
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-186
10.4103/jehp.jehp_1051_23
Original Article
Out-of-pocket expenses and healthcare service utilisation among maintenance haemodialysis patients: A study at a tertiary care hospital in Udupi, Karnataka
Ramesan Anandhu K.
D’Souza Brayal 1
Sekaran Varalakshmi Chandra
Department of Health Policy, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
1 Department of Social and Health Innovation, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
Address for correspondence: Dr. Varalakshmi Chandra Sekaran, Department of Health Policy, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India. Dr. Brayal D’Souza, Department of Social and Health Innovation, Manipal, Karnataka, India. E-mail: varalakshmi.cs@manipal.edu, brayal.dsouza@manipal.edu
2024
05 7 2024
13 18618 7 2023
12 10 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are 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 appropriate credit is given and the new creations are licensed under the identical terms.
Background:

Financial burdens faced by patients in India suffering from chronic kidney disease (CKD) are linked to healthcare access and inadequate insurance coverage. This study analyses out-of-pocket expenses and explores their healthcare utilisation patterns.

Materials and Method:

This time-bound hospital-based cross-sectional study was conducted in a tertiary care hospital in Udupi district, Karnataka, among patients who have undergone haemodialysis (HD) treatment for at least a year. Following ethics approval and CTRI registration, informed consent was obtained from all the patients prior to data collection.

Result:

The study involved 109 HD patients. The direct medical and non-medical costs incurred by HD patients were Rs 9,400 (IQR = 13,700) and Rs 3,200 (IQR = 2,000), respectively. The monthly health-related OOPE was Rs 16672.0 (IQR = 14,630.0). Overall, 103 (94.5%) individuals had been hospitalised since they began HD, and 50.5% of patients were hospitalised within the past year. On linear regression analysis, it was observed that the joint monthly income (β 0.134, 95% CI 0.007 - 0.182, P value = 0.048), number of dialyses per week (β 1.14, 95% CI 7541.5 - 16551.07, P value < 0.001), and social security (β −1.02, 95% CI −13463.0 - 7982.56, P value < 0.001) exhibited significant correlations and served as predictors for household out-of-pocket expenditure (HROOPE) experienced by the patients.

Conclusion:

The study concludes that people receiving HD incur a considerable financial cost. Additionally, the CKD population uses healthcare services at a notable rate, including frequent hospital stays, visits to outpatient departments (OPDs), and emergency treatment, underscoring the pressing need for an increase in insurance coverage.

Chronic kidney disease
haemodialysis
healthcare service utilisation
out-of-pocket expenditure
social security
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pmcIntroduction

The escalating prevalence of non-communicable diseases and its strain on limited healthcare resources have made chronic kidney disease (CKD) a significant and pressing healthcare challenge in numerous developing nations worldwide.[1] The condition is characterised by persistent renal abnormalities for at least 3 months and decreased glomerular filtration rate (GFR) or albuminuria.[2,3] Managing CKD presents challenges due to high treatment costs and many patients. The disease is predicted to become the fifth leading cause of death by 2040.[4] Recent studies have shown that approximately 843.6 million people globally are affected by CKD stages 1–5.[5] Dialysis in CKD patients is a huge financial burden to the patients themselves and their families.[6,7] Haemodialysis (HD) is India’s most widely used Renal Replacement Therapy (RRT) method.[8] Non-medical factors, including economics, lack of trained teams, and psychological factors, contribute to the preference for one form of dialysis.[9] HD is expensive and can have a substantial financial impact on CKD patients. Inadequate healthcare investment and insurance protection against catastrophic costs contribute to India’s reliance on out-of-pocket medical spending.[8] In a 2019 study assessing India’s Pradhan Mantri National Dialysis Programme (PMNDP) impact on aiding low-income families with dialysis expenses, the researchers discovered that despite subsidies, 91% of 835 participants undergoing maintenance HD still faced catastrophic health expenditure.[10] A recent study conducted in India revealed that the annual cost of HD per patient amounted to an average of 35% of the total annual patient expenditure in rupees.[11] Analysing the financial impact of managing chronic, incapacitating health conditions becomes crucial to creating more sustainable treatment options and coping mechanisms.[8] HD is still expensive for patients with advanced renal disease, even though the average cost of treatment in India is much lower than the global average. CKD patients and their families face significant financial risks and may fall into poverty due to high treatment costs, disability, loss of employment, and out-of-pocket expenditures.[11]

