a prospective analysis was carried out in amrita institute of medical sciences , kerala which is a tertiary care hospital , to compare the outcome of hemodialysis patients from different socioeconomic status .
patients were allotted in different shifts either in morning , afternoon or evening , based on their preferences .
the patient sociodemographics , cost details of dialysis , adverse reactions occurred during dialysis , cost to manage such adverse reactions , regularity , affordability , outcome and patient satisfaction to dialysis , etc .
a total of 79 patients were undergoing dialysis per week in three different shifts during the study period .
sampling was done and every second patient in the op was selected for the study . for simple analysis , patients undergoing dialysis thrice in a week , without considering the duration of dialysis were included in the study .
patients with major illness such as severe cardiac or neurological problems and those who avail reimbursement were excluded .
based on the education , occupation and income , patients were categorized into upper , middle , and lower socioeconomic classes .
patient perspective was taken for the analysis of cost component and the details were collected by direct patient interview .
details of direct medical cost , direct non - medical cost and indirect cost were analyzed .
direct medical cost includes cost of hemodialysis , laboratory investigation , erythropoietin , av fistula , blood transfusion , x - ray and medications whereas direct non - medical costs include cost of food , transportation , and extra family care .
other costs such as intangible cost and opportunity costs were excluded . from the data obtained ,
overall costs of hemodialysis per session as well as total cost for a period of 6 months were calculated .
the patient data were collected by using the patient data collection form and by the direct patient interview .
patient 's demographics , socioeconomic status , comorbid conditions , cost of therapy , regularity , and affordability of hemodialysis , etc . were incorporated in the data collection form .
socioeconomic status was also studied using kuppuswamy 's scale since the hospital is located in urban area , and the patients are also from such places .
outcomes were compared between patients of different socioecomic status in order to assess regularity , affordability , clinical condition and satisfaction .
statistical tests ( pearson correlation ) were applied to analyze the data using statistical package for the social sciences ( spss ) version 14 .
a total of 79 patients were undergoing dialysis per week in three different shifts during the study period .
sampling was done and every second patient in the op was selected for the study . for simple analysis , patients undergoing dialysis thrice in a week , without considering the duration of dialysis were included in the study .
patients with major illness such as severe cardiac or neurological problems and those who avail reimbursement were excluded .
based on the education , occupation and income , patients were categorized into upper , middle , and lower socioeconomic classes .
patient perspective was taken for the analysis of cost component and the details were collected by direct patient interview .
details of direct medical cost , direct non - medical cost and indirect cost were analyzed .
direct medical cost includes cost of hemodialysis , laboratory investigation , erythropoietin , av fistula , blood transfusion , x - ray and medications whereas direct non - medical costs include cost of food , transportation , and extra family care .
other costs such as intangible cost and opportunity costs were excluded . from the data obtained ,
overall costs of hemodialysis per session as well as total cost for a period of 6 months were calculated .
the patient data were collected by using the patient data collection form and by the direct patient interview .
patient 's demographics , socioeconomic status , comorbid conditions , cost of therapy , regularity , and affordability of hemodialysis , etc . were incorporated in the data collection form .
socioeconomic status was also studied using kuppuswamy 's scale since the hospital is located in urban area , and the patients are also from such places .
outcomes were compared between patients of different socioecomic status in order to assess regularity , affordability , clinical condition and satisfaction .
statistical tests ( pearson correlation ) were applied to analyze the data using statistical package for the social sciences ( spss ) version 14 .
out of 79 patients undergoing hemodialysis during the study period , 30 patients were selected based on the inclusion and exclusion criteria , which is given in detail in the methodology section .
the sociodemographics as well as the comorbid conditions of the patients were given in table 1 .
majority of the patients were in the age group of 5160 with a mean age of 49.72  13.2 and associated with comorbid conditions .
diabetes and hypertension were found to be the predominant causes compared to other disease states . out of this
duration of renal failure as well as duration of dialysis was also calculated and the result was 4.2  1.6 and 2.8  1.8 years , respectively .
sociodemographics data socioeconomic status of the patients was also calculated according to modified kuppuswamy scale based on their educational qualification , occupation , and annual income .
it was found that 18 patients were on upper class and 12 were on middle class .
lower class patients were not there , that may be due to the fact of non - affordability .
all the 18 patients on upper socioeconomic class were regular on dialysis and were able to afford the cost by themselves .
the patients from middle class family were also regular on dialysis , but three patients could afford it with the financial help of friends or relatives .
clinical outcome was also analyzed to assess whether the patients had better , worse or no change in outcome . by doing a comprehensive survey , we asked the patients to rate their clinical outcome on a visual analog scale from 1 ( worsen the condition after treatment ) to 5 ( improved very much after the treatment ) . fifteen patients on upper class and eight from middle class experiences better clinical outcome .
the correlation between the socioeconomic status and parameters such as regularity , affordability , outcome and patient satisfaction were tested .
it revealed that there is no significant correlation between socioeconomic status and regularity , affordability or outcome .
analysis of patient satisfaction showed that all the patients from upper class were satisfied with the dialysis modality while two patients from the middle class family were not at all satisfied with the treatment .
patient satisfaction scale was used in order to evaluate this and the result showed 26.5  1.2 vs 18.4  2.6 ; p<0.001 .
the sociodemographic details along with the regularity , affordability , clinical outcome and patient satisfaction were given in table 1 .
the cost of each session of dialysis and the overall cost for 6 months were calculated and found that the direct cost is more than the indirect costs .
details of the categorization of costs were given in the cost analysis section of methodology .
fifty six percent of the total cost was contributed by direct medical cost and 19.6% was for the direct non - medical cost .
