The Economic Benefits of Community-based Stand-alone Hemodialysis Units (SAUs) in Kerala.

To the Editor:

Bradshaw et al. explored household financial hardship in the context of medical subsidy among patients with chronic kidney disease on hemodialysis in Kerala. The study results showed that 9 of 10 households with a family member on maintenance hemodialysis spend 40% to 80% of their nonfood expenditure to support their therapy, and that even after receiving some form of subsidy, they were more likely to engage in distress financing. However, this study explored the economics of only hospital-based hemodialysis units, which, in our view, is the major limitation of the study. Community stand-alone dialysis centers have already become an important alternative to hospital dialysis units (HDUs) in meeting the growing demand for renal replacement therapy, especially in the northern part of Kerala. In a recent research work, we explored hemodialysis delivery in community-based stand-alone units (SAUs) associated with 2 tertiary care hospitals in Calicut district, Kerala, with respect to expanding coverage, feasibility, safety, and economic benefits. We found that, during 2017, of the total 16,182 hemodialysis sessions provided in HDUs and SAUs combined, 75.3% were provided at SAUs. Importantly, dialysis at SAUs resulted in a significant reduction in the mean patient cost of treatment per session, from $12.86 to 27.15 down to $7.43, compared to sessions at HDUs. Costs are further subsidized in SAUs through community-generated resources and the involvement of philanthropists. In addition, with SAUs usually being near patients’ residences, indirect out-of-pocket costs related to hemodialysis such as travel and relatives’ wage loss are likely reduced. Most of the SAUs are organized and operated by nongovernmental organizations providing dialysis on a no-profit, no-loss basis. Laboratory services and relatively expensive medications such as erythropoietin are made available at a lower cost, in addition to transport facilities. Local self-government programs are also made available for all patients, through which $42.86 is provided as a dialysis subsidy every month. Our study has shown that SAUs cater to a large number of patients, improving access to renal replacement therapy in North Kerala. Moreover, we have found that delivery of hemodialysis with structured patient safety measures is feasible in SAUs at significantly lower direct patient costs. By limiting data collection only to patients in HDUs, Bradshaw et al. may have missed out on a sizeable population of patients on maintenance hemodialysis in North Kerala, which could have significantly influenced the study results.