Cost of Hemodialysis in a Tertiary Care Hospital in North India

health problem with significant health consequences and involves high cost of treatment world wide. CKD patients often delay treatment due to lack of noticeable symptoms associated with renal disease as well as ignoring these symptoms. This usually results in decline of kidney function which ultimately leads to End Stage Renal Disease (ESRD).1 Although Renal transplant is a cost effective treatment option for ESRD,2 use of Hemodialysis in patients with ESRD remains one of the most resource intensive but expensive therapeutic intervention in India.3 Shortage of kidneys transplantation and the increase in demand for RRT will have to be met by dialysis .Of the dialysis modalities currently in use HD places a higher demand especially trained staff. Dialysis has been found reasonably effective at sustaining life in the majority of patients with ESRD.3 Patients with ESRD must rely on dialysis for the remainder of their lives unless they undergo kidney transplantation. Additionally growing number Correspondence: Dr. Ajaz Mustafa Associate Professor Hospital Administration & Dy. Med. Supdt. Sher-i-Kashmir Institute of Medical Sciences, Srinagar-190011, J & K, India E-Mail: dramustafa07@yahoo.co.in ORIGINAL


A B S T R A C T Discussion
The exact cost of RRT in developing countries is hard to estimate and varies with the prescription and the way a unit is set up.The overall treatment cost although less in developed countries because of lower staff salaries and the low cost of drugs is still 10-20 times higher than the per capita gross national product and remains out of reach of most of the Hemodialysis population.
As per December 2007 index Rajya Sabah , per capita income in India was 20734 per annum 26% of total population live below poverty line with daily earning Rs 20/-only.Government spends barely US # 8 per capita on health.(1) Chronic kidney disease (CKD) is a world wide public health problem.Although Renal transplant is a cost effective treatment option for ESRD, use of Hemodialysis in patients with ESRD remains one of the most resource intensive and hence expensive therapeutic intervention in India.India has 950 nephrologists 700 dialysis centers, 4000 dialysis machines and 20,000 patients undergoing dialysis at these centers.¹These centers are owned predominantly by private sector and are hence concentrated in cities.Government hospitals admit patients on the basis of severity of disease and hence patients on 4 maintenance dialysis are forced to visit to private hospitals.
Cost of each Hemodialysis session in India varies from RS 150/-in Government hospitals to Rs 2000/-in some corporate hospitals.¹Average national cost of each session of ¹,² hemodialysis in India is Rs.1,100/-.Monthly cost averages to of ESRD patients will devour a greater proportion of health care budget.The present study is aimed at determining the cost per session of hemodialysis and annual economic burden of hemodialysis on patient and Hospital.An accurate estimate of cost of Hemodialysis treatment for patients with ESRD would help in making policy decisions and enable cost efficient utilization of ESRD programme (HD), most common treatment modality.

Methodology
A prospective study at Hemodialysis Centre of a tertiary care Teaching Hospital (Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India) was conducted between January 2010 to December 2010.Patients with ESRD and who underwent hemodialysis, were incorporated in the study.Patients who survived less than 3 months after commencement of treatment were excluded.Relevant data was collected by using a predesigned proforma and semi structured interview of the patients and staff at hemodialysis centre was conducted.Case records and electronic data base of hospital were also examined for supplementing the data.
The variables recorded for cost analysis were:-(Direct and Indirect costs) Cost of Laboratory investigations Cost of instruments purchased locally from market Cost of Drugs purchased from market Cost of diet Staff salaries (Physician, technologist etc.) Average variable cost was calculated as total variable cost divided by total number of dialysis sessions during the year of study.Non medical Supply cost calculated were:-Electricity cost, cost of water, sanitation cost, Linen & Laundry, building cost after depreciation plus maintenance and equipment capital cost after depreciation plus maintenance.
Data was scientifically organized and statistically analyzed to identify major cost centres and important variables determining cost of services.A descriptive statistical method to describe demographic variables and disease factors was used.A linear regression model was used to examine the effects of risk factors on variable costs for dialysis patients.

Results
58 patients were incorporated in the present study.Mean age of the study patients was 46.4+8 in years.Among the 58 patients studied 51% were male.Two patients expired during study and two patients were lost to follow up.Eighty six percent (n=50) of patients received three sessions of HD weekly with duration per session varying between two to four hours (average 3 hours ).The breakdown of costs incurred are shown in table 1 as under :- Rs. 12,000/-and yearly Rs, 1,40,000/-.This is cheapest in world yet more than 90% of the Indians cannot afford it.As 26% population live below poverty line where daily earnings is Rs.20/-.¹The results of our study reveal that cost of hemodialysis per session is Rs.2,001.84amounting to annual burden of Rs. 2,09,449.10approximately.Cost of hemodialysis in Kashmir is higher than average cost in other states of India (Rs.1100/-per session) but lower than other SAARC countries.The reason was that our patients had to buy instruments, hemodialyzer and other drugs from market as the same were not available in hospital during the study period.
In Iran the annual cost of dialysis is similar to other developing countries but significantly less than the cost in developed countries.Cost of each session of hemodialysis in  Arora reported that female patients tend to have more physician visits high out patient expenditure and length of stay 10 than males.However, our study revealed more utilization of hemodialysis services by male gender in the percentage of 51%.
Tabish SA, Ajaz Mustafa and Rangrez RA in a study conducted in a tertiary care hospital in India reported 61.48 % cost on salary, 12.81% on drugs and 18.67% on other activities 11 of total budget.Our study revealed 20.84% cost on salary,12.84%cost on drugs, 32.50 % cost on instruments and 18.20 % on building rental.Principal expenses born by hospital were in the percentage of 43.89 % on salary and 38.31 % on account of building rental.

Limitation
The shortcomings of this study are that Values for overhead costs may not have fully reflected the true overhead cost.A subjective bias may have existed.Secondly labeled prices are not generally charged from patients and these patients get discounts on labeled prices because of the rapo developed with chemists because of chronicity of disease.
Despite these shortcomings we believe that the results of our analysis give a good indication of the magnitude of true cost.

Conclusion
Results of this study could enable health policy makers to design a fair and more convincible reimbursement system for dialysis procedures in future.
Change in dialysis delivery could lead to a more efficient resources utilization.Since the cost of Peritoneal Dialysis is lower, from the public health care providers view , either more patients could be treated with in a fixed budget or the same number of patients could be treated at a lower cost .
In our single centre study, we found that the annual cost of dialysis is comparable to other states of India and cheaper than other SAARC countries.Approaches to reduce cost further are needed by:-1) Reduce number of ESRD patients by preventing progression to Chronic Kidney Disease by timely and appropriate treatment of Diabetes, Hypertension, Glomerulo nephritis, obstructive Nephropathy , UTI , Vasculitis and pregnancy.
2) Continuous Peritoneal Dialysis can be utilized as a cost reduction measure in selected group of patients.
3) Kidney transplant is most cost effective treatment mode for ESRD.
4) Hemodialysis can reduce transportation charges and is better option in certain patients.This will also reduce Work days lost on treatment.
5) Insurance reimbursements is an option to meet out cost of treatment, this will help both patient and hospital in a long way especially kidney transplant.
Satellite units, free standing centers and charitable NGO owned hemodialysis centres can in a long way prove as cost reduction options.

Table 3 . Risk factors associated with increased cost of Hemodialysis
Percentage cost borne by Hospital and patient per session