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Original Article

Pharmacoeconomic Evaluation of Hemodialysis

Patients: A Study of Cost of Illness

S Fathima, Uday Venkat Mateti, Malona Lilly Philip, Janardhan Kamath1

Department of Pharmacy Practice, Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences, Nitte (Deemed to be University),
1
Department of Nephrology, KS Hegde Medical Academy, Nitte (Deemed to be University), Justice KS Hegde Charitable Hospital, Mangalore,
Karnataka, India

Abstract
Objective: The objective of the study is to analyze the health‑care costs of the hemodialysis (HD) patients
in a charitable hospital. Subjects and Methods: A prospective observational study was carried out in an
outpatient HD unit of nephrology department in a charitable hospital for a period of 8 months from August 2016
to March 2017. The collected direct medical and nonmedical cost data were analyzed for the median interquartile
(Q3–Q1) cost incurred in treating the HD patients. Results: A total of 39 outpatients were included in the
study. Of 39 patients, majority of the HD patients were males (66.2%) followed by females (33.8%). Most of the
patients underwent HD for twice a week (89.7%) followed by thrice a week (10.3%). The median direct medical
costs (85,999.2 Indian rupee [INR]) were found to be higher than direct nonmedical costs (14,437.1 INR).
Conclusions: The study revealed that the total median direct cost was found to be uppermost for the age group
of 41–60 years (1,12,438.8 INR) when compared to all other age groups, and it was also observed that the total
median direct cost for males (1,07,522.4 INR) was higher than females (1,03,170.7 INR). The factors such as
type of comorbidities, age, and number of HD per week may affect the cost of illness.

Key words: Cost of illness, end‑stage renal disease, hemodialysis

INTRODUCTION 1990 because of CKD which may increase to 7.73 million

Chronic kidney disease (CKD) includes different
pathophysiologic processes associated with abnormal kidney
function and a deterioration in glomerular filtration rate.[1]
CKD is a major health problem, which is one of the reasons
for illness and financial burden on patients and even loss of
life in the developing countries.[2-4] The global prevalence
of CKD ranges between 8% and 16%.[5] It was found that
50 million patients around the world required treatment for
CKD and that there were 3.78 million deaths in the year
Address for correspondence: Dr. Uday Venkat Mateti,
Department of Pharmacy Practice, Nitte Gulabi Shetty Memorial
Institute of Pharmaceutical Sciences, Nitte (Deemed to be University),
Deralakatte, Mangalore ‑ 575 018, Karnataka, India.
E‑mail: udayvenkatmateti@gmail.com
Access this article online
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in the future.[6,7]
End‑stage renal disease (ESRD) not only has increased in the
prevalence but also has a major impact on the financial burden.[8‑10]
The prevalence of ESRD has been on the rise since the past few
years in India. If the prevalence of ESRD continues, the ESRD
population will exceed 2 million patients by the year 2010.[11]
The only treatment option left is either hemodialysis (HD) or
transplantation, and due to the unaffordable expenses, only HD
can be opted by the Indian population.[12]
HD and peritoneal dialysis continue to be the most extensively
used treatment procedures due to least availability of kidney
This is an open access article distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the
work non‑commercially, as long as the author is credited and the
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Fathima S, Mateti UV, Philip ML, Kamath J.
10.4103/jina.jina_4_18 Pharmacoeconomic evaluation of hemodialysis patients: A study of cost of
illness. J Integr Nephrol Androl 2018;5:54-9.

