The economics of home nocturnal hemodialysis: how should we cost the benefits?

Home nocturnal hemodialysis (HNHD) has been established as a safe and effective way to provide dialysis for patients who require renal replacement therapy. Non-randomized studies have shown that patients switched to HNHD have improvements in blood pressure, left ventricular mass and quality of life. At present, there are no RCTs or long-term observational studies demonstrating a clear reduction in cardiovascular events or mortality. Several HNHD centers have published articles documenting the costs of this modality as compared to conventional HD. Some of these studies have found HNHD to provide significant cost savings, while others have found the two modalities to be relatively equivalent in terms of costs. In this paper, we review the results of these costing studies and illustrate some of the limitations associated with these studies including the lack of randomization, inconsistent reporting of HNHD start-up costs, potential patient selection biases and limited follow-up. On balance, it appears premature to conclude that HNHD is cost-saving in comparison to conventional hemodialysis. However, two ongoing randomized trials, which are collecting resource use information, will help to answer this question. Once these data are available, a formal economic evaluation should be done to determine the impact of HNHD on both clinical outcomes and costs. This information will assist decision-makers in determining whether to make HNHD more widely available.