title: The impact of home nocturnal hemodialysis on end-stage renal disease therapies: a decision analysis.
abstract: Home nocturnal hemodialysis (HNHD) is cost-effective relative to in-center hemodialysis (IHD) in short-run analyses. The effect in long-run analyses, when technique failures, declining benefits, delayed training, transplantation and death are considered, is unknown. We used decision analysis techniques to examine the relative cost-effectiveness of HNHD and IHD, projecting future costs and health effects over a lifetime with end-stage renal disease. We developed a Markov state-transition model comparing two strategies: only IHD or starting on IHD and subsequently transferring to HNHD. The model incorporates transplantation. In the base case, half the population was eligible for transplantation, with (1/3) of grafts from live donors. The time to transplant was 0.75 years for live and 5 years for deceased donor transplants. The delay before initiation of HNHD was 5 years. Costs and outcomes were discounted at 3% per annum. Model parameters were derived from a literature review. We also conducted one-way sensitivity analyses and Monte Carlo simulations. The HNHD strategy was associated with a quality-adjusted survival estimate of 5.79 quality-adjusted life years (QALYs), with lifetime costs of $538 094. The values for IHD were 5.31 QALYs and $543 602, respectively. Thus, HNHD is cost saving while improving quality of life. The incremental cost-utility ratio was consistently less than $50 000 per QALY in sensitivity and Monte Carlo analyses. Important determinants of cost-effectiveness were transplantation time and whether benefits declined over time. Our model suggests that HNHD improves quality-adjusted survival over IHD at an economically attractive cost-effectiveness ratio.
authors.affiliation: St Michael's Hospital, 61 Queen Street East, 9th Floor, Toronto, Ontario, Canada M5C 2T2. phil.mcfarlane@utoronto.ca
authors.forename: P A
authors.initials: PA
authors.lastname: McFarlane
authors.forename: A M
authors.initials: AM
authors.lastname: Bayoumi
authors.forename: A
authors.initials: A
authors.lastname: Pierratos
authors.forename: D A
authors.initials: DA
authors.lastname: Redelmeier
mesh_terms: D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D006437:Hemodialysis, Home / Q000191:economics / Q000401:mortality; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics / Q000401:mortality / Q000628:therapy*; D008390:Markov Chains; D019057:Quality-Adjusted Life Years; D012680:Sensitivity and Specificity; D013997:Time Factors