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Fathima, et al.: Pharmacoeconomic evaluation of hemodialysis patients
donors. As regular HD usually results in financial pressure
in some population, it is necessary to evaluate the therapy by
analyzing the treatment costs.[13]
Since CKD is associated with the high economic burden
on patients, it is necessary to obtain the exact details of
expenditures of patients undergoing the HD. However, there
is no literature available which contains details on the cost
for HD in India. Therefore, the burden of disease can only
be estimated by analyzing the cost. Hence, this study was
conducted to estimate the direct costs of HD in a charitable
hospital in Mangalore.
SUBJECTS AND METHODS
A prospective observational study was carried out in an
outpatient HD unit of nephrology department for a duration
of 8 months (from August 2016 to March 2017). The study
was approved by the institutional ethics committee (REF:
INST. EC/EC/67/2016‑17).
The sample size was calculated based on the similar study
conducted by Suja et al. and subject to availability of patients
in the HD unit.[11] The minimum sample size required for this
study was thirty patients. Outpatients undergoing maintenance
HD with age more than 18 years and either gender were
included in the study. The inpatients, patients not willing
to participate in the study, patients with missing data, and
pregnant women were excluded from the study.
Data collection form was designed as per the study requirements.
The details such as age, gender, diagnosis, number of HD
per week, number of visits to HD, comorbid conditions, and
number of medicines per prescription were obtained from the
patient medical records. The pharmacoeconomic‑related direct
medical costs (medicines, HD, laboratory investigations,
consultations, hospitalization, and miscellaneous costs) and
nonmedical costs (transportation to visit HD unit and food
expenses during HD) were collected from the patient records,
medical bills, hospital accounts section, and interviewing the
patients or patient parties. From the data obtained, the total
cost of HD for 6 months was calculated.
The collected data were analyzed for the median
interquartile (Q3–Q1) cost incurred in treating the HD
patients and were calculated based on the total amount spent
by the patients to that of a total number of patients. Details
of direct medical and nonmedical costs were analyzed. The
direct costs are the sum of the direct medical and nonmedical
costs. The data of all the costs in Indian rupee (INR)
were converted into the United States dollar (USD), i.e.,
1 INR = 64.62 USD.
Journal of Integrative Nephrology and Andrology | Volume 5 | Issue 2 | April-June 2018
Statistical analysis
The normally distributed continuous variables were presented
as mean ± standard deviation, and skewed distribution
variables were presented as median and interquartile
range (Q3–Q1). The categorical variables were presented as
frequency and percentage. All the data were analyzed using
the SPSS Statistics for Windows, Version 20.0. (IBM Corp.,
Armonk, NY, United States of America).
RESULTS
A total of 39 HD patients were included in the study, of
which 66.2% and 33.8% were males and females, respectively.
Baseline characteristics of patients such as age, comorbid
conditions, occupation status, educational status, and other
details are specified in Table 1. In the present study, most of
the patients belonged to the age group of 41–60 years, i.e.,
18 (46.2%), and the mean age of the HD patients was found
to be 51 ± 12.7 years. Majority of HD patients had normal
BMI (n = 25, 64%) with the mean BMI of 21.7 ± 3.7 kg/
m2.
It was observed that most of the HD patients had completed
their high school certificate (30.8%) followed by patients who
were illiterate (23.1%). Of these, the majority of them were
not working (53.8%) and only a few patients had the history
of smoking (15.4%) and drinking alcohol (10.3%). In the
study, most of the patients were found to have a duration of
HD for less than a year (31%) as depicted in Table 1.
In the present study, the maximum number of medications prescribed
to HD patients ranged from 6 to 9 medications (79.5%),
and the median number of medications prescribed per HD
patients was found to be 9 (11–7) as summarized in Table 1.
Higher incidence of various comorbidities among HD patients
was hypertension (46.2%) and hypertension with diabetes
mellitus (25.6%) as is depicted in Table 1.
The median direct medical costs (85,999.2 INR) were found
to be higher than that of direct nonmedical costs (14,437.1
INR) as summarized in Table 2. The median cost per
patient for each session of HD was 980 INR (1100–900
INR). Among the various direct medical cost components, the
median cost was found to be highest for HD sessions (44,000
INR) followed by medication charges (30,507 INR). In
this study, the median cost for the transportation of patients
to visit the HD unit was 9600 INR, and food cost during
HD was 3720 INR.
Costs were also categorized based on the age groups, where
it was observed that the total median direct cost was found
to be highest for the age group of 41–60 years (1,12,438.8
55
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Fathima, et al.: Pharmacoeconomic evaluation of hemodialysis patients

