Intensifying dialysis: how far should we go and at what cost?

Intensifying dialysis: how far should we go and at what cost?
Lieven Annemans

Department of Public Health, Ghent University, Belgium

Correspondence and offprint requests to: Lieven Annemans, Department of Public Health, Ghent University, De Pintelaan 185, Blok A 2de verd, GENT, Belgium. Tel: +32-476241144; Fax: +32-2-2709434.

Keywords: centre-based dialysis; cost-effectiveness

In a recent issue of JASN, Lee and colleagues [1] presented the results of a simulation model estimating the cost-effectiveness of different modalities of centre-based dialysis, increasing frequency and/or duration.

Their simulation shows that this intensified approach, even with—according to the authors—rather conservative assumptions about its benefit is associated with poor cost-effectiveness. None of the simulations resulted in a cost per quality adjusted life year (QALY) below $75 000. Generally, the societal threshold for the willingness to pay for gaining 1 QALY is around $50 000 as the authors confirm.

In other words, the extra money spent on the increased frequency and/or increased duration does not result in a proportionally acceptable health benefit. Spending this money elsewhere (for instance on better prevention of nephropathy, or on alternative non-centre-based types of dialysis) would bring much more benefit to society.

One could moreover argue that the assumptions are not that conservative at all: the rare evidence existing about this intensified approach was not able to show any difference in frequency or duration of hospitalizations or in complications. Yet, a 32% reduction in mortality and a gain of 2 QALYs for the ‘best’ scenario (six times per week, 4.5 h per session) was assumed, which seems rather optimistic. Also, it is not clear where the data to calculate the QALY weights were obtained from and whether the increased frequency and duration were associated with a (negative) impact on quality of life.

But regardless of these comments, there is clearly no economic case for intensified dialysis, based on the current assumptions. A possibility is to make efforts to reduce the cost per session. For instance, the cost of five times per week at 2.5 h per session should decrease by 43% in order to obtain a break-even compared to thrice a week in Lee et al. [1]. But even if that would be possible by increasing the efficiency dramatically and decreasing the cost of staff and material, this would also have an effect on the base case (three times per week, 3.5 h per session), a decrease that should also be taken into account.

The authors developed a decisional framework in which several input data needed to be assumed and then were made subject to extensive sensitivity analysis. Despite some criticisms on the type of modelling that Lee et al. [1] performed, because it is not based on hard evidence, it should be encouraged, because it provides an excellent framework to test scenarios and answer to several ‘what if’ questions, thereby increasing our knowledge about the condition and its management [2].

Some would also argue that even if the cost-effectiveness is not very good, we are dealing here with people's lives. In other words: ‘are we going to deny better care to these people for the reason of cost?’ I would rather talk about value than about cost. The real question is what is the value of this intensified care? Is it value for money? After all, the goal of health care is to produce health [3], and in any production process, one needs to aim for being productive, i.e. to produce the most possible output (here health) with the invested money. When a given production process is not productive, then we must not undertake it, because we spend money that could have been better spent elsewhere. In other words, proceeding with such not cost-effective care means denying better health care to other patients and to society.

How would the results of this study look like in a European setting? First, in contrast to our general belief, cost of dialysis in Europe may not be much lower. For instance, Van Biesen et al. [4] documented for Belgium a cost for in-hospital dialysis per year of {euro}53 000 versus {euro}32 000 for peritoneal dialysis, while in Lee et al., the cost in the first year was $64 000. Dialysis as such is borderline cost-effective in Europe as shown by Salonen et al. [5], with a cost per QALY of ±{euro}40 000. Hence, one could argue that the incremental cost-effectiveness of intensified dialysis (the extra cost divided by the extra QALYs versus the base case of three times per week) should remain below that value. Given the above, I doubt it.

Hence, if I were a payer (whether it would be an insurer or NHS responsible) I would not pay for this care, based on these results. I would invest much more in alternative non-in-centre based types of dialysis. I could of course request additional information and allow the use of intensified dialysis in a research setting, hence reimbursing it conditionally upon more evidence to be expected. This will likely reduce uncertainty, but this also costs money. A possible way out is to calculate the value of information beforehand. This method, based on modelling techniques, focuses on the value of obtaining further information that will reduce uncertainty [6]. If that value turns out to be lower than the cost of this further research, one may decide not to undertake this further research. Calculating this value of information may perhaps be a new challenge for Lee et al. [1].

Conflict of interest statement. None declared.

References
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References

1. Lee CP, Zenios SA, Chertow GM. Cost-effectiveness of frequent in-center hemodialysis. J Am Soc Nephrol (2008) 19:1792–1797.[Abstract/Free Full Text]
2. Weinstein MC, O’Brien B, Hornberger J, et alISPOR Task Force on Good Research Practices—Modeling Studies. Principles of good practice for decision analytic modeling in health-care evaluation: report of the ISPOR Task Force on Good Research Practices—Modeling Studies. Value Health (2003) 6:9–17.[CrossRef][ISI][Medline]
3. Annemans L. Health economics for non-economists. An introduction to the concepts, methods and pitfalls of health economic evaluations. (2008) Academia Press.
4. Van Biesen W, Lameire N, Peeters P, et al. Belgium's mixed private/public health care system and its impact on the cost of end-stage renal disease. Int J Health Care Finance Econ (2007) 7:133–148.[Medline]
5. Salonen T, Reina T, Oksa H, et al. Alternative strategies to evaluate the cost-effectiveness of peritoneal dialysis and hemodialysis. Int Urol Nephrol (2007) 39:289–298.[CrossRef][ISI][Medline]
6. Coyle D, Oakley J. Estimating the expected value of partial perfect information: a review of methods. Eur J Health Econ (2008) 9:251–259.[Medline]

Received for publication: 6.11.08
Accepted in revised form: 13.11.08

http://ndt.oxfordjournals.org/cgi/content/full/gfn680