CKD and end-stage renal disease (ESRD) are influenced by socio-demographic factors, including age, gender, diabetes, and hypertension.[12,13] Poverty worsens outcomes and increases the likelihood of CKD progression.[12] India faces a shortage of nephrologists and dialysis infrastructure, resulting in limited access to maintenance dialysis. Addressing these issues requires increased public spending, reduced reliance on out-of-pocket payments, improved health insurance coverage, and enhanced social protection programmes[14] which –are encompassed under ‘social security’ as described by the International Labour Organization: ‘Social security is the protection that a society provides to individuals and households to ensure access to health care and to guarantee income security, particularly in cases of old age, unemployment, sickness, invalidity, work injury, maternity or loss of a breadwinner’. Understanding healthcare utilisation patterns among HD patients is crucial for resource planning and patient management. HD necessitates periodic visits to healthcare facilities and frequently includes several healthcare providers. Planning and distributing healthcare resources can benefit from examining patterns in healthcare services. It can help estimate the ideal facility capacity, spot gaps or inefficiencies in service delivery, and enhance patient management procedures. Analysing out-of-pocket expenses and healthcare service utilisation can provide insights into the challenges patients and their families face in accessing and affording necessary healthcare services.[15] Overall, this study aims to explore the impact of out-of-pocket expenses on HD and related healthcare services and the frequency of healthcare utilisation among HD patients.

Materials and Method

Study design and setting

The study employed an institution-based cross-sectional survey design, focusing on patients’ households undergoing HD treatment for at least 1 year prior to the interview date. The research was conducted in the Udupi district on the southwestern coast of Karnataka, India. According to the 2011 Census, the district had a population of 1,177,361, estimated to have increased to approximately 1.3 million in 2021. The study occurred at a tertiary care hospital, a prominent tertiary teaching hospital in Udupi district. The hospital has a specialised HD facility consisting of 19 dialysis units, serving patients with acute kidney injury and those requiring critical care. To gather data, a time-bound enumeration sampling technique was employed for the study. The data collection followed ethical guidelines and involved interviews with eligible participants to obtain relevant information regarding out-of-pocket expenditure and healthcare service utilisation.

Study participants and sampling

The study was conducted at a tertiary care hospital between March 2023 and April 2023. Inclusion criteria encompassed patients who received treatment at a tertiary care hospital, were at least 18 years old, and had been receiving dialysis for at least 1 year prior to the interview date. Patients on peritoneal dialysis who had undergone renal transplants, were pregnant, or had mental disabilities were excluded from the study. A total of 109 interviews were carried out during the specified time frame. Confidentiality was maintained.

Data collection tools and technique

A semi-structured questionnaire which was validated by public health professionals, consisting of 37 questions, was used during the interviews, covering demographic information, patterns of healthcare service utilisation, and medical expenditure of the patients. The interview process involved asking only essential questions to the participants, with a specific focus on avoiding any distress. Questions concerning medical records and financial aspects were deliberately excluded from the interview. After gathering primary data from 109 participants, secondary data pertaining to the same participants was collected from the MRD and Finance Department. The secondary data consisted of medical records containing information about patients’ visits to the outpatient department (OPD), hospitalisations in the past year, and their financial information. A comprehensive understanding of the medical expenditure and healthcare service utilisation among maintenance HD patients in the Udupi district could be obtained by combining primary and secondary data.

Ethics consideration

Kasturba Medical College and Kasturba Hospital Institutional Ethic Committee, Manipal, approved the study protocol (IEC2: 626/2022) on 23rd February 2023. After ethics clearance, the study was registered under the Clinical Trial Registry of India (CTRI/2023/03/050488) on 9th March 2023. Before the interview, informed consent was obtained from each participant. All the interviews were conducted within the premises of the dialysis centres.

Analysis

The data were collected, entered in MS Excel, and then analysed using Jamovi version 2.3.21 software. Descriptive analysis summarised the socio-demographic characteristics and the patient’s treatment and illness attributes. To explore potential associations between variables, inferential analysis was carried out. A significance level of P < 0.05 was adopted to determine statistical significance. The association between total monthly household out-of-pocket expenditure (HROOPE) and categorical variables with two levels was examined using the Mann-Whitney U test. For categorical variables with three or more levels, the Kruskal-Wallis test was employed. A multivariate linear regression was performed on further analysis to explore the correlation between HROOPE and other continuous and categorical variables. To identify the pattern of healthcare service utilisation, the number of Nephrology OPD visits, the number of hospitalisations the patient had since been initiated in dialysis, the number of hospitalisations in the last year, and the status of other OPD visits were considered. A bivariate comparison was performed using a Kruskal–Wallis test for all the quantitative data (based on median values) and a Chi‐square test for categorical data.

