To the Editor,
It was with great interest that we read the article by Lamas et al1 published in your journal which discussed the costs of haemodialysis (HD) and peritoneal dialysis (PD) outsourcing agreements. The cost analysis is initially simple as it is based on pure mathematics, but biases may be introduced when selecting addends.
According to the published article, the cost of PD is nearly higher than that of HD. However, this is based on several assertions that we will list below.
The first is the cost of medical transport. This item entails very significant costs. The article implies that PD patients may not need transport, which would reduce the overall cost differential. However, patients on PD visit the clinic, as do all other outpatients. If they have mobility problems, they are provided transport, as is the case for other outpatients. In the case of HD, however, transport is provided to all patients. I therefore believe that transport should be included in Table 1. Furthermore, if we analyse Figure 3, we find that costs (even for outsourced HD) are higher for HD than for DP if we consider the average cost for all the regions. Table 2 outlines the personnel costs involved in PD based on the salaries of public hospital employees. However, the HD section only includes the amount paid to outsourced HD centres. The article should state the percentage of patients undergoing HD with an outsourced service and those on dialysis in public hospitals, and this must be adjusted for the hospital personnel costs. With regard to vascular/peritoneal access, the PD section lists the cost per catheter and catheter extension. However, it does not mention the percentage of HD patients who have a native fistula, how many have PTFEs and how many have temporary or permanent catheters or the cost of these consumables (in addition to surgery and hospitalisation costs, etc.) and urokinase. The PD section lists the percentage of patients treated with different techniques and volumes. However, it does not mention the percentage of patients treated with high-flux membranes or convective techniques, or how many undergo sessions more frequently than is normal (which would significantly increase the costs). The authors state that HD creates direct jobs. If 1 person is hired to care for each patient, it is true that more jobs are being created. However, this is not efficiency but wasting public resources, which are growing scarce. We cannot agree with the authors’ conclusions regarding the cost of different techniques, except for the statement that “discrepancies between the different studies published in Spain regarding the comparative costs of PD and HD need more rigorous studies that can shed more light on this topic”. We hope that one day the Government will undertake a rigorous and unbiased cost study in order to determine the true cost of dialysis in Spain.
Conflicts of interest
The authors affirm that they have no conflicts of interest related to the content of this article.
