest cost. The total direct median cost of HD treatment was 1,06,971.2 INR. The total median direct cost was more for the patients undergoing three dialysis sessions per week (1,27,682.4 INR). Type of comorbidities, unemployment, age, number of HD per week, and number of medicines prescribed may affect the cost of illness. The costs incurred for the HD patients were higher and can be minimized by providing concerns from the charitable hospitals, allowances from governments, and supporting with more insurance schemes.
We would like to thank the Nitte (Deemed to be University) for providing participants recruited in this study. The authors wish to acknowledge the directors and staff of the respective dialysis units for their contribution toward the successful completion of the project.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bargman JM, Skorecki KB, Joanne M, Skorecki K. Chap 280.chronic kidney disease. In:Kasper DC, Hauser SL, Jameson JL, Fauci AS, Longo DL, Loscalzo J, editors. Harrison's Principles of Internal Medicine. 18th
ed., Vol. 1. Part 13. United States of America: MC Graw Hill Education; 2012. p. 1-10.
Dirks JH, de Zeeuw D, Agarwal SK, Atkins RC, Correa-Rotter R, D'Amico G, et al
. Prevention of chronic kidney and vascular disease: Toward global health equity – The Bellagio 2004 declaration. Kidney Int Suppl 2005;98:S1-6.
Zelmer JL. The economic burden of end-stage renal disease in Canada. Kidney Int 2007;72:1122-9.
Prodjosudjadi W. Incidence, prevalence, treatment and cost of end-stage renal disease in Indonesia. Ethn Dis 2006;16:S2-14-6.
Jha V, Garcia-Garcia G, Iseki K, Li Z, Naicker S, Plattner B, et al
. Chronic kidney disease: Global dimension and perspectives. Lancet 2013;382:260-72.
Szczech LA, Lazar IL. Projecting the United States ESRD population: Issues regarding treatment of patients with ESRD. Kidney Int Suppl 2004;90:S3-7.
Modi GK, Jha V. The incidence of end-stage renal disease in India: A population-based study. Kidney Int 2006;70:2131-3.
United States, Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, US Renal Data System (USRDS). 2011 Atlas of CKD and ESRD. Minneapolis, MN: USRDS; 2011. Available from: http://www.usrds.org/atlas11.aspx
. [Last accessed on 2016 Dec 8].
Kontodimopoulos N, Niakas D. An estimate of lifelong costs and QALYs in renal replacement therapy based on patients' life expectancy. Health Policy 2008;86:85-96.
Ranasinghe P, Perera YS, Makarim MF, Wijesinghe A, Wanigasuriya K. The costs in provision of haemodialysis in a developing country: A multi-centered study. BMC Nephrol 2011;12:42.
Prasad N, Jha V. Hemodialysis in Asia. Kidney Dis (Basel) 2015;1:165-77.
Suja A, Anju R, Anju V, Neethu J, Peeyush P, Saraswathy R, et al
. Economic evaluation of end stage renal disease patients undergoing hemodialysis. J Pharm Bioallied Sci 2012;4:107-11.
Sowinski KM, Churchwell MD, Decker BS. Hemodialysis and peritoneal dialysis. In: Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy – A Pathophysiologic approach. 9th
ed. New York: McGraw Hill; 2014. p. 1526-71.
Al Saran K, Sabry A. The cost of hemodialysis in a large hemodialysis center. Saudi J Kidney Dis Transpl 2012;23:78-82.
Mateti UV, Nagappa AN, Vooradi S, Madzaric M, Mareddy AS, Attur RP, et al
. Pharmacoeconomic evaluation of hospitalized pre-dialysis and dialysis patients: A comparative study. AMJ 2015;8:132-8.
Al-Shdaifat EA, Manaf MR. The economic burden of hemodialysis in Jordan. Indian J Med Sci 2013;67:103-16.
] [Full text]
Mushtaq A, Mustafa A, Najar MS, Farooq AJ, Anil M, Hakim A. Cost of hemodialysis in a tertiary care hospital in north India. J Med Sci 2012;15:47-50.
Shyamala KV, Gopala DV. Current status of haemodialysis in a tertiary care government hospital. Indian J Clin Anat Physiol 2017;4:84-6.
de Abreu MM, Walker DR, Sesso RC, Ferraz MB. A cost evaluation of peritoneal dialysis and hemodialysis in the treatment of end-stage renal disease in Sao Paulo, Brazil. Perit Dial Int 2013;33:304-15.
Lorenzo V, Perestelo L, Barroso M, Torres A, Nazco J. Economic evaluation of haemodialysis. Analysis of cost components based on patient-specific data. Nefrologia 2010;30:403-12.
Khanna U. The economics of dialysis in India. Indian J Nephrol 2009;19:1-4.
] [Full text]
Kao TW, Chang YY, Chen PC, Hsu CC, Chang YK, Chang YH, et al
. Lifetime costs for peritoneal dialysis and hemodialysis in patients in Taiwan. Perit Dial Int 2013;33:671-8.
Roggeri DP, Roggeri A, Salomone M. Chronic kidney disease: Evolution of healthcare costs and resource consumption from predialysis to Dialysis in Piedmont region, Italy. Adv Nephrol 2014;680737:1-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]