Study: Peritoneal dialysis offers better outcomes, lower costs vs in-center hemodialysis
A Canadian study that compared patients who started on peritoneal dialysis vs. in-center hemodialysis found PD offered lower costs and better quality of life.
The study used a baseline model that looked at outcomes during a 10-year period and accounted for changes in modality options – a process not often evaluated when examining the cost of dialysis care, the study authors wrote.
“Although most patients who undergo dialysis will receive only a single modality, up to 40% will switch modalities or setting during the course of their treatment,” Thomas W. Ferguson, MSc, of the department of internal medicine at the University of Manitoba in Winnipeg, Manitoba, Canada, and colleagues wrote. “For example, patients initiating with facility-based [hemodialysis] HD may transition to home modalities or receive a kidney transplant, reducing costs. Transplant recipients may subsequently experience allograft failure and revert to facility-based HD, increasing costs.
“As such, tools to accurately plan resource use that incorporate modality switches and setting changes are needed to aid efficient planning, particularly in the face of a growing kidney failure population and expanding dialysis programs,” the authors wrote.
The researchers used data from the Canadian Organ Replacement Register to identify all facility-based HD and home PD starts between 2004 and 2013, The total number of patients was 39,318, with 31,148 patients on facility-based HD and 8,170 patients having initiated home PD.
“Mean ages of facility-based HD and home PD starters were 64.6 and 61.3 years, respectively,” the authors wrote, “and 60.6% of all facility-based HD starters were men, whereas 58.5% of all home PD starters were men. Patients who initiated dialysis with home PD had fewer comorbid conditions.”
Up to six possible treatment states – conventional (thrice-weekly) facility-based hemodialysis, conventional (thrice-weekly) home HD (HHD), intensive facility-based hemodialysis, intensive HHD, home PD and transplantation – were part of the study.
“We included only patients who initiated dialysis with conventional facility-based HD or with PD because relatively few patients initiated with other treatment modalities (eg, HHD) and we were unable to derive robust transition probabilities due to insufficient sample size,” the authors wrote.
The analysis of the data during the 10-year period showed the cost for all patients initiating dialysis was $103,779 per quality-adjusted life-year (QALY) in comparison to no treatment.
“Patients who initiated with facility-based HD were treated at a cost-utility ratio of $104,880/QALY and patients who initiated with home PD were treated at a cost-utility ratio of $83,762/QALY,” the authors wrote. “During this [10-year] time horizon, the total mean cost and QALYs per patient were estimated at $350,774 ± $204,704 and 3.38 ± 2.05 QALYs, respectively.”
The results showed patients who started on PD “generally lived longer than people who started on in-center hemodialysis and so they received higher quality-adjusted life-years,” Paul Komenda, MD, MHA, a study co-author, told Healio Nephrology. “Then, we calculated costs and we found out that if you started on PD, over a lifetime spent on dialysis vs. starting on in-center hemodialysis, you get more life years and it costs less.
“Generally, that equals lower costs for the health care system.”
In a separate editorial, Nattawat Klomjit, MD, and colleagues from the Mayo Clinic in Rochester, Minnesota, said the expanded use of criteria, such as modality changes, and the incorporation of the simultaneous risk of mortality and infection in the study provided multiple advantages to determining outcomes compared to previous studies. “The model also provides more flexibility as the cost estimation can be adjusted based on changing baseline characteristics, enabling its use in changing populations,” Klomjit and colleagues wrote. Some issues require further study, they said, including the cost incurred to patients and their families and the impact of each modality choice on employment and productivity.
“Importantly, given the model’s many strengths, including the use of national, broadly generalizable data in Canada, this model could be adapted to other populations to inform policy makers regarding cost-effectiveness of dialysis modalities,” they wrote.