Cost analysis of in-centre nocturnal compared with conventional hemodialysis

Abstract

Background: Provision of in-centre nocturnal hemodialysis (ICNHD; 6-8 hours thrice weekly) is associated with health benefits, but the economic implications of providing this treatment are unclear. Objective: We conducted a health care costing study comparing ICNHD to in-centre thrice-weekly conventional hemodialysis (CvHD). Design: Micro-costing of both ICNHD and CvHD as practiced at our centre. Setting: Hemodialysis unit at a tertiary-care hospital in Edmonton. Participants: An informal survey of 2 other Canadian ICNHD programs was conducted to inform practices that may deviate from ours to guide sensitivity analysis. Measurements: Resources consumed for each strategy were determined, and the cost of each unit (CAN $2012) was used to calculate incremental costs of ICNHD and CvHD. Methods: We focused on resources that differ between strategies (staffing, dialysis materials, and utilities). The reference case considered 1:3 staff to patient ratio; alternate scenarios explored nursing pay grade and ratio, full care vs. self-care dialysis (including training costs), and medication costs. Results: In the reference case, ICNHD was $61 more costly per dialysis treatment compared with CvHD ($9,538 per patient per year). Incremental annual costs for staffing, dialysis materials, and utilities were $8,201, $1,193, and $144, respectively. If ICNHD reduces medication use (anti-hypertensives, bone mineral metabolism medications), the incremental cost of ICNHD decreases to $8,620 per patient per year. In a scenario of self-care ICNHD utilizing a staff-to-patient ratio of 1:10, ICNHD is more costly in year 1 ($15,196), but results in cost savings of $2,625 in subsequent years compared with CvHD. Limitations: The findings of this cost analysis may not be generalizable to other health care systems, including other parts of Canada. Conclusions: Compared to CvHD, provision of ICNHD is more expensive, largely driven by increased staffing costs as patients dialyze longer. Alternate staffing models, including self-care ICNHD with minimal staff, may lead to net cost savings. The incremental cost of treatment should be considered in the context of impact on patient health outcomes, staffing model, and pragmatic factors, such as current capacity for daytime CvHD and the capital costs of new dialysis stations.