The Economics of Home Dialysis: Acting for the Individual While Planning Responsibly for the Population Paul Komenda and Manish M. Sood Traditional medical education paradigms tend not to focus on health economics and economic evalu- ation. This has led to a culture in which bedside clinicians simply allocate health care resources made available to them, with often minimal input as to what these resources are at the population or health care system level. Life sustaining chronic dialysis therapies for end-stage renal disease are heteroge- neous in terms of health care costs and the quality of life provided to patients receiving them. From the traditional clinician’s perspective, they may be considered equivalent because there are no well- designed randomized control trials establishing the superiority of one particular dialysis modality in terms of all-cause mortality or cardiovascular events. The intent of this review is to provide clinicians practicing in the area of chronic kidney disease some insights into the concepts of economic evaluation and how it may be integrated into clinical decision making at a programmatic level while not compro- mising individual patient care at the bedside. An epidemiologic perspective will be used to help frame how the implementation of home dialysis modalities vary depending on local health policies in place. Lessons learned by regional nephrology care systems may be readily transferable to other jurisdictions in augmenting the uptake of home dialysis modalities where they are dwindling or struggling to grow. A high-level understanding of economic data in this area may help influence health policy in the direc- tion of the most efficient provision of dialysis to patients while not adversely affecting their quality of life or health outcomes. Q 2009 by the National Kidney Foundation, Inc. All rights reserved. Index Words: Home dialysis; Economic evaluation; Health policy T he provision of life-sustaining chronic dial- ysis is extraordinarily resource intense in a patient population with poor overall health outcomes. Many publicly funded health care systems in industrialized nations have declared chronic dialysis as a core essential service. Medicare in the United States with primarily privately provided health care services has enti- tled citizens to reimbursement for dialysis since 1972. 1,2 There is a great deal of variability in the pervasiveness of home dialysis modalities, not only worldwide but even within regions in the same health care system. 3,4 This inter- and intrasystem variability reinforces the notion that economics, health care policy, and the prac- tice of specific health care providers interact in a complex fashion and play a significant role in how dialysis is delivered to a population. 5 The aims of this review are to provide clini- cians with some fundamental concepts in eco- nomic evaluation and how this can be integrated into clinical decision making in car- ing for end-stage renal disease (ESRD) pa- tients. We frame the discussion with some background epidemiology on the global bur- den of ESRD and how various health care sys- tem factors have likely influenced the uptake of home modalities. We review the economics of home peritoneal dialysis (PD) and home he- modialysis (HHD) in terms of costs, outcomes, and quality of life as compared with the dom- inant modality of chronic renal replacement therapy, conventional in-center hemodialysis (HD). These concepts potentially provide in- sight into a rationale behind encouraging home-based therapies in providing high- quality and economically efficient provision of dialysis services to a population. Taking into account the variability in geography and access to resources, the intent is to provide in- sights into the need for the development of customized local policies to improve the penetration of home therapies. From the Department of Medicine, Section of Nephrology, University of Manitoba, St Boniface General Hospital, Winni- peg, MB, Canada. Address correspondence to Paul Komenda MD, FRCPC, MHA, CHE, University of Manitoba, St Boniface General Hos- pital, 409 Tache Ave, BG007, Winnipeg, MB, Canada R2H 3A6. E-mail: paulkomenda@yahoo.com Ó 2009 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/09/1603-0009$36.00/0 doi:10.1053/j.ackd.2009.02.006 Advances in Chronic Kidney Disease, Vol 16, No 3 (May), 2009: pp 198-204 198