An estimate of lifelong costs and QALYs in renal replacement therapy based on patients’ life expectancy
Introduction
Quality adjusted life-years (QALYs) are a measure of health status which account for both quality and duration of survival in a single outcome measure and express health status in terms of well years of life [1]. Quality adjustment is based on a set of values or weights (utilities), one for each possible health state, that reflect the relative preference of the individual for that health state relative to others. In cost utility analyses (CUA), the incremental cost of a program, considered from a particular viewpoint, is compared to the incremental health improvement – measured in QALYs – attributable to the program. CUA has been used to assess health technologies and compare treatment strategies, to assess the benefits of health interventions and in the decision analysis field. Review studies are available in the literature [2].
In end-stage renal disease (ESRD), the modalities available for treatment are hemodialysis (HD), peritoneal dialysis (PD) and renal transplantation (Tx), with the latter globally recognized as the best option, both in terms of costs and outcomes. Compared to HD, PD has some noted advantages such as better preserved residual renal function, delaying the need for blood access sites and reducing the risk of various cross-infections. It is generally preferred for home therapy and for patients with diabetes, cardiovascular problems or HIV infection, providing that patients are medically fit and willing to participate actively in their treatment [3]. On the other hand, HD is by far the most frequently used modality and is typically administered three times a week in dialysis facilities. Generally patients stay on HD longer than PD and experience fewer adverse incidents.
Renal replacement therapy (RRT), for ESRD, has undoubtedly been among the first medical interventions to be assessed with regard to its cost and outcomes. This is related to the large and rapidly increasing number of potential beneficiaries of such treatments, in conjunction to the large treatment costs. In Greece, for example, almost 10,000 patients are on some form of RRT with 75% on HD, 8% on PD and the rest have been transplanted. The augmentation of the RRT “pool” (also considering patient deaths) is close to 8% per year. The Greek estimate of €240 for the average cost of a dialysis session [4] implies that the aggregate annual economic impact exceeds 250 million Euros.
Despite increasing renal transplantation and advances in dialysis having contributed to improved patient survival, health-related quality of life (HRQOL) in this disease group is much lower than in the general population [5], [6]. Concerning treatment methods, it is clear that Tx patients have a better HRQOL than their dialysis counterparts [7], [8]. Contrarily, many studies comparing HD and peritoneal PD have not concluded on the superiority of either, with respect to HRQOL [9], [10]. In terms of survival, successful transplant provides a better overall outcome compared to dialysis and increased life expectancy. Although transplant recipients initially face an increased risk of death, ultimately the long-term mortality risk is significantly less compared to dialysis patients [11], [12], due to better immunosuppressive medication, organ procurement, patient preparation and surgical technique.
The majority of studies on the cost-effectiveness of ESRD treatment have used a combination of empirical data and literature-based evidence or estimations [13]. Similarly, the present study uses empirical quality-of-life data to estimate utilities, combined with literature-based survival data to calculate QALYs. Cost estimates for HD and PD are derived via a micro-costing analysis performed within the study, whereas the cost of Tx was extracted from an official Greek report. This study constitutes the first, to our knowledge, cost utility analysis of ESRD treatment methods based on expected remaining life years. Lifelong QALYs were estimated using SF-6D utilities derived from the generic SF-36 Health Survey, which was administered to a large and representative sample of the Greek ESRD population. Lifelong treatment costs for HD, PD and Tx were estimated in terms of annual costs, which were extrapolated over each patient's expected remaining lifetime.
Section snippets
Sample and data collection
The sample was comprised of RRT patients: (i) on in-center HD, (ii) on home PD or (iii) successfully transplanted. All such patients enlisted in the archives of the Hellenic Renal Registry were eligible participants, providing they were at least 18 years old, they had sufficient knowledge of Greek for self-administration of a survey containing the SF-36 and common sociodemographic and disease-related questions, and were physically and mentally capable of completing the survey with minimal
Results
Socio-demographic and health-related characteristics of the sample are given in Table 1. According to modality, mean ages were 58.1 (HD), 58.7 (PD) and 43.7 (Tx), with the latter significantly different (P < 0.01) from the two dialysis groups. Overall, 61.3% were male and 38.7% had completed only primary school. Most patients were married and 44.6% were currently employed (mostly transplant patients). In the HD and PD groups, 35.1% were on the transplant list, whereas approximately 10% had
Discussion
Interestingly, the first study to address QALYs, although not explicitly using the same term, was in the field of nephrology and concluded that transplanted patients experience a quality of life approximately 25% better than their dialysis counterparts [27]. Since then, many QALY studies have been published and according to a recent literature review of studies based on actual measurements of patients’ HRQOL [28], the SF-6D was used in 5% of them. This figure is encouraging, considering that
Conclusions
Results from this and similar studies could help to initiate a campaign in favor of organ donation. No previous economic evaluation has disputed that renal transplant is the most cost-effective RRT method, however it is usually limited by the number of donated kidneys available. This situation is unfortunately more persistent in Greece where it is impossible to meet demands for kidneys with only 6.5 donors per million population, resulting in 10-year (or longer) waiting lists. Helping to
Acknowledgements
We appreciate the help provided by Dr. John Boletis – President of the Hellenic Society of Nephrology – and Dr. Georgios Skoutelis for their help in collecting patient data and for willingly sharing their expertise with us. We are grateful to the Board of Directors of the Hellenic National Transplant Organization for providing the interim cost report. We also thank A. Mazaraki, N. Motsios and E. Patsia – M.Sc. students of the Hellenic Open University – for collecting dialysis cost data.
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