Results

Participants

The study involved 109 participants, consisting of 82 men (75.2%) and 27 women (24.8%), with an average age of 52.58 ± 13.2 years. Among them, 80.7% of patients were unemployed. The mean age at the time of CKD diagnosis was 45.3 (±14.0) years, indicating that middle-aged individuals were commonly diagnosed. Among the patients, 62.4% were referred for kidney transplantation, with 64.7% being between 40 and 60 years old, highlighting a higher demand for transplantation in this age group. Within the unemployed category, 45.4% were previously employed but unable to work, 2.2% were students, and 35.2% were retired individuals. The median monthly joint household income was INR 28,000 (IQR = 15,000), and 61.6% of households had an income between INR 20,000 and INR 39,999. The average distance between patient residences and the healthcare facility was 16 km (IQR = 23), with 35.8% residing beyond a range of 25 km. About 61.5% of the patients did not have health insurance, leaving them without adequate social security. Among the participants with insurance, the most common type was Employee State Insurance (ESI), held by 32 patients, followed by Medicare and Sampoorna Suraksha Insurance, each used by five patients. Regarding dialysis frequency, 88.1% underwent two haemodialysis weekly, while 11.9% had three [Table 1].

Table 1 Characteristics of the socio-demographic profile, illness, and treatment of the patients and household (n=109)

Variables	Frequency	Percentage	
Age of the patient in years	
  18–39 years	20	18.3%	
  40–59 years	54	49.6%	
  60 years and above	35	32.1%	
Gender	
  Female	27	24.8%	
  Male	82	75.2%	
Household size	
  Four or less	66	60.6%	
  More than four	43	39.4%	
Educational qualification of the patient	
  Secondary school or lower	65	59.6%	
  Higher secondary school or more	44	40.4%	
Highest educational qualification in the household	
  Secondary school or lower	20	18.3%	
  Higher secondary school or more	89	81.7%	
Occupational status	
  Unemployed	88	80.7%	
  Employed	21	19.3%	
Joint household income	
  <Rs 20,000	21	19.2%	
  Rs 20,000–Rs 39,999	67	61.6%	
  Rs 40,000 and more	21	19.2%	
Duration under dialysis	
  <30 months	35	32.1%	
  30–71 months	36	33.0%	
  72 months or more	38	34.9%	
Treatment before dialysis	
  No treatment	46	42.2%	
  Allopathy	53	48.6%	
  AYUSH	10	9.2%	
Suggested kidney transplantation	
  Yes	68	62.4%	
  No	41	37.6%	
Distance from facility	
  <9 km	34	31.2%	
  9–24 km	36	33.0%	
  25 km and more	39	35.8%	
Social security	
  Absent	67	61.5%	
  Present	42	38.5%	
Type of social security	
  Nil	67	61.5%	
  ESI	32	29.3%	
  Sampoorna Suraksha	5	4.6%	
  Medicare	5	4.6%	
Number of dialyses per week	
  Two/week	96	88.1%	
  Three/week	13	11.9%	

Out-of-pocket expenditure

The median direct medical cost incurred by the patient is INR 9,400 (IQR = 13,700), and the median direct non-medical cost was found to be INR 3,200 (IQR = 2,000). The average HROOPE for the sample population was INR 16,672.0 (IQR = 1,4630.0). The analysis revealed that the average monthly household expenditure among the sampled population was INR 15,516.7 (IQR = 5,933.33). The study discovered noticeable associations between HROOPE and gender, social security, and the number of dialyses per week. Specifically, the research found that gender is significantly associated with HROOPE, with a P value of 0.04. Furthermore, the study revealed a strong association between HROOPE and social security and the frequency of weekly dialysis, with both factors showing a P value of less than 0.001. However, the study did not reveal any clear link between HROOPE and occupational status [Table 2].

