Frequent dialysis may benefit but at what cost?

[okarol]

Public release date: 9-Jul-2008

Contact: Shari Leventhal
sleventhal@asn-online.org
202-416-0658
American Society of Nephrology

Frequent dialysis may benefit but at what cost?
Changes in hemodialysis procedures are needed to offset costs

More frequent hemodialysis sessions might improve the health of patients with end-stage renal disease (ESRD), but under reasonable assumptions of expected benefit, the overall costs are likely to increase, according to a study appearing in the September 2008 issue of the Journal of the American Society Nephrology (JASN). The findings indicate that strategies are needed to reduce the costs of delivering hemodialysis if patients receive hemodialysis more than three times a week.

Despite ongoing therapy with current in-center hemodialysis procedures, which involve three sessions a week for three to four hours at a clinic per session, patients with ESRD experience relatively poor health and high mortality rates. Published studies suggest that more frequent hemodialysis for patients may improve their quality and length of life and cut down on hospitalizations and other costs. In recent years, several hemodialysis centers around the world have explored this strategy, and two ongoing clinical trials in the United States are currently comparing frequent and conventional hemodialysis.

To assess the potential effects of hemodialysis frequency on life expectancy and costs, Dr. Glenn Chertow of the Stanford University School of Medicine in Stanford, CA, and his colleagues from Stanford's Graduate School of Business and the Wharton School at the University of Pennsylvania examined data from a national registry that is representative of the US hemodialysis population. Using a sophisticated simulation model, they set out to determine if more frequent hemodialysis strategies could enhance longevity at a reasonable cost.

The investigators determined that a change from conventional in-center hemodialysis (three times per week, 3.5 hours per session) to a more frequent hemodialysis strategy might be expected to increase life expectancy by between two and 24 months depending on the frequency (four, five, or six times per week, across a range of session lengths from two to 4.5 hours per session). However, more frequent hemodialysis would be considerably more expensive than the current protocol.

Dr. Chertow's group found that it was possible for more frequent hemodialysis to break even in total lifetime costs by reducing the cost for each hemodialysis session. For a frequency of four times per week, four hours per session, the cost reduction needs to be 32%. For a frequency of five sessions per week, 2.5 hours per session, a cost reduction of 43% is required.

"These results imply that frequent in-center hemodialysis strategies are unlikely to be cost neutral unless increasing the frequency of in-center hemodialysis exerts much more favorable effects on outcomes and associated costs than assumed here," the authors concluded. "The cost of more frequent in-center hemodialysis may be prohibitive unless the benefits are overwhelming and/or the costs of delivering hemodialysis could be significantly reduced," they explained.

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The article, entitled "Cost-Effectiveness of Frequent In-Center Hemodialysis," will be available online at http://jasn.asnjournals.org/ beginning on Wednesday, July 9, 2008 and in print in the September issue of JASN.

ASN is a not-for-profit organization of 11,000 physicians and scientists dedicated to the study of nephrology and committed to providing a forum for the promulgation of information regarding the latest research and clinical findings on kidney diseases. ASN publishes JASN, the Clinical Journal of the American Society of Nephrology (CJASN), and the Nephrology Self-Assessment Program (NephSAP). In January 2009, the Society will launch ASN Kidney News, a newsmagazine for nephrologists, scientists, allied health professionals, and staff.

http://www.eurekalert.org/pub_releases/2008-07/ason-fdm070708.php

[kitkatz]

So...if I go to dialysis three times a week, it kills me off quicker, but if I go fives times a week I will have a better outcome and feel better?  That is worth the 43% increase!

[stauffenberg]

The cost they don't consider in this cost-benefit analysis is the cost in time and freedom to the patient in having to be dialyzed that often, creating the paradox found in much chronic illness, that to save the patients' health you have to destroy their quality of life.  How is the essential step to rehabilitaton, returning to productive work, to be accomplished if the patient has to be dialyzed every day? 

In diabetes management the same issue emerges, since while the regimen of strict control reduces complications, it also cuts the quality of life in half by about half.  The question for the patient becomes, do you want a good life or a long life? 

[petey]

The question for the patient becomes, do you want a good life or a long life?

Marvin wants a good AND long life.  It appears that with home hemo (6 x week), he's getting both!

[Hemodoc]

I have spent several hours today researching and reading this article and many related articles on the issue of daily dialysis.  After a very involved day, the conclusion that I have reached is that the data used for the assumptions in this simulation study, in my opinion, are flawed.  Here is my post in Bill's page.

You can't take  these studies without proving them for yourself.

I thus do not draw the flawed conclusions that the authors of this paper do, yet I suspect that they will get much more press than my little editorial will on their article.  Nevertheless, the decades of observation studies and actual patient care in every major dialysis nation outside of the US contradicts the conclusions of this study.  Buyer beware.

Peter

http://www.billpeckham.com/from_the_sharp_end_of_the/2008/07/cost-effectiven.html

[Hemodoc]

I would greatly appreciate a study comparing the cost effectiveness of home daily/nocturnal/short daily dialysis with standard three days a week incenter dialysis.  America has a shameful record of fistula use and home dialysis access.  It is time to turn our national shame into a national treasure.

http://www.medscape.com/viewarticle/542738