by Peter Laird, MD
Cost effectiveness of incenter daily dialysis is the subject of an article in this week’s JASN titled Cost-Effectiveness of Frequent In-Center Hemodialysis. The authors: Lee, Zenios and Chertow acknowledge, reluctantly it seems, that quotidian dialysis has many proven benefits over conventional three times a week dialysis schedules, yet they argue that the cost of incenter daily hemodialysis is not economically viable based on their “Monte Carlo” simulation model.
However, it is readily apparent that the “conservative” assumptions that these conclusions are based upon do not reflect the known values reported in several daily dialysis papers. For example, the JASN paper describes their value of mortality reduction as “generous” at 32% which belies survival rates 2-3 times higher found in observational studies (here, here) A 2 to 3 times higher survival rate than the baseline 20-25% mortality often quoted for American dialysis patients.
The entire paper is based on the utilitarian concept of QALY which denotes both the length of survival coupled with a derived quality factor. Medical economists introduced the concept of QALY over 15 years ago as an “objective” measure of healthcare outcomes.
It is best understood as a utilitarian measurement method of healthcare expenditures with the intent to maximize the healthcare economies of scale. Unfortunately, published articles on QALY’s do not have uniform calculation parameters, nor do they take into account the ethical principles of justice that states it is unethical to leave sick people untreated. Instead, medical economist use data generated from QALY’s to advocate cessation of any treatments over $100,000/QALY.
Thus, this utilitarian system discriminates against the chronically ill with high priced treatments. Indeed, some studies list the cost per QALY/year for dialysis in center at $96,000 which places all CKD-5 patients at risk of being beyond societies presumed ethical limit of treatment.
Here also, the authors fail to use comparable data for their simulation. Hospital admissions in this study at baseline is listed at 1.20/patient year with a reduction of only 8.3% to 1.06/patient year for the 5 day/week short daily dialysis regimen. One study lists the actually observed hospitalization rate as low as 0.27 hospitalizations/patient-year for short daily dialysis patients. I thus must stand in question of the data used for this end point as well by Lee, Zenios and Chertow.
The listed reduction for short daily dialysis hospital utilization in many studies is between 24-40%. The cost of maintaining CKD-5 patients is driven mainly by their high hospital utilization with one study in 2003 documenting 78% of total care costs for 76 “ESRD” patients from hospital expenditures alone. The conclusion by these authors that the reduction in hospitalizations will not overcome the increased incenter costs of frequent dialysis is flawed by these discrepancies in data assumptions.
I readily confess that my bias in this debate leans directly towards the daily dialysis option for all that wish to undergo this treatment. This recent article on the hypothetical simulation of inenter frequent dialysis has not swayed my opinion due to its faulty assumptions and flawed conclusions.
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