What are the effectiveness and cost–effectiveness of home compared with hospital or satellite unit haemodialysis for people with end-stage renal failure?
The issue
End-stage renal failure is the irreversible loss of kidney function. At the point that the kidneys fail to support life, renal replacement therapy (RRT) is required. For suitable patients, kidney transplants are generally considered the most cost-effective approach. Because transplantation is limited by the supply of donor kidneys, many people need lifelong haemodialysis or peritoneal dialysis. Home haemodialysis can be tailored more closely to individual requirements than the other two methods. Hospital haemodialysis is provided in a specialist unit of a large district general hospital or teaching hospital, while satellite haemodialysis units tend to be based in smaller district hospitals.
Findings
Available evidence indicates that home haemodialysis is more effective than hospital haemodialysis, and also moderately more effective than satellite haemodialysis. It has been suggested, however, that the partners of dialysis patients tend to be less satisfied with it, with both the home setting for haemodialysis and the patients’ increased dependence on them. Compared with hospital haemodialysis patients, home haemodialysis patients are hospitalized less, tend to live longer, are more likely to work full time, and experience fewer adverse events during haemodialysis. These home dialysis patients, however, are a highly selected group; they tend to be younger and have fewer co-morbidities than those being dialysed in hospital or satellite units. Because of these differences and the opportunities for longer and more frequent haemodialysis sessions at home than would normally be available in hospital or satellite units, it is difficult to provide an accurate estimate of the relative effectiveness of home haemodialysis.
The evidence is overwhelmingly in favour of lower total costs for home haemodialysis compared with hospital haemodialysis. For low-risk adults (the base case analysis), home haemodialysis is less costly per session than satellite haemodialysis, which in turn is less costly than hospital haemodialysis.
Policy considerations
Expanding home and satellite haemodialysis services may provide a method of addressing the increasing number of people requiring renal replacement therapy (RRT), without using as many resources as would otherwise be needed to expand hospital haemodialysis services. However, while the expansion of home haemodialysis may improve the well-being and financial security of patients, it may add considerably to the stress on caregivers and families. The net effect on family income is uncertain because it depends upon what, if any, paid employment the caregiver would give up. The expansion of home haemodialysis programmes may be difficult to achieve without recruiting and training additional nurses. More research on these issues is needed.
The views expressed in this summary are based on a publication of a HEN Network member agency and do not necessarily represent the decisions or stated policy of WHO/Europe.
