Costs of home haemodialysis offset by better health, fewer hospitalisations

Daily haemodialysis administered in patients’ homes is associated with better health outcomes compared with peritoneal dialysis, according to an article in the October issue of the American Journal of Kidney Diseases, the official journal of the National Kidney Foundation.

As a result, the extra cost of providing in-home haemodialysis is balanced out by lower expenditures for medications and hospital admissions, physicians at a health maintenance organisation in southern California report.

Dialysis is a way of cleaning blood when a person’s kidneys can no longer do the job. It gets rid of the body’s wastes, extra salt and water, and helps to control blood pressure. There are two kinds of dialysis: haemodialysis and peritoneal dialysis.

In haemodialysis, blood is pumped out of the patient’s body to an artificial kidney machine where the blood is filtered through a special membrane, called a dialyser, and then returned to the body.

In peritoneal dialysis, the inside lining of the patient’s own belly acts as a natural filter. Wastes are taken out by means of a cleansing fluid called dialysate, which is washed in and out of the abdomen in cycles through a surgically placed soft plastic tube (catheter).

“You can do haemodialysis at a dialysis centre where a nurse or technician performs the tasks required during treatment,” says Dr Kerry Willis, Senior Vice President for Scientific Activities at the National Kidney Foundation. “You can also do haemodialysis at home where you and a care partner are the ones doing your treatment. At home, you may be better able to fit your treatments into your daily schedule.”

In addition to the convenience, “many reports indicate that people using daily home haemodialysis take less medication to control blood pressure and anaemia, feel better during dialysis and less ‘washed out’ afterward, and have more energy for daily tasks,” Dr Willis pointed out.

However, it has been suggested that better health outcomes may simply be the result of healthier patients opting for home treatment.

In their article, Dr Victoria A Kumar and her associates at the Southern California Permanente Medical Group in Los Angeles tested this theory by comparing one group of patients treated with daily home haemodialysis with a group of patients treated with peritoneal dialysis. Home dialysis was performed on average 5.4 times per week.

Dr Kumar’s group treated the 22 patients in the daily haemodialysis group and the 64 in the peritoneal dialysis group for at least 6 months between 2003 and 2007. The groups were comparable in age, the number of patients with diabetes, and causes of kidney failure.

Despite these similarities, patients treated by peritoneal dialysis spent nearly twice as many days each year in the hospital compared with patients treated with home haemodialysis (average 5.6 days/patient-year versus 3.3 days/patient-year).

Those treated by daily home haemodialysis were also able to reduce the number of medications required to keep their blood pressure under control, and had better nutritional status than they did prior to starting treatment, as shown by higher serum albumin levels.

Dr Kumar and her associates point out that their organisation could support the program of home haemodialysis because the cost of equipment, supplies, and patient training was offset by lower expenditures for hospital care and medications.

Unfortunately, many patients do not have the option of home dialysis because Medicare does not fully reimburse health care providers for the costs associated with such a program and not all dialysis centres offer education and training for home haemodialysis. Another challenge relating to home haemodialysis is the need for a care partner.

“If the costs of providing more frequent haemodialysis treatments do not pose a financial burden on the Medicare system,” Dr Kumar and her associates state, “the modality should be freely available to motivated patients with end-stage renal disease.”

(Source: American Journal of Kidney Diseases: National Kidney Foundation: October 2008)