Table 2 Average monthly health-related OOPE and its association with other variables (n=109)

Variables	n (%)	Health-related OOPE in Rs	P	
Median	IQR	
Age in years	
  18–39 years	20 (18.3)	14,044	14,474	0.176, χ2=3.47	
  40–59 years	54 (49.6)	16,570	14,592	
  60 years and above	35 (32.1)	19,115	16,139	
Gender	
  Male	82 (75.2)	17,954	15,740	0.040*	
  Female	27 (24.8)	7,952	13,459	
Occupation status	
  Unemployed	88 (80.7)	16,427	16,839	0.593	
  Employed	21 (19.3)	17,985	8,169	
Educational qualification of the patient	
  Secondary school or less	65 (59.6)	14,929	14,733	0.270	
  Higher secondary school or more	44 (40.4)	19,038	15,578	
Duration under dialysis	
  Under 30 months	35 (32.1)	16,982	14,076	0.996, χ2=0.008	
  30–71	36 (33.0)	16,915	12,110	
  72 months or more	38 (34.9)	14,729	18,006	
Joint household income	
  <20,000 Rs	21 (19.3)	19,611	8,155	0.050, χ2=6.00	
  20000–39999 Rs	67 (61.4)	15,328	14,385	
  40,000 Rs and more	21 (19.3)	202,812	18,751	
Distance	
  <9 km	34 (31.2)	16,772	18,522	0.707, χ2=0.693	
  9–25 km	36 (33.0)	13,653	12,619	
  ≥25 km	39 (35.8)	18,769	11,160	
Social security	
  Present	42 (38.5)	6,488	3,576	<0.001**	
  Absent	67 (61.5)	20,282	7,316	
Number of dialyses per week	
  2	96 (88.1)	14,747	13,985	<0.001**	
  3	13 (11.9)	33,683	11,618	
Household size	
  Four or less	66 (60.6)	16,009	17,143	0.963	
  More than four	43 (39.4)	17,614	13,660	

Healthcare service utilisation

Out of 109, 103 (94.5%) individuals had been hospitalised since they began HD. Notably, 50 (45.9%) patients had been admitted to the hospital more than four times, indicating a need for frequent medical attention. Among the reasons for hospitalisation, deterioration of CKD or complications related to AV fistula accounted for 32 (29.4%) cases, while breathlessness and acute pulmonary oedema affected 25 (22.9%) patients, necessitating hospital admissions. Half of the patients, 55 (50.5%), had been hospitalised within the past year, with 31 patients experiencing multiple hospitalisations during this period. Regarding OPD visits, 82 (75.2%) patients sought care from the Nephrology Department, highlighting the importance of follow-up and ongoing care. Of these, 47 (43.1%) patients had made four or more visits within the last year, emphasising their reliance on nephrology OPD services for disease management. Additionally, 72 (66.05%) patients attended OPDs outside of Nephrology for various comorbidities during the same period. The Cardiology Department had the highest number of patients (24 patients, 22.0%), followed by the Orthopaedic Department (nine patients, 8.3%), indicating the need for multidisciplinary care for patients with comorbidities.

Statistical analysis revealed significant associations between hospitalisations in the previous year and the duration of HD treatment (P value = 0.004) and between the number of weekly dialyses and hospitalisations in the previous year (P = 0.003). Additionally, the number of Nephrology OPD visits in the last year was significantly associated with the patient’s hospitalisation frequency (P < 0.001). A significant association was also found between the number of Nephrology OPD visits in the last year and the duration of HD treatment (P value < 0.001). Moreover, the number of dialyses per week was significantly associated with the number of Nephrology OPD visits in the last year (P value = 0.024).

Pearson’s Chi-Square test indicated significant associations between the status of other OPD visits and various factors, including the duration of dialysis (P value = 0.039), frequency of dialysis per week (P value = 0.006), number of hospitalisations in the past year (P value <0.001), and the number of Nephrology OPD visits (P value <0.001). Patients undergoing HD for less than 30 months or more than 72 months tended to visit other OPDs more frequently, possibly indicating a higher rate of complications due to comorbidities during these periods. Patients receiving three dialyses per week were more likely to visit other OPDs. In comparison, 38.5% of those receiving two dialyses per week had no other OPD visits, suggesting a higher rate of comorbidities in the former group. Patients with more hospitalisations and Nephrology OPD visits in the past year also tended to visit other OPDs [Table 3].

