The “Value” of Life: A new threat to patients on dialysis?

By Peter Laird, MD

Anna and Bill commented on the British health care system’s justification of expenditures based on cost effectiveness criteria and the value of preserving life based solely on cost analysis. American dialysis patients should pay close attention to Britain’s example as many in the American health care think tanks are already paving the road for rationing here in America as well. In a prior post on this issue, Bill brought the issue of QALY to our attention What is a quality-adjusted year of life for a dialyzor?:

Lee and his co-authors, Glenn M. Chertow, of the division of nephrology at Stanford University's department of medicine, and Stefanos A. Zenios, of Stanford's Graduate School of Business, examined records from more than a million patients. The study results show that the incremental cost effectiveness ratio of dialysis in current practice relative to the next least costly alternative is on average $61,294 per year, or $129,090 for a quality-adjusted year of life (QALY) -- a measure that combines the length of time that life is extended and the quality of that life.

The outspoken recommendation by Dr. Lee and Dr. Chertow is to start treating American dialysis patient’s based on a value based rationing system:

"In this country we're really uncomfortable with the notion of health care rationing," says Lee. "On the other hand, the fact of the matter is when you have finite resources -- and that is the case here -- you are always rationing, whether explicitly or implicitly.”

Dr. Chertow and Dr. Lee have a series of forthcoming articles on these issues. It is likely that they will singlehandedly lay the groundwork for reduction of dialysis utilization in the high risk populations based on the same justifications also given in NICE.

(with G.M. Chertow and S.A. Zenios)
“Optimal initiation and management of dialysis therapy.” Operations Research (Forthcoming).

(with G.M. Chertow and S.A. Zenios)
“An empiric estimate of the value of life: updating the renal dialysis cost-effectiveness standard.” Value in Health (Forthcoming).

(with G.M. Chertow and S.A. Zenios)
“Evaluating the potential effects of frequency and duration of hemodialysis on longevity, cost and cost-effectiveness.” Journal of the American Society of Nephrology (Forthcoming).

The advocates for more frequent and longer duration hemodialysis strategies are facing even greater opposition in the coming months. Despite the clear benefits to patients with a higher dose of dialysis either by increasing the frequency or duration of dialysis sessions or both, the battle continues over what constitutes optimal dialysis as part of a rational health care plan.

When these health benefits are coupled with the markedly reduced hospital utilization rates seen in daily dialysis strategies as well as nocturnal strategies, we also find reduced medication usage and fewer long term comorbidities which greatly benefit the health care payer. Thus, it is difficult to justify the hard line approach that Dr. Lee and Dr. Chertow appear to be recommending. Rationing based on unproven utilitarian concepts will not give us optimal management of dialysis therapy while at the same time denying that our current thrice weekly dialysis protocols are not frequent enough, nor long enough to optimally treat CKD-5 patients.

Comments

[Tracy Lynn]

I am starting to really hate Glenn Chertow.