conventional HD but the savings and quality of life improvements varied by technique failure rate, training time, and dialysis modalities from which patients are drawn. 126 The study was also limited by the small sample size and short study duration. Results from a modeling study, based on data from Australia, Canada, and the United Kingdom, found costs of conventional HHD and frequent HHD were similar to costs of in-center HD in the first year but over time conventional HHD and frequent HHD could be less costly than in-center HD depending on the frequency of dialysis.127 The model predicted that conventional HHD would save payers between $7612 (US$6668 in 2014) and $12,403 (US$10,865) over the first year of conventional in-center HD. An Australian study, based on new ESRD patients in the ANZDATA Registry from 2005 to 2010, estimated that switching patients from hospital HD to HHD would produce a net saving of $47 million Australian dollars by 2010 (US$40 million in 2014), suggesting changes in clinical practice would not only reduce costs but also improve patient quality of life. 128 However, the analysis did not incorporate indirect costs such as lost earnings and productivity and direct out-of-pocket costs to patients and their care givers. These results were supported by an earlier cost-effectiveness modeling study based on data from a systematic review. 129 A Finnish study reported no significant differences in the total costs between HHD and satellite HD and costs for both modalities were clearly less than those reported for hospital HD in other studies.130 The results were limited by the younger age and shorter dialysis duration compared to general dialysis patients, limiting the application of the results to older and frailer patient populations. A Canadian study that analyzed patients’ conventional HD costs during the 12 months before study entry found reduced costs and improved quality of life after switching to quotidian HHD, but the study was very small and under-powered to detect statistically significant differences in costs. 131 Older analyses have reported that reductions in costs associated with HHD compared to conventional HD are linked to a lesser need for nursing and other personnel and the exclusion of overhead costs of dialysis center or unit management. 132,133 Costs of Peritoneal Hemodialysis (PD) versus In-Center HD (Appendix C, Table 7) A recent Canadian study, based on data from the Alberta renal programs, found PD patients and patients who transitioned from HD to PD had significantly lower total health care costs at one and 3 years. Patients who had PD technique failure had costs similar to, not in excess of, HD patients at 3 years, supporting an economic rationale for a PD-first policy in all eligible patients.134 A study from Spain reported costs related to dialysis access at 1 year from the time of 54 Home-based versus In-center Dialysis Evidence-based Synthesis Program first dialysis. 135 There were significantly more access-related interventions in the HD groups (tunneled cuffed catheter or arteriovenous fistula) than the PD group. Access-related costs were significantly higher for the tunneled cuffed catheter HD group (€4208, US$4467 in 2015) compared to the arteriovenous fistula HD group (€1555, US$1651) or PD group (€1171, US$1244). A retrospective cohort study based on a US health insurance database reported that PD patients had significantly lower total healthcare costs during the year following initiation of dialysis, largely a result of higher emergency department visits and hospitalizations in the HD group.136 Median total per-patient healthcare costs over the 12-month follow-up period for the PD and HD patients were $129,997 and $173,507, respectively. Findings from a UK study also reported lower costs associated with PD compared to in-center HD. 137 Costs associated with PD were mainly the costs of solutions and management of anemia while costs associated with HD were mainly due to disposables, nursing, and the overheads associated with running the dialysis unit. Other analyses also estimated that PD was the more economically advantageous dialysis modality138-140 and a longer time on PD better sustained this economic advantage even after a switch to conventional HD.139 Several of these PD cost analysis studies were limited by basing the analyses from the health-care provider perspective or including direct costs only and not incorporating indirect costs such as lost earnings and productivity.134,138,139 55 Home-based versus In-center Dialysis Evidence-based Synthesis Program SUMMARY AND DISCUSSION Key Findings and Strength of Evidence · We found few randomized or controlled clinical trials or prospective clinical cohort studies comparing home-based and in-center kidney dialysis. Available clinical trials were small in size and had short follow-up durations. · Most of the data on mortality is from registry studies. Results from these studies should be interpreted with caution due to likely residual confounding and selection bias. · Home hemodialysis (HHD) versus in-center HD: · We found low strength of evidence (findings from registry studies) that HHD is associated with improved overall survival compared to in-center HD (Table 6). There were few studies of variations of HHD (including longer duration or more frequent sessions). · There is