Table 3 Distribution of patients among the Healthcare Service Utilisation Indicators (n=109)

Variables	Frequency	Percentage	
Number of total admissions since dialysis	
  Two or less	24	22.0%	
  2–3	35	32.1%	
  Four or more	50	45.9%	
Cause of the last admission	
  No admission	6	5.5%	
  Worsening of symptoms	32	29.4%	
  Cardiac	2	1.8%	
  Pulmonary	25	22.9%	
  Other	44	40.4%	
Total admissions in last year	
  Nil	54	49.5%	
  1	24	22.0%	
  Two or more	31	28.5%	
Nephrology OPD visits last year	
  Nil	27	24.8%	
  1–3	35	32.1%	
  Three or more	47	43.1%	
Other OPD visits in the last year	
  No	37	33.9%	
  Yes	72	66.1%	

Multivariate analysis

The linear regression model demonstrated a strong linear relationship with an R-value of 0.80. The model had an adjusted R² of 0.617, which indicated that it explained 61.7% of the variability in HROOPE. Based on the findings, it was discovered that HROOPE is correlated with the joint monthly income (P value = 0.048), the number of dialyses per week (P value <0.001), and the social security level of the patients (P value <0.001). The patient’s monthly joint income (β 0.134, 95% CI 0.007 - 0.182, P value = 0.048) was significantly positively correlated with the HROOPE, indicating that as the joint household income increases, the HROOPE also increases significantly. Similarly, the group of patients with three dialyses per week (β 1.14, 95% CI 7541.5 - 16551.07, P value < 0.001) have more HROOPE than the group with two dialyses per week. However, the group of patients with social security (β −1.02, 95% CI − 13463.0 - −7982.56, P value < 0.001) had significantly lower HROOPE than those with social security [Table 4].

Table 4 Multivariate linear regression between patient characteristics, healthcare service utilisation, social security, and HROOPE (n=109)

Variables	Coefficient Estimate	β	P	95% CI (Lower, Upper)	
Age in years	81.62	0.101	0.630	–253.9, 417.15	
Gender	
  Female	
  Male	2333.39	0.222	0.126	–670, 5337	
Duration under dialysis in months	7.12	0.037	0.707	–30.4, 44.66	
Age at diagnosis in years	21.90	0.029	0.894	–303.0, 346.7	
Monthly joint income	0.09	0.134	0.048*	0.007, 0.182	
Number of dialyses per week	
  2	
  3	12046.3	1.14	< 0.001**	7541.5, 16551.07	
Number of nephrology OPD visits in last year	15.60	0.004	0.951	-489.8, 520.94	
Number of hospitalisations in last year	783.38	0.140	0.068	-60.5, 1627.25	
Social security level	
  No	
  Yes	–10722.77	–1.02	< 0.001**	–13463.0, –7982.56	

Discussion

The present study assessed the out-of-pocket expenditure and the pattern of their healthcare service utilisation of patients undergoing maintenance HD in a tertiary care hospital in Udupi. The mean age at the time of CKD diagnosis was 45.3 ± 14.0 years, indicating that middle-aged individuals are more prone to get diagnosed with CKD. Compared with the national average from the CKD registry (50.1 ± 14.6 years), the age at CKD diagnosis was less.[12] The study revealed that 35.8% of patients resided outside the 25 km range, with some living 80 km or more away. This highlights the challenges faced by rural patients in accessing healthcare. It underscores the need for HD units in rural areas. However, in comparison to a previous review by Bharati et al.,[8] where it was found that 60% of Indian HD patients had to travel over 50 km. Still, only 10.1% of patients in this study population had to travel that far. This indicates improved healthcare accessibility. Among the patients, 61.5% lacked health insurance, resulting in a lack of social security. This reflects the financial vulnerability of the population and how it affects their healthcare utilisation and benefits.[16,17]

Recent data from the World Bank[18] indicates India’s per capita income as Rs 1,86,302.19, making the estimated HROOPE of Rs 2,00,064.0 per year burdensome for households, even if multiple family members are employed. There is a strong association (P value <0.001) between HROOPE and social security, specifically the availability of health insurance, which can lower out-of-pocket expenses. Studies by Biswas et al.[6] and Shet et al.[19] support these findings, demonstrating that a lack of social security increases the risk of catastrophic health expenditures, potentially pushing households into poverty. Moreover, the frequency of dialysis per week is significantly associated with HROOPE, as more frequent sessions incur higher treatment costs.

