Christina Bradshaw1, Sajith Narayanan2, Ranjit Narayanan3, Shuchi Anand1. 1. Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA. 2. Department of Nephrology and Urology, Aster MIMS Hospital, Kozhikode, Kerala, India. 3. Department of Nephrology, KMCT Medical College, Manassery, Kerala, India.
We thank Hafeeq et al. for closely evaluating our work. Hafeeq et al. point out that stand-alone units (SAUs) provide dialysis to a substantial number of patients in North Kerala and may be associated with lower patient-level costs due to lower session and travel costs.Although not stated in the text, much of our data from North Kerala were collected from SAUs affiliated with a tertiary care hospital in Kozhikode and Malabar Institute of Medical Sciences Charitable Trust (N = 332, 61% and 40% of Northern and overall data, respectively). Of this group, 63% reported receiving financial assistance from the government and/or a charity, with a median monthly assistance amount of US $72.50 (25th, 75th percentile $43.50−$87.00). The median dialysis procedure cost per session was $5.08 (25th, 75th percentile $1.21−$14.50), compared with $9.67 (25th, 75th percentile $0.12−$16.92) for hospital dialysis units (HDUs) (P = 0.12). The median transport cost per session associated with SAUs was $2.42 (25th, 75th percentile $1.81−$4.35), lower than the median transport cost for HDUs at $4.83 (25th, 75th percentile $1.81−$6.04) (P < 0.05). Despite the reduced transport costs, the prevalence of catastrophic health expenditure and distress financing among patients attending SAUs in North Kerala remained high at 92% and 85%, respectively.We acknowledge the efforts of the nephrology community in Kerala to provide quality care to patients on dialysis, and we look forward to reading the findings of Hafeeq et al.