Table 1: Baseline characteristics of hemodialysis patients twice‑weekly HD sessions which lead to increase in expenses
Characteristics Number of on transportation, food, HD sessions, and medications as
patients (%) described in Table 5. In this study, most of the HD patients
Age (years) were under various schemes and few without schemes, of which
18‑40 10 (25.6) the median (Q3–Q1) direct medical cost was found to be
41‑60 18 (46.2)
highest in patients with MED scheme (95,674.3 INR). In
61‑80 11 (28.2)
case of the median, the direct nonmedical cost was highest
Body mass index (kg/m2)
<18.5 7 (18)
in patients with group scheme (31,892.9 INR). The overall
18.5‑24.9 25 (64) median direct cost was found to be highest in patients who
25‑29.9 5 (13) were not on schemes (1,12,438.8 INR) as described in
≥30 2 (5) Table 6. The direct medical cost was high in the case of MED
Educational status scheme because patients availed reimbursements; hence,
Illiterate 9 (23.1) they preferred high‑end treatments as there are no monitory
Primary school certificate 5 (12.8) implications for them. Therefore, their medical costs would be
Medium school certificate 8 (20.5)
higher when compared to those patients who received no such
High school certificate 12 (30.8)
reimbursements. The total median cost was high in patients
Intermediate/posthigh‑school diploma 3 (7.7)
Graduate/postgraduate 2 (5.1)
without scheme as they were not getting any concessions and
Occupational status they had to spend more on transportation to the hospital.
Working 18 (46.2)
Not working 21 (53.8) DISCUSSION
Social habits
Alcoholic 4 (10.3) ESRD is a condition where there is irreversible loss of normal
Smoker 6 (15.4)
kidney function, and it has a greater impact on health economics.
Duration of dialysis (years), median (Q3‑Q1) 2 (5‑1)
The role of HD is to treat ESRD, which remains one of the
Number of medications prescribed
2‑5 3 (7.7)
most intensive and expensive therapeutic interventions. Thus,
6‑9 31 (79.5) this study was conducted to assess the expenditure of HD
>10 5 (12.8) patients to get the detailed information on their direct medical
Comorbid conditions and nonmedical costs in a charitable hospital.
No comorbidities 3 (7.7)
Hypertension 18 (46.2) A total of 39 HD patients were selected for the study, of
Pulmonary diseases 1 (2.6) which majority of them belonged to the age group of
Hypothyroidism 1 (2.6) 41–60 years (46.2%). The mean age of HD patients was found
Cardiovascular with hypertension 2 (5.1)
to be 51 ± 12.7 years which is comparable with the study results
Hypertension with diabetes mellitus 10 (25.6)
obtained by Suja et al., where it was reported that majority of
Hypertension with pulmonary diseases 1 (2.6)
Cardiovascular with hypertension and diabetes 1 (2.6)
the patients belonged to the age group of 51–60 years, and the
mellitus mean age of the patients was 49.72 ± 13.2 years.[11]
Hypertension with diabetes mellitus and 1 (2.6)
pulmonary diseases Of 39 patients, the majority were males (66.2%) followed by
Cardiovascular with hypertension, diabetes 1 (2.6 ) females (33.8%). Similar results were found in the studies of
mellitus and pulmonary diseases
Al Saran et al., Mateti et al., Al‑Shdaifat et al., where it was
reported that majority were males (60%, 80.7% and 53.6%)
INR) when compared to all other age groups. It was because followed by females (40%, 19.3% and 46.4% ).[14-16]
these patients were traveling from distant places, so they had
to spend more on traveling and food during HD sessions In this study, it was observed that hypertension (46.2%) and
as presented in Table 3. It was also observed that the total hypertension with diabetes (25.6%) were the major comorbid
median direct cost for males (1,07,522.4 INR) was higher conditions. Similar results were also found in the studies
than females (1,03,170.7 INR) as presented in Table 4. conducted by Suja et al., Mushtaq et al., and Shyamala et
al., where diabetes and hypertension were the leading causes
Among the HD patients, 89.7% underwent twice a week and in HD patients compared to other disease states.[12,17,18]
10.3% thrice a week. It was also found that the total median
direct costs were highest in patients on thrice‑weekly HD In this study, most of the patients were found to have HD
sessions (1,27,682.4 INR) when compared to patients on sessions for less than a year (31%). The median duration of

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Fathima, et al.: Pharmacoeconomic evaluation of hemodialysis patients

Table 2: Direct cost components of hemodialysis patients

Cost components Median (Q3‑Q1) costs
INR USD
Direct medical costs
Medication costs 30,507 (36,837.9‑25,664.2) 472.1 (570.1‑397.2)
Laboratory charges 2675 (5330‑2010) 41.4 (82.5‑31.1)
Consultation charges 5160 (6320‑4640) 79.9 (95.6‑71.8)
Hemodialysis costs 44,000 (49,880‑37,660) 680.9 (771.9‑582.8)
Hospitalization charges 4186.4 (10,380‑1700) 64.8 (160.6‑26.3)
Miscellaneous charges 690 (3565‑400) 10.7 (55.2‑6.2)
Direct nonmedical costs
Transportation charges to HD center 9600 (19,600‑4800) 148.6 (303.3‑74.3)
Food costs 3720 (4800‑2340) 57.6 (74.3‑36.2)
Direct cost components
Direct medical costs 85,999.2 (103,245.5‑76,316.5) 1336.8 (1585.3‑1182.7)
Direct nonmedical costs 14,437.1 (24,400‑7,237.1) 222.8 (377.6‑111.4)
Total direct costs 106,971.2 (136,219.9‑92,846.5) 1638.6 (2097.7‑1429.4)
INR: Indian rupee, USD: US dollar, HD: Hemodialysis