indirect cost was calculated based on the number of missed working hours and the percentage of current income compared to the income that the patients had before they entered the dialysis procedure .
cost analysis of hemodialysis treatment since the patients had different co morbidities , the management cost of comorbid conditions were also analyzed .
the major complications were muscle cramps , nausea , itching , dyspnoea , vomiting and anemia . these were also properly managed and the additional expenses were provided in table 4 .
the cost to manage the co morbid conditions may further aggravate the situation . since diabetes and hypertension are the major contributing factor of renal failure that has to be managed properly in its initial stage itself .
the lifelong treatment of renal failure along with diabetes and hypertension significantly increase the burden on patients and decreases the outcome also . a study conducted by rao et al
. showed that diabetes is the main cause of poor outcome along with cardiovascular risk .
studies revealed that the mean age of esrd patients on hemodialysis in developing countries is lower ( 32 - 42 years ) than the developed countries ( 6063 years ) .
our study is also consistent with this , with a mean age of 49.72  13.2 .
the reason for the progression of renal failure may be the delay in detecting the renal disease , late referral , and failure to introduce preventive measures .
jha illustrates that 70% of the dialysis centers are in private sector and are accessible for upper income patients only . in this study
according to the report of kher , 60% of the hemodialysis patients were lost to follow up within 3 months because of its high cost .
another study conducted by mani described that only 4% of people can pay from their own resources , 63% from their employers or charity , 30% will sell the property or jewellery , and 20% will take loan .
the study conducted by abraham illustrates that the proportionate hemodialysis cost in low income countries is about five times greater than in developed countries .
this may lead to dropout and further complication of the diseased state . according to the socioeconomic status of the patient
, only upper and middle class people can afford the hemodialysis service offered by the private sector .
patients on low economic status take pain for the regular dialysis and to manage the complications .
since they can not afford the costs in private hospitals , they usually approach public hospitals .
patients from the middle income family face difficulty in affording the costs for the management of co morbid conditions along with the dialysis cost
. this will affect the clinical outcome as well as the satisfaction with the treatment .
upper class patients experiences better clinical outcome as well as patient satisfaction when compared to middle class people because they were able to manage the cost without affecting much to their daily life .
there is no significant difference in the regularity as well as affordability even though the middle class people face a lot of problems .
research is necessary in this area to quantify the cost of therapy at the public sector .
studies have to be conducted to evaluate the cost and outcome of hemodialysis patients approaching public vs private hospitals .
the quality of life of patients at both the centers also should be evaluated in order to assess the cost effectiveness .
if the patients achieve better quality of life at the public sector , government has to take initiative to commence more dialysis centers at the public level .
recently various non - governmental organizations as well as charity trusts are coming up in order to provide more cost - effective management .
drugs mainly for hypertension as well as diabetes supplying at free of cost will also help the patients to reduce the overall burden of renal failure .
this is the first study to analyze the direct as well as indirect cost of hemodialysis in a tertiary care hospital of south india . from this observational study
, we could found that 75.6% of the cost was due to direct costs ( direct medical and non - medical costs ) and 24.4% was due to indirect costs .
the dialysis modality for the esrd patients remains the most preferred resources . the non availability or less availability of dialysis unit in public sector compared to private sector , and also lack of reimbursing or insurance scheme to
only the upper or upper middle class people can afford hemodialysis due to its high cost .
they are also several approaches to reduce the annual cost of renal replacement therapy ( rrt ) .
obviously in long term , the most important factor is to reduce the number of patients with esrd .
early detection and treatment of these diseases play a vital role in the prevention of progression of renal failure and to postpone the need of rrt to an extent .
a clinical pharmacist can be really helpful to prevent this progression of esrd by providing patient counseling about lifestyle modification and educating the risk group and motivating them for regular check up and adhering to the treatment . and
also better helping hands from the government sector like more hemodialysis unit , insurance and reimbursement scheme to the patients can provide better patient outcome in our country .
long - term studies are needed to assess the cost and consequences of the treatment modalities of esrd patients .
 background : in india the incidence of end stage renal disease ( esrd ) is increasing day by day and the option for the treatment of esrd is dialysis or transplantation . in the present scenario , due to the cost of treatment normal people can afford only hemodialysis rather than transplantation . 
 since the cost of hemodialysis differs across the country , research is needed to evaluate its exact cost.aim:this study is to analyze the healthcare cost of hemodialysis in a private hospital of south india.materials and methods : this is a prospective , observational study carried out in a tertiary care hospital . 
 patients who are undergoing routine hemodialysis in this hospital were selected for the study . 
 patient data as well as cost details were collected for a period of six months . 
 thirty patients were selected for the study and a total of 2160 dialysis sessions were studied . 
 patient perspective was taken for the analysis of cost . 
 both direct and indirect costs were analyzed . 
 this includes cost of dialysis , investigations , erythropoietin , food , transportation , lost wages etc . 
 socioeconomic status of the patient was also studied.result:the total cost per session was found to be around rs . 
 4500 . 
 fifty six percent contributes direct medical cost whereas 20% contributes direct non medical cost . 
 twenty four percent cost was due to indirect costs . 
 since the patients are paying from their own pocket , only the upper or upper middle class patient can undergo hemodialysis regularly.conclusion:these findings are important to find out the impact of cost of hemodialysis on patients suffering from esrd . 
 further studies related to costs and outcome , otherwise known as pharmacoeconomic studies , are needed to analyze the pros and cons of renal replacement therapy and to improve the quality of life of esrd patients . 
 thus pharmacoeconomical studies are needed to realize that government has to take initiative to provide insurance or reimbursement for the common people . 
Materials and Methods
Patient allotment and data collection
Cost analysis
Results
Discussion
Strength and Weakness of the Study
Conclusions