The study revealed a high hospitalisation rate, with 94.5% of patients being hospitalised from the start of dialysis until the interview. A significant portion (45.9%) required more than four hospitalisations. About 29.4% of patients were admitted to the hospital due to the advancement of CKD or issues associated with arteriovenous (AV) fistula. These findings highlight the need to closely monitor CKD patients and prompt medical intervention to prevent complications. It is common for HD patients to require frequent acute medical treatment, as evidenced by 50.5% being hospitalised within the last year. Repeated hospitalisations indicate ongoing health issues requiring consistent medical attention and causing a significant financial burden for patients. Previous studies have also shown that patients with ESRD are at high risk of hospitalisation, and CKD patients have a higher probability of long-term hospitalisation and mortality.[20,21] These findings underscore the importance of addressing the healthcare needs of CKD patients to improve their outcomes and quality of life.

In this study, 75.2% of patients visited the Nephrology OPD over the last year; among them, 43.1% had visited the OPD at least four times during the same period. This highlights the reliance of these patients on Nephrology OPD services for disease management. However, frequent visits may lead to higher medical expenses, including consultation fees and laboratory tests. Several factors were significantly associated with hospital admissions among dialysis patients in the past year. A study conducted by Tam-Tham et al.,[22] in 2020 in Alberta, Canada, on CKD patients also reported a similar finding, linking the duration of dialysis treatment with the number of hospitalisations. This suggests that patients undergoing dialysis for longer may experience more health issues or complications requiring hospitalisation. Thus, initiating dialysis can involve a trade-off between more prolonged survival and increased utilisation of healthcare services.

According to the findings of this study, the frequency of weekly dialysis treatments is associated with hospital admissions, indicating that more frequent dialysis may signal underlying health problems rather than reducing the need for hospitalisation. Moreover, a higher number of visits to the OPD in the past year is significantly linked to hospital admissions, suggesting that patients requiring regular OPD care may have complex medical conditions requiring closer monitoring and management. Additionally, dialysis patients often visited other OPDs, indicating the presence of comorbidities. A study by Bayliss et al.[23] emphasised the importance of coordinated care for dialysis patients with comorbidities. This study revealed that coordinated care was crucial in addressing the diverse health issues faced by dialysis patients.

Limitations and recommendation

The data adds to the gap in the literature regarding the OOPE and is one of the first studies in India assessing the healthcare service utilisation of HD patients. Due to its cross-sectional nature the study assesses associations but not causal relations and cannot establish temporality. The study was limited by social desirability bias, where some patients might have provided inaccurate information about their joint household income and expenses to present themselves favourably or conform to societal expectations.

Potential policy implications

By considering both clinical and economic factors, policymakers can develop interventions to improve patient outcomes and ensure fair access to care. Evidence-based research can guide policy formulation, assessment, and the development of interventions to remove financial barriers and enhance healthcare delivery. Our study suggests that CKD patients receiving dialysis treatment and experiencing comorbidities bear higher OOPE and healthcare utilisation. With the government of India’s focus on expanding the Pradhan Mantri National Dialysis Programme, increased insurance coverage that encompasses outpatient services would be instrumental in alleviating the financial burden associated with CKD and dialysis treatment. Promoting preventive measures and screening at the community level with a focus on early detection may help reduce the burden on the health system and reduce morbidity as well as the attendant financial consequences. Implementing an expanded and comprehensive health insurance scheme and improving health access by strengthening primary care infrastructure, enhancing healthcare professionals’ skills in CKD management while also increasing human resources to address the increasing health burden and improving access to dialysis and transplantation may be the way forward.

Conclusion

The direct medical and non-medical costs of the maintenance HD patients as well as the total monthly health-related out-of-pocket expenditure (Rs 16,672) were found to add a significant burden to the patients on HD. In all, 88.1% were found to have catastrophic health expenditures. The frequency of hospitalization among them was also significantly high with the need for ongoing care. As discussed above, improving healthcare access, lowering healthcare costs and introducing comprehensive disease management programmes may be effective in providing treatment, regular monitoring, early intervention, patient education, and collaborative healthcare.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

