Dialysis: the best quality at the lowest cost

Dialysis is a life-sustaining therapy for end-stage renal disease patients, and hemodialysis (HD) is the most widely used modality of renal replacement therapy. Worldwide, dialysis costs are approached in different ways. Most of the time, we tend to look at the dialysis cost as the reimbursement fee fixed by governments and third-payers and packed to cover the direct and indirect costs of the treatment itself¹. This bundled amount may or may not include the doctor’s fees, the intravenous medications, and the laboratory expenses. When policy-makers try to understand further the cost of dialysis, they analyze the cost-of-illness of dialysis patients, which usually includes, in addition to the above-mentioned treatment costs, the hospitalizations and/or the transportations. Also, when it comes to comparing the highly variable costs of HD among countries, we use the cost-effectiveness ratio and we normalize it to the GNI per capita of each country for more accuracy². Thus, healthcare providers emphasize a lot the economic burden of dialysis, yet they may neglect sometimes the quality of treatment when assessing cost-effectiveness.

This issue of The Journal of Medical Economics includes a study by Rizk et al.³ that addresses the cost-of-illness of HD in Lebanon. Lebanon is a developing upper middle-income country of the middle-east area, with a total population estimated at 4.5 million people and a GNI per capita of $10,030 based on the World Bank 2014⁴. It had ∼3,500 patients on dialysis in 2015, and this is the first time that the cost-of-illness of HD in Lebanon is reported. Rizk et al.³ took a sample of 119 patients from six out of 65 Lebanese dialysis facilities in 2011 and estimated the societal costs for each HD patient for 6 months at $9,258 (annually $18,516). They included in the cost the reimbursement fee provided by third payers in 2011 ($6,632 for 6 months) and they added the rate of hospitalizations, the medications ($1,640 annually for erythropoietin that is already a part of the reimbursed amount by MOPH), the travel, productivity losses, healthcare professionals, and professional home care. Patients of those six centers were undergoing an average of 11.2 sessions per month, meaning that half of them were dialyzed twice per week, which is not representative of the whole country.

Although they over-estimated the erythropoietin cost, under-estimated the number of sessions, and concluded that the economic burden of HD in Lebanon was high, they basically under-estimated the total real cost of HD in the country in 2015.

In fact, the HD reimbursement’s policy was amended at the end of 2014 by the Lebanese Ministry of Public Health (MOPH). Lebanon has always had an expanded reimbursement package that includes medical costs such as nursing, HD machines, membranes and tubing, radiology, laboratory, erythropoietin, as well as non-medical costs such as the building, electricity, cleaning, and water costs. The nephrologist’s fee has also been fixed at $25 per visit for several years, and one nephrologist visit per dialysis session is mandatory.

Since the new decree release, number 1/1690, the Lebanese MOPH increased the reimbursement amount of each HD session of $29 in order to give the incentive to hospitals to improve the quality of treatment and upgrade their dialysis water to ultrapure and the membranes from low- to high-flux. Ultrapure water is characterized by an endotoxin level below 0.03 EU/mL, as recommended by the International Organization for Standardization 11663: 2014. MOPH recommended also that all patients be dialyzed three times per week. This new regulation led to an increase in the session cost to $127 instead of $98 in the previous years. This raised the annually reimbursed fee of HD per patient (if dialyzed three times per week) from $15,340 to $19,916. If we add the costs estimated by Rizk et al.³ such as costs of hospitalizations, outpatient consultations, productivity losses, and intravenous drugs (excluding the duplicate cost of erythropoietin), the total cost-of-illness of HD per patient per year reaches $21,300.

Hence, the more important question appears to be whether HD with ultrapure water and high-flux membranes is cost-effective in a developing country. We already know that the cost of HD varies significantly between developed and developing countries. According to the USRDS 2013 Annual Report, the annual per patient cost of HD in the US is ∼$89,000 per year⁵. Developed countries, especially European ones, already use the high-flux membranes and ultrapure water. When it comes to low-to-middle-income countries, the cost of dialysis is highly variable between countries and within one country category, and this is probably due to differences in cost estimation’s methodologies or quality of treatment (HD cost ranged from $3,424–$42,785)^6–8. Anyway, the estimated HD cost in Lebanon, even with ultrapure water, remains lower to many other reported costs of upper middle-income countries (e.g. Brazil, Chile, China, Malaysia, South Africa, and Turkey)⁸.

Moreover, if we use the incremental cost-effectiveness ratio (ICER)—i.e. the difference in costs divided by the difference in health effects—by keeping in mind that a patient who does not get dialysis dies, ICER of a dialysis treatment is calculated as its cost per quality-adjusted life-year (QALY) gained. In order to compare ICERs between two healthcare systems in two different countries, the World Health Organization’s Choosing Interventions that are Cost-Effective (WHO-CHOICE) project proposed the ratio between cost and per capita GNI. A ratio less than one is regarded as highly cost-effective and less than three as cost-effective². Based on this cost-effectiveness threshold we can state that HD with ultrapure water in our country is still cost-effective.

Upgrading the quality of HD may also be cost-effective on the long run. First, patients who are dialyzed three times instead of twice per week require less medication and show less morbidity⁸. Second, ultrapure water has the advantage of decreasing morbidity and increasing survival. Since 2002, the European Best Practice Guidelines for HD recommends the use of synthetic high-flux membranes and ultrapure dialysis fluid as a standard for all patients to reduce long-term complications⁹. Reducing the endotoxin levels in dialysis fluid might improve the response to erythropoietin, decrease inflammation, and improve the outcome of HD patients^10–12. The HEMO study showed a benefit of high-flux over low-flux membranes on survival when dialysis duration exceeded 3.7 years¹³. The membrane permeability outcome (MPO) study demonstrated a significantly higher survival rate for patient sub-groups with a serum albumin below 4 g/dL and for diabetic patients when they were treated with high- compared with low-flux membranes¹⁴. Another prospective observational study showed that the high-flux group had a risk of death that was 60% lower than the low-flux group in patients without residual renal function¹⁵.

Encouraging other modalities of renal replacement therapy in end-stage renal-disease patients is another way to reduce the costs and offer a good quality-of-life. Rizk et al.³ pointed out in their conclusion the high economic burden of HD. They rightly mentioned that transplantation and home HD could be two alternative cost-effective treatments based on previous international studies. In Lebanon, home HD is not reimbursed so far by the government, and the national cadaveric transplantation program needs further improvement. However, another option of home-based therapy is the peritoneal dialysis that is more cost-effective than HD in several countries^1,8. In Lebanon, peritoneal dialysis is reimbursed partially by third payers that cover the solutions and the medications, but do not cover the peritoneal catheter, the nephrologist’s fees, or the nurses. Only 6% of the Lebanese dialysis patients are on peritoneal dialysis. This modality should be offered to a larger proportion of end-stage renal disease patients and be totally reimbursed by MOPH because of its cost-effectiveness.

In summary, the initiative taken by Rizk et al.³ of estimating for the first time the cost-of-illness of HD in Lebanon is very useful and thoroughly detailed. Their analysis, however, targeted a small number of centers in the era before the implementation of ultrapure water and the increase in the reimbursement of HD. This opens the door in the future to a cost-of-illness study that includes all the dialysis centers in the country with the new established fees. It is crucial also that cost analysis studies of HD, whether in Lebanon or another developing country, be conducted assessing not only the costs but also the quality of treatment delivered. The number of sessions per week and the use or not of high-flux membranes and ultrapure water are very important parameters to focus on. Finally, it is the ultimate goal of engaged healthcare stakeholders to ensure an optimized system that balances best treatments at lowest costs.