Table 3: Categorization of costs based on the age of hemodialysis patients

Age Direct medical costs Direct nonmedical costs Total direct costs
(years) INR USD INR USD INR USD
18‑40 98,787.5 1526.5 6792.3 104.4 104,596.7 1614.1
(108,609.6‑85,203.5) (1668.1‑1308.6) (15,173.4‑4445.6) (215.4‑68.7) (135,564.2‑94,900.8) (2078.8‑1429.3)
41‑60 83,843.7 1299.3 18,749.7 289.7 112,438.8 1729.8
(100,425.3‑76,273.7) (1553.6‑1171.1) (40,219.9‑13,593.4) (620.8‑209.8) (142,434.0‑98,692.3) (2184.7‑1529.9)
>60 80,954.1 1252.7 12,037.1 185.7 96,987.8 1491.5
(94,711.3‑73,832.9) (1452.9‑1142.6) (21,637.1‑7680) (334.3‑118.8) (131,324.8‑88,752.9) (2032.3‑1373.5)
INR: Indian rupee, USD: US dollar

Table 4: Categorization of costs based on the gender of hemodialysis patients

Gender Direct medical cost Direct nonmedical cost Total direct costs
(n=39) INR USD INR USD INR USD
Male 85,415.9 1318.2 12,055.7 185.7 107,522.4 1646.6
(n=26) (105,154‑78,972.1) (1614.1‑1224.1) (26,118.6‑7014.7) (403.9‑107.9) (138,174.2‑96,438.1) (2120.4‑1476.0)
Female 85,999.2 1344.9 14,474.3 222.8 103,170.7 1598.8
(n=13) (101,365.4‑76,097.6) (1564.2‑1167.9) (28,120.9‑8699.4) (434.5‑133.7) (128,528.7‑89,929.1) (1975.2‑1384.8)
INR: Indian rupee, USD: US dollar

Table 5: Categorization of costs based on number of hemodialysis per week

Number of HD/ Direct medical cost Direct nonmedical cost Total direct costs
week (n=39) INR USD INR USD INR USD
Twice (n=35) 82,680.3 1299.6 14,437.1 222.8 105,110.4 1626.6
(99,485.2‑76,145.3) (1543.1‑1171.8) (24,074.3‑7680) (371.4‑118.8) (131,324.8‑92,369.6) (2032.3‑1422.8)
Thrice (n=4) 108,850.1 1680.1 18,803.6 289.7 127,682.4 1967.4
(131,634.6‑86,348.8) (2040.4‑1326.2) (35,177.9‑4430.9) (543.2‑67.9) (150,660.9‑107,803.6) (2332.2‑1655.2)
INR: Indian rupee, USD: US dollar, HD: Hemodialysis

HD sessions was 2 (5–1) years. Similar results were obtained
in a study conducted by Suja et al., where it was reported that
the mean duration of HD was 2.8 years.[11] In the present
study, the median number of medications prescribed in our
study was 9 (11–7), and in the study conducted by Mateti
et  al., the mean number of medications prescribed was
13.10 ± 4.86.[12,15]
Patients undergo HD either twice or thrice weekly depending
on the severity of their disease state and affordability. Of the
total number of 39 HD patients, majority of the patients
underwent HD for twice a week (89.7%) followed by thrice
a week (10.3%). Similar results were observed in the study
by Abreu et  al., where they selected patients undergoing
maintenance HD (2–3 HD sessions per week).[19]

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Fathima, et al.: Pharmacoeconomic evaluation of hemodialysis patients

