Cost-effectiveness analysis of online hemodiafiltration versus high-flux hemodialysis

Abstract

BackgroundClinical studies suggest that hemodiafiltration (HDF) may lead to better clinical outcomes than high-flux hemodialysis (HF-HD), but concerns have been raised about the cost-effectiveness of HDF versus HF-HD. Aim of this study was to investigate whether clinical benefits, in terms of longer survival and better health-related quality of life, are worth the possibly higher costs of HDF compared to HF-HD.MethodsThe analysis comprised a simulation based on the combined results of previous published studies, with the following steps: 1) estimation of the survival function of HF-HD patients from a clinical trial and of HDF patients using the risk reduction estimated in a meta-analysis; 2) simulation of the survival of the same sample of patients as if allocated to HF-HD or HDF using three-state Markov models; and 3) application of state-specific health-related quality of life coefficients and differential costs derived from the literature. Several Monte Carlo simulations were performed, including simulations for patients with different risk profiles, for example, by age (patients aged 40, 50, and 60 years), sex, and diabetic status. Scatter plots of simulations in the cost-effectiveness plane were produced, incremental cost-effectiveness ratios were estimated, and cost-effectiveness acceptability curves were computed.ResultsAn incremental cost-effectiveness ratio of €6,982/quality-adjusted life years (QALY) was estimated for the baseline cohort of 50-year-old male patients. Given the commonly accepted threshold of €40,000/QALY, HDF is cost-effective. The probabilistic sensitivity analysis showed that HDF is cost-effective with a probability of ~81% at a threshold of €40,000/QALY. It is fundamental to measure the outcome also in terms of quality of life. HDF is more cost-effective for younger patients.ConclusionHDF can be considered cost-effective compared to HF-HD.

Evaluation of the efficacy of a medium cut-off dialyser and comparison with other high-flux dialysers in conventional haemodialysis and online haemodiafiltration

“…Its benefits to patient survival were first pointed out by retrospective studies [ 7–10 ] and afterwards confirmed by large randomized clinical trials like the Convective Transport Study CONTRAST study [ 11 ], the Turkish study [ 12 ] and the Estudio de Supervivencia de Hemodiafiltración On-Line (ESHOL) [ 13 ] study, whose main conclusion was that high-efficiency post-dilution OL-HDF reduces all-cause mortality compared with conventional HD, especially when higher convective volumes are achieved. Unfortunately, OL-HDF techniques are not available for every patient for different reasons, including vascular access dysfunction, water treatment systems unable to provide ultrapure water or economic problems, even though OL-HDF can be considered cost effective compared with HF HD [ 14 ]. In these situations, a novel class of membranes with a higher pore size designed to increase the removal of larger middle molecules in conventional HD, called medium cut-off (MCO) dialysers, could be promising [ 15 ].…”

Impact of Regular or Extended Hemodialysis and Hemodialfiltration on Plasma Oxalate Concentrations in Patients With End-Stage Renal Disease

“… 20 This may reflect the increasing implementation of HDF in European RRT units, despite continued controversy about its cost-effectiveness. 21 , 22 , 23 , 24 , 25 , 26 Previous reports have indicated that an oxalate elimination of 6 to 10 mmol/1.73 m 2 per week on standard hemodialysis (HD) is inadequate to lower P Ox ; on this regimen, predialysis P Ox values averaged approximately 45 μmol/l. 10 , 27 , 28 , 29 In search of an optimized therapeutic regimen to eliminate P Ox , 3 studies in patients with secondary hyperoxalemia 29 , 30 , 31 reported higher oxalate clearances with HDF compared with standard HD treatment ( Table 1 ).…”

Cardiovascular Risk Factors in End-Stage Renal Disease Patients: The Impact of Conventional Dialysis versus Online-Hemodiafiltration

“…Some studies comparing cost-effectiveness of OL-HDF and HD reported that HD is more cost-effective; however, a recent analysis by Ramponi et al [77] showed that OL-HDF is as cost-effective as high-flux HD. An advantage over high-flux HD is the substantial effect of OL-HDF on the improvement of patient's satisfaction and QoL [78].…”