Frequent dialysis may benefit patients, but at what cost?

Frequent dialysis may benefit patients, but at what cost?

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Posted on: 08/11/2008
Renal Business Today

An interview with Chris P. Lee, PhD

Editor's Note: Lee is an assistant professor of Operations and Information Management at the University of Pennsylvania's Wharton School of Business. He was also an author of a study in the September issue of the Journal of the American Society of Nephrology that looked into the cost-effectiveness of more frequent in-center hemodialysis

Why did you and your team set out to study the cost-effectiveness of frequent in-center dialysis?

The rationale is that a lot of researchers in the United States, and in other countries, have speculated for quite some time now that more frequent and longer dialysis might improve outcomes. To some extent, the improvement in outcomes is not necessarily the only policy dimension to consider. There’s also the issue of the economic costs associated with longer, more frequent dialysis. The purpose behind this study was to look at whether or not the cost could be balanced with potential improvement in outcomes. We’re looking at things from a cost effectiveness perspective rather than just the effectiveness part.

Can you explain some of the reasons behind why three-times-a-week dialysis is the norm today?

It’s more of a historical relic than anything else. The international standards that were established informally back in the 1970s have always prescribed putting patients on dialysis roughly three or four times a week, and three or four hours per session. That’s not to say there’s no variation; it’s just that for the longest time nephrologists have been doing things this way. Studies have appeared in other countries, in Canada and Europe, suggesting that some of the nephrologists from those countries have experimented with longer times with better outcomes. But nothing in a systematic manner. So in conducting this analysis, we contacted quite a number of large dialysis chains in this country, and it was reported that despite the fact there was some variation in terms of frequency and duration, it isn’t as large as one might expect.

How did you define more-frequent dialysis in the study?

Essentially, our panel of nephrologists convened on what are the kind of combinations of dialysis frequencies and durations that would be feasible ranges to consider. Durations were in the range of two hours to as long as five-and-a-half hours, also for frequency we looked at two times a week to six times a week. So we looked at all these different combinations along these two different parameters.

What were the main findings of the study?

There are combinations of frequent and longer durations of dialysis that are cost effective, but that doesn’t mean all of them are. A big part of the reason is the fact there is a fixed cost associated with each dialysis session. Because of that, you can’t just tack on more dialysis sessions per week and expect that to be cost effective. Among all the combinations of durations and frequencies that were considered, some of them are cost effective in the sense that they lie within the band of what is normally considered the cost effective threshold. Somewhere between $50,000 and $100,000 of quality-adjusted life year (QALY), meaning that if a particular combination of dialysis strategies can extend the patient’s life by one quality-adjusted year without incurring expenditure greater than $50,000 to $100,000, that is considered cost effective. Many of these combinations fall within that band, while many fall outside.

In terms of making responsible decisions for quality care, what should be the takeaway message of this study?

One thing that’s definitely on my mind is that currently the dialysis facilities within this country have not been established based on the considerations for more frequent, longer duration dialysis. There is some variation in practice patterns, but, by and large, the variation is limited. Running more frequent dialysis, for instance, means a dramatic increase in terms of the overhead. So, the organization of dialysis might be reconsidered, in terms of how dialysis clinics are organized, how the technology for dialysis has been designed, so that we might be able to offer more frequent and longer durations of dialysis at a much lower cost. One of the ideas that is frequently talked about is home-based dialysis, and home-based dialysis is one of those things that, presumably, leads to a lower overhead if you have longer durations. It does not involve the patient, for instance, traveling to a dialysis clinic several times a week. All of that is part of the cost. All these things have to do with the organization of how dialysis is provided, and in order frequent and longer duration dialysis to become more widespread, we have to improve along those dimensions.

Would it be a huge project for the dialysis industry to overhaul its infrastructure to accommodate more frequent dialysis?

It certainly might. The infrastructure has been so set with the concept of three-times-a-week, three-and-a-half hours each time, that there’s going to be a need to adjust capacities in terms of how the rest schedules for the care professionals—all those things that need to be modified to make frequent dialysis more tenable. When we say more frequent, dialysis, it does not necessarily mean that everybody ought to go on dialysis more frequently. It means some patients ought to. In some sense, this is taking a step from the past, when we gave everybody the same thing, towards a new frontier where we say that different patients ought to receive different amounts of dialysis. For those things to happen, a lot of things need to change.

Given the fact that the dialysis population is expected to grow substantially in the next 10 to 20 years, is home dialysis the best avenue to take in providing more frequent dialysis?

Right now, it’s difficult to gauge whether home dialysis will prove to be the Holy Grail. Part of the reason is there is no standardized home-based dialysis. There are different device manufacturers that have produced home-based dialysis machines. They all have different configurations. The clinical results on these different pieces of equipment are still quite lacking. There’s not a whole lot of clinical evidence out there to suggest home-based dialysis is currently on par with in-center hemodialysis in terms of outcomes. If we look at the cost side of the equation, home-based dialysis is likely to be significantly cheaper than in-center hemodialysis. Per patient per year, we’re looking about $50,000 to $70,000 for in-center hemodialysis. Along the cost-dimension, home-based dialysis will be a preferred approach; it’s currently the outcomes side of the equation that’s not well understood.

Would large-scale clinical trials about more frequent dialysis be necessary to make sound economic decisions in the future?

Absolutely. When we conducted the study, the intentions were not to say, “Look, we now have this simulation model, and it’s so good and powerful that it completed the need for randomized clinical trials.” Rather, we took on the perspective that conducting randomized clinical trials is usually enormously expensive and takes a very long time. So before we commit ourselves to such large trials, can we do something as a preliminary study to isolate and identify more feasible combinations of frequency and duration, which we would then validate using clinical trials. If anything, this study provides an indication towards what might be feasible combinations of duration and frequency. Before national guidelines can be altered to advocate these forms of dialysis, more formal randomized clinical trials ought to be conducted.

Was the study able to identify other ways more frequent dialysis could be made more cost effective?

These costs are born by different entities. For instance, if I were to improve the quality of dialysis, one of the things I can do is place more clinical staff, make sure dialysis filters are changed as frequently as possible, and to make sure I do all my lab tests correctly on these patients. All these things will cost money on the part of the dialysis clinics. Let’s say that the dialysis clinic cuts back in order to save money on these things, and as a result the patient gets hospitalized more frequently. The dialysis clinic is not bearing that cost. It’s Medicare that’s bearing that cost. In some sense, the payment system for end-stage renal disease creates these conflicts of interest. In some sense, the ideal payment structure has yet to be devised.

It sounds like all the payers have to do a better job at understanding how dialysis interacts with other payments.

Most definitely. In our study, we did consider costs from an all-in perspective. So it’s not costs just from dialysis clinics or hospitals, but rather all the costs borne by all the different parties. In reality, all these costs are borne by different entities, and that is why they are not necessarily behaving in the best interest of each other.

Would you like to add anything else?

Not long before this study was into the final stage of publication, we studied the marginal cost effectiveness as a benchmark for how much health authorities should consider paying for medical therapies. It’s based on the notion that as soon as dialysis was established in the 1970s, it has for the longest time been used as a benchmark for what is cost effective and what isn’t. The frequently used threshold is $60,000 per quality-adjusted life year. That number actually came from dialysis, and what the cost effectiveness of dialysis was in the 1970s. Using the same tool box that we built for this current study, we used the same tool box to study what would be the modern day economic value of a quality-adjusted year of life. The question is whether or not that is higher or lower than before, or whether or not it remains a suitable benchmark for setting, for instance, coverage policies by health insurance companies. That is something that is related to this particular study. RBT

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