Table 6: Health‑care scheme‑wise costs of hemodialysis patients

Health‑care Direct medical cost Direct nonmedical cost Total direct costs
scheme (n=39) INR USD INR USD INR USD
Without scheme 92,803.9 1353.2 16,885.9 260.7 112,438.8 1731.8
(n=16) (106,440.1‑75,298.7) (1644.2‑1160.1) (23,464.9‑9796.1) (362.1‑150.4) (148,341.6‑97,901.1) (2280.6‑1444.9)
SMP (n=9) 80,710.4 1252.8 7680 118.8 89,148.3 1448.2
(91,082.8‑74,689.3) (1439.9‑1163.7) (19,437.1‑3919.6) (300.2‑60.2) (122,887.1‑80,909.4) (1903.2‑1298.5)
Group (n=4) 81,412.6 1249.3 31,892.9 492.1 111,687.3 1704.8
(108,449.1‑77,521.6) (1675.6‑1190.1) (35,177.9‑15,018.6) (543.2‑232.1) (144,170.3‑95,182.6) (2226.1‑1458.8)
ESI (n=7) 92,547.2 1437.2 12,037.1 185.7 105,504.4 1621.9
(100,330.7‑85,999.2) (1543.9‑1344.9) (23,215.4‑6347.4) (357.5‑97.3) (137,344.3‑98,949.1) (2100.6‑1523.9)
MED (n=3) 95,674.3 1481.2 14,437.1 222.8 110,563.9 1693
(105,689.6‑76,049.9) (1618.7‑1167.2) (39,929.1‑4800) (616.5‑74.3) (136,219.9‑90,709.9) (2097.7‑1389.9)
ESI: Employers scheme insurance, Group: It is a scheme meant for hospital employee and their relatives, MED: It is a scheme meant for bank employees which is known
as Medi‑assist, SMP: Sampoorna Suraksha Scheme

In this study, the median direct medical costs (85,999.2
INR) were found to be higher than direct nonmedical
costs (14,437.1 INR). Similar study results were reported
by Mateti et al., who reported that the median direct medical
costs of HD patients were higher (573.11 INR) than direct
nonmedical costs (67.50 INR).[15]
Among the various direct medical cost components, the
median cost was found to be highest for HD sessions (44,000
INR) followed by medication charges (30,507 INR). Similar
results were reported by Lorenzo et  al., which stated that
major expenditure was from HD sessions (51%) followed
by medications (27%).[20] In this study, the median cost
of hematopoietic agents (55.1%) was highest followed by
phosphate binders (22.9%), which was similar to the results
obtained from the study carried out by Lorenzo et al., where
it was reported that 68% of total pharmaceutical cost was
contributed by hematopoietic agents.[20]
Proportional allocation of costs in our study was as follows:
HD sessions (50%), medications (35%), diagnosis (6%),
hospitalization (5%), laboratory investigations (3%), and
miscellaneous (1%). This was similar to the results obtained
by Lorenzo et  al., where it was reported that proportional
allocation of costs in their study was HD sessions (51%),
pharmacy (27%), hospitalization (17%), transportation (3%),
and ambulatory care (2%).[20] The median cost for each
session of HD was 980 INR (1100–900 INR) which was
similar to the results obtained by Khanna et al., where it was
reported that the cost per each session of HD in South India
was 1100 INR.[21]
In our study, it was observed that the total median direct cost
was highest for the age group of 41–60 years (1,12,438.8
INR) when compared to all other age groups. In contrast,
the study conducted by Kao et al. concluded that the total
cost per life year of patients was found to be highest for the
age group of ≥65 years (23,664 USD).[22]
In the present study, it was observed that the total median direct
cost for males (1,07,522.4 INR) was highest followed by
females (1,03,170.7 INR). In case of median direct medical
cost, it was found that cost for female patients (85,999.2
INR) was higher than male patients (85,415.9 INR). Similar
results were reported in the study conducted by Roggeri
et al., where it was found that the total costs for male patients
(53,945€/year/patient ± 14,884€) were highest followed
by female patients (53,467€/year/patient ± 14,356€).[23]
CONCLUSIONS
This study gives an insight on the direct costs and the impact
of economic burden on the HD patients. The most commonly
prescribed medication was found to be hematopoietic agents,
which consumes the highest cost. The total direct median cost
of HD treatment was 1,06,971.2 INR. The total median
direct cost was more for the patients undergoing three dialysis
sessions per week (1,27,682.4 INR). Type of comorbidities,
unemployment, age, number of HD per week, and number of
medicines prescribed may affect the cost of illness. The costs
incurred for the HD patients were higher and can be minimized
by providing concerns from the charitable hospitals, allowances
from governments, and supporting with more insurance schemes.
Acknowledgment
We would like to thank the Nitte (Deemed to be University)
for providing participants recruited in this study. The authors
wish to acknowledge the directors and staff of the respective
dialysis units for their contribution toward the successful
completion of the project.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.

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Fathima, et al.: Pharmacoeconomic evaluation of hemodialysis patients
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