Economic impact of a modification of the treatment trajectories of patients with end-stage renal disease.
BACKGROUND
This study assumed that some patients currently treated at hospital-based haemodialysis centres can be treated with another renal replacement therapy (RRT) modality without any increase in mortality risk and sought to evaluate the monthly cost impact of replacing hospital-based haemodialysis, for which fees are highest, by different proportions of other modalities.


METHODS
We used a deterministic model tool to predict the outcomes and trajectories of hypothetical cohorts of incident adult end-stage renal disease (ESRD) patients for 15 years of RRT (10 different modalities). Our estimates were based on data from 67 258 patients in the REIN registry and 65 662 patients in the French national health insurance information system. Patients were categorized into six subcohorts, stratified for age and diabetes at ESRD onset, and analyses run for each subcohort. We simulated new strategies of care by changing any or all of the following: initial distributions in treatment modalities, transition rates and some costs. Strategies were classified according to their monthly per-patient cost compared to current practices (cost-minimization analysis).


RESULTS
Simulations of the status quo for the next 15 years predicted a per-patient monthly cost of €2684 for a patient aged 18-45 years without diabetes and €7361 for one older than 70 years with diabetes. All of the strategies we analysed had monthly per-patient costs lower than the status quo, except for daily home HD. None impaired expected survival. Savings varied by strategy.


CONCLUSIONS
Alternative strategies may well be less expensive than current practices. The decision to implement new strategies must nonetheless consider the number of patients concerned, feasibility of renal care reorganization, and investment costs. It must also take into account the role of patients' choice and the availability of professionals.
REIN Registry, Agence de la biomédecine, Saint-Denis La Plaine, France.
Cécile
C
Couchoud
Service évaluation économique et santé publique, Haute Autorité de Santé, Saint-Denis La Plaine, France.
Anne-Line
AL
Couillerot
Hospices Civils de Lyon, Service de Biostatistique, Lyon, France Université Lyon I, CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique Santé, Villeurbanne, France.
Emmanuelle
E
Dantony
Hospices Civils de Lyon, Service de Biostatistique, Lyon, France Université Lyon I, CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique Santé, Villeurbanne, France.
Mad-Hélénie
MH
Elsensohn
REIN Registry, Hospices Civils de Lyon, Lyon, France.
Michel
M
Labeeuw
Université Lyon I, CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique Santé, Villeurbanne, France Nephrology Unit, Saint Luc Saint Joseph Hospital, Lyon, France.
Emmanuel
E
Villar
Hospices Civils de Lyon, Service de Biostatistique, Lyon, France Université Lyon I, CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique Santé, Villeurbanne, France.
René
R
Ecochard
Service évaluation économique et santé publique, Haute Autorité de Santé, Saint-Denis La Plaine, France.
Isabelle
I
Bongiovanni
D000293:Adolescent; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D003198:Computer Simulation; D005260:Female; D017048:Health Care Costs; D006301:Health Services Needs and Demand; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D012042:Registries; D006435:Renal Dialysis / Q000191:economics*; D017582:Renal Replacement Therapy / Q000191:economics*; D055815:Young Adult
cost; dialysis; medico-economic evaluation; simulation tool; transplantation