Blog entry by Meguid El Nahas
Economic Evaluation of Frequent Home Nocturnal Hemodialysis Based on a Randomized Controlled Trial
Scott Klarenbach, Marcello Tonelli, Robert Pauly, Michael Walsh, Bruce Culleton, Helen So, Brenda Hemmelgarn, Braden Manns
Provider and patient enthusiasm for frequent home nocturnal hemodialysis (FHNHD) has been renewed; however, the cost-effectiveness of this technique is unknown. We performed a cost-utility analysis of FHNHD compared with conventional hemodialysis (CvHD; 4 hours three times per week) from a health payer perspective over a lifetime horizon using patient information from the Alberta NHD randomized controlled trial. Costs, including training costs, were obtained using microcosting and administrative data (CAN$2012). We determined the incremental cost per quality-adjusted life year (QALY) gained. Robustness was assessed using scenario, sensitivity, and probabilistic sensitivity analyses. Compared with CvHD (61% in-center, 14% satellite, and 25% home dialysis), FHNHD led to incremental cost savings (-$6700) and an additional 0.38 QALYs. In sensitivity analyses, when the annual probability of technique failure with FHNHD increased from 7.6% (reference case) to ≥19%, FHNHD became unattractive (>$75,000/QALY). The cost/QALY gained became $13,000 if average training time for FHNHD increased from 3.7 to 6 weeks. In scenarios with alternate comparator modalities, FHNHD remained dominant compared with in-center CvHD; cost/QALYs gained were $18,500, $198,000, and $423,000 compared with satellite CvHD, home CvHD, and peritoneal dialysis, respectively. In summary, FHNHD is attractive compared with in-center CvHD in this cohort. However, the attractiveness of FHNHD varies by technique failure rate, training time, and dialysis modalities from which patients are drawn, and these variables should be considered when establishing FHNHD programs.
There is a trend and fashio to promote frequent nocturnal HD based on the FHN trial implying benefit. This is of concern as the FHN trial failed to shwo survival advantage, but showed a benefit on left ventricular hypertrophy; as combined endpoints were evaluated it served to the fall impression that the combined endpoint of survival and left ventricular hypertrophy were imrpoved by Frequent HD, which wasnt the case...
Also, Frequent HD was associated with longer time, UF, as well as higher weekly KT/V in the treated group compared to standard thrice weekly HD; so to attribute the benefit to increased frequency is a misleading assertion as it could as well be due to longer weekly HD or better UF...
Form such weak, short term, data to embark on changing HD practices worldwide is a folly....the paper above also remind us of cost implications.
Nephrologist sare all too keen to embrace new practices to show that they are keeping up with the literature (often without understanding it...) and fashion (something most are attracted by....),
1. Critically examining the facts and data.
2. Examining their utility and usefulness to their own patients population.
3. Without adequate comparisons to their own practices
4. Without assessing the Risk versus Benefit; in this case the risk of jeopardising vascular access by frequent cannulation/puncture.
5. Without assessing the COST versus BENEFIT as outlines in the paper by the Alberta group. A cost benefit analysis that takes the primary intervention cost advantage over conventional HD and showing some advantages but than examining the true cost of any new intervention including the cost of complications and related medical care, the cost of technique failure and loss of vascular access, etc...ONLY THEN DOES THE TRUE COST EFFECTIVENESS OF A NEW TECHNIQUE starts to fade away as gain per QALY exceeds $50,000, the threshold for cost effectiveness in high economines.
Cost effectiveness in middle and low economies could be a gaing per QALY of as little as <$5,000, cost per QALY gained higher tha $5,000 per annum is an unacceptable cost in many low economies.
It would be great that cost benefit analysis also give some insights and figures for cost effectiveness not only in their societies and wealthy healthcare systems but also in poorer economies based on a GDP adjustement.
This would be a great excercise that would enhance the value and UTILITY of such analysis beyond a restricted healthcare system, that in which the reporting autors work within.