Towards sustainable dialysis modality selection: a multi-expert fuzzy analytical hierarchy process based approach for guided decision making

Despite its proven cost-effectiveness and its capacity to cover the increasing demand for dialysis, especially hemodialysis, home hemodialysis (HHD) is not yet implemented in Tunisia. The aim of this paper is to conduct a socio-economic study of its introduction in Tunisia and provide guidance for nephrologists to select a dialysis modality while considering sustainability dimensions. First, a multi-expert fuzzy analytic hierarchy process (FAHP) based approach was conducted to assess HHD position among the existing dialysis modalities in Tunisia. Several criteria were considered: environmental; social; economic; organizational and medical. Furthermore, pairwise comparisons were provided by judgments of experts from two different contexts: one where HHD was already implemented (France) and another where HHD was not yet implemented (Tunisia). Based on the collected judgments, FAHP generated the ranking of dialysis modalities. Moreover, the impact of criteria weights variation on the ranking was studied. Then a decision model was proposed to guide nephrologists' prescription of dialysis modality based on the generated ranking as well as constraints related to the patient's environment and preferences. Our results highlighted that although in-center hemodialysis is the commonest modality in Tunisia, it is the least sustainable. However, HHD modalities proved to be more sustainable and are well ranked regarding all the considered criteria. Hence, it is worthy to introduce HHD in Tunisia from both medico-organizational and sustainability perspectives. By leveraging the FAHP results, this study demonstrated the practical application of the decision model, specifically designed for use by nephrologists, to foster sustainability in dialysis decision-making processes.