HD accounted for >70% of the aggregate costs of the Spanish RRT programme in 2010. From a costs minimization perspective, it would be preferable if the number of incident and prevalent patients in PD were increased.

♦ Background: We undertook a cost-effectiveness analysis of the Spanish Renal Replacement Therapy (RRT) program for end-stage renal disease patients from a societal perspective. The current Spanish situation was compared with several hypothetical scenarios. ♦ Methods: A Markov chain model was used as a foundation for simulations of the Spanish RRT program in three temporal horizons (5, 10, and 15 years). The current situation (scenario 1) was compared with three different scenarios: increased proportion of overall scheduled (planned) incident patients (scenario 2); constant proportion of overall scheduled incident patients, but increased proportion of scheduled incident patients on peritoneal dialysis (PD), resulting in a lower proportion of scheduled incident patients on hemodialysis (HD) (scenario 3); and increased overall proportion of scheduled incident patients together with increased scheduled incidence of patients on PD (scenario 4). ♦ Results: The incremental cost-effectiveness ratios (ICERs) of scenarios 2, 3, and 4, when compared with scenario 1, were estimated to be, respectively, -€83 150, -€354 977, and -€235 886 per incremental qualityadjusted life year (ΔQALY), evidencing both moderate cost savings and slight effectiveness gains. The net health benefits that would accrue to society were estimated to be, respectively, 0.0045, 0.0211, and 0.0219 ΔQALYs considering a willingness-to-pay threshold of €35 000/ΔQALY. ♦ Conclusions: Scenario 1, the current Spanish situation, was dominated by all the proposed scenarios. Interestingly, scenarios 3 and 4 showed the best results in terms of cost-effectiveness. From a cost-effectiveness perspective, an increase in the overall scheduled incidence of RRT, and particularly that of PD, should be promoted.

BackgroundA cost-effectiveness analysis of timely dialysis referral after renal transplant failure was undertaken from the perspective of the Public Administration. The current Spanish situation, where all the patients undergoing graft function loss are referred back to dialysis in a late manner, was compared to an ideal scenario where all the patients are timely referred.MethodsA Markov model was developed in which six health states were defined: hemodialysis, peritoneal dialysis, kidney transplantation, late referral hemodialysis, late referral peritoneal dialysis and death. The model carried out a simulation of the progression of renal disease for a hypothetical cohort of 1,000 patients aged 40, who were observed in a lifetime temporal horizon of 45 years. In depth sensitivity analyses were performed in order to ensure the robustness of the results obtained.ResultsConsidering a discount rate of 3 %, timely referral showed an incremental cost of 211 €, compared to late referral. This cost increase was however a consequence of the incremental survival observed. The incremental effectiveness was 0.0087 quality-adjusted life years (QALY). When comparing both scenarios, an incremental cost-effectiveness ratio of 24,390 €/QALY was obtained, meaning that timely dialysis referral might be an efficient alternative if a willingness-to-pay threshold of 45,000 €/QALY is considered. This result proved to be independent of the proportion of late referral patients observed. The acceptance probability of timely referral was 61.90 %, while late referral was acceptable in 38.10 % of the simulations. If we however restrict the analysis to those situations not involving any loss of effectiveness, the acceptance probability of timely referral was 70.10 %, increasing twofold that of late referral (29.90 %).ConclusionsTimely dialysis referral after graft function loss might be an efficient alternative in Spain, improving both patients’ survival rates and health-related quality of life at an affordable cost. Spanish Public Health authorities might therefore promote the inclusion of specific recommendations for this group of patients within the existing clinical guidelines.

No abstract

A189 Objectives: The Lack of Adherence to Immunosuppressive Treatment (LAIT) has been associated with Chronic Humoral Rejection (CHR) and decreased graft survival which can increase Health Resource Utilisation (HRU). Prevalence of LAIT has been reported to range between 7.4% and 41.8% of Spanish Kidney Transplant (KT) patients and published studies suggest LAIT may cause up to 20-50% of CHR episodes in Spain. The objective of this study was to estimate the resource utilization associated with LAIT in KT patients in Spain. MethOds: A systematic literature review was conducted using Medline, PsycINFO and BVS to identify Spanish studies published between 2009 and 2013 focusing on KT and LAIT. Following the review a questionnaire was developed to explore HRU associated with LAIT. Six national experts in KT from Spain completed the survey and the data was analyzed using Computer Assisted Qualitative Data Analysis (CAQDAS). HRU was estimated independently for suspected LAIT, suspected CHR, confirmed CHR and graft loss. Results: Suspected LAIT and CHR were associated with additional HRU quantified by additional nephrologist visits, heightened immunosuppressive blood-level monitoring, and 2 measurements of anti-HLA antibodies (Luminex), 1 ultrasound scan and 1 kidney biopsy. Confirmed CHR was associated with additional HRU such as increases in the number of follow-up visits from 1 visit every 4-6 months to 1 visit every 1-2 months, associated monitoring and testing (bloods, ultrasonography, donor-specific antibodies, proteinuria). A proportion of these patients are treated with intravenous immunoglobulin, rituximab and plasmapheresis, and kidney biopsy to check whether CHR is resolved. Finally, most CHR episodes, up to 60%, cause graft loss with increased HRU associated with intensive patients' follow-up to prepare the return to dialysis and renal replacement therapy. cOnclusiOns: The lack of adherence to immunosuppressive treatment may lead to CHR and graft loss with an associated increase of healthcare resource utilization.