Acknowledgement

The authors express their gratitude towards the current study’s participants, the KMC, the KH administration, and the Nephrology Department’s HOD.
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1 Agarwal SK Srivastava RK Chronic kidney disease in India: Challenges and solutions Nephron Clin Pract 2009 111 c197 203 19194110
2 Ammirati AL Chronic kidney disease Rev Assoc Med Bras (1992) 2020 66 Suppl 1 S03 9
3 Levey AS Eckardt KU Tsukamoto Y Levin A Coresh J Rossert J Definition and classification of chronic kidney disease: A position statement from Kidney Disease: Improving Global Outcomes (KDIGO) Kidney Int 2005 67 2089 100 15882252
4 Foreman KJ Marquez N Dolgert A Fukutaki K Fullman N McGaughey M Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: Reference and alternative scenarios for 2016–40 for 195 countries and territories Lancet 2018 392 2052 90 30340847
5 Jager KJ Kovesdy C Langham R Rosenberg M Jha V Zoccali C A single number for advocacy and communication—worldwide more than 850 million individuals have kidney diseases Kidney Int 2019 96 1048 50 31582227
6 Biswas RSR Nath JD Ahmed KF Financial burden of Chronic Kidney Disease Patients on Maintenance Hemodialysis in Chittagong, Bangladesh [Internet] Nephrology 2021 Jul. Available from: http://medrxiv.org/lookup/doi/10.1101/2021.07.15.21260572. [Last accessed on 2022 Nov 12]
7 Khanna U The economics of dialysis in India Indian J Nephrol 2009 19 1 4 20352002
8 Bharati J Jha V Global dialysis perspective: India Kidney360 2020 1 1143 7 35368789
9 Phadke G Khanna R Renal replacement therapies Mo Med 2011 108 45 9 21462611
10 Bradshaw C Gracious N Narayanan R Narayanan S Safeer M Nair GM Paying for hemodialysis in Kerala, India: A description of household financial hardship in the context of medical subsidy Kidney Int Rep 2019 4 390 8 30899866
11 Khan A Jan FA Rashid H Economic burden of end stage renal disease: A study from India SchJ Econ Bus Manag, Jan, 2021 8 1 X
12 Rajapurkar MM John GT Kirpalani AL Abraham G Agarwal SK Almeida AF What do we know about chronic kidney disease in India: First report of the Indian CKD registry BMC Nephrol 2012 13 10 22390203
13 Charles C Ferris AH Chronic kidney disease Prim Care 2020 47 585 95 33121630
14 Khan A Jan FA Rashid H Prevalence of distress financing and catastrophic health expenditure among end stage renal disease patients attending a tertiary care teaching hospital of North India Biomed J Sci Tech Res 2020 32 25133 5
15 Bassi A John O Gallagher M Kotwal S Joshi R Essue B Methodological challenges to collecting clinical and economic outcome data: Lessons from the pilot dialysis outcomes India study Nephrology (Carlton) 2019 24 445 9 29570911
16 Shami E Tabrizi JS Nosratnejad S The effect of health insurance on the utilization of health services: A systematic review and meta-analysis Galen Med J 2019 8 e1411 34466508
17 Essue BM Jha V John O Knight J Jan S Universal health coverage and chronic kidney disease in India Bull World Health Organ 2018 96 442 29962543
18 World Bank Open Data [Internet] World Bank Open Data Available from: https://data.worldbank.org. [Last accessed on 2023 Jun 7]
19 Shet N Butt I Sharma P Qadri G Kanali G A study to assess the economic burden faced by rural households due to Out-of-pocket expenditure on healthcare in Uttar Kannada and Udupi districts of Karnataka J Family Med Prim Care 2021 10 4573 7 35280604
20 Daratha KB Short RA Corbett CF Ring ME Alicic R Choka R Risks of subsequent hospitalization and death in patients with kidney disease Clin J Am Soc Nephrol 2012 7 409 16 22266573
21 Plantinga LC Jaar BG Preventing repeat hospitalizations in dialysis patients: A call for action Kidney Int 2009 76 249 51 19904257
22 Tam-Tham H Ravani P Zhang J Weaver RG Quinn RR James MT Association of initiation of dialysis with hospital length of stay and intensity of care in older adults with kidney failure JAMA Netw Open 2020 3 e200222 32108896
23 Bayliss EA Bhardwaja B Ross C Beck A Lanese DM Multidisciplinary team care may slow the rate of decline in renal function Clin J Am Soc Nephrol 2011 6 704 10 21273376
