title: A simulation model to estimate the cost and effectiveness of alternative dialysis initiation strategies.
abstract: BACKGROUND
  Patients with end-stage renal disease (ESRD) require dialysis to maintain survival. The optimal timing of dialysis initiation in terms of cost-effectiveness has not been established.
  
  
  METHODS
  We developed a simulation model of individuals progressing towards ESRD and requiring dialysis. It can be used to analyze dialysis strategies and scenarios. It was embedded in an optimization frame worked to derive improved strategies.
  
  
  RESULTS
  Actual (historical) and simulated survival curves and hospitalization rates were virtually indistinguishable. The model overestimated transplantation costs (10%) but it was related to confounding by Medicare coverage. To assess the model's robustness, we examined several dialysis strategies while input parameters were perturbed. Under all 38 scenarios, relative rankings remained unchanged. An improved policy for a hypothetical patient was derived using an optimization algorithm.
  
  
  CONCLUSIONS
  The model produces reliable results and is robust. It enables the cost-effectiveness analysis of dialysis strategies.
authors.affiliation: Operations and Information Management Department, The Wharton School, University of Pennsylvania, PA, USA.
authors.forename: Chris P
authors.initials: CP
authors.lastname: Lee
authors.forename: Glenn M
authors.initials: GM
authors.lastname: Chertow
authors.forename: Stefanos A
authors.initials: SA
authors.lastname: Zenios
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003198:Computer Simulation / Q000706:statistics & numerical data*; D003365:Costs and Cost Analysis; D003710:Demography; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics / Q000628:therapy*; D016030:Kidney Transplantation / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D006435:Renal Dialysis / Q000191:economics / Q000379:methods*; D016019:Survival Analysis