The STARRT trial: a cost comparison of optimal vs sub-optimal initiation of dialysis in Canada

Piwko, Charles; Vicente, Colin; Marra, Lou; Jivraj, Farah; Appel, E; Wolpin, Jacob; Camacho, Fernando; Mendelssohn, David C.; McFarlane, Phil

doi:10.3111/13696998.2011.630850

Cited by 14 publications

(19 citation statements)

References 21 publications

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“…Canadian data showed that the average total cost per patient was an estimated $63,225 for the suboptimally initiated patients and $39,260 for the optimally (dialysis initiation as an outpatient, using arteriovenous fistula, graft, or PD catheter) initiated patient 37. Most developed countries can provide PD at lesser expense to the health care system than HD 18.…”

Section: Discussionmentioning

confidence: 99%

Factors influencing access to education, decision making, and receipt of preferred dialysis modality in unplanned dialysis start patients

Machowska¹,

Alscher²,

Vanga³

et al. 2016

PPA

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ObjectivesUnplanned dialysis start (UPS) leads to worse clinical outcomes than planned start, and only a minority of patients ever receive education on this topic and are able to make a modality choice, particularly for home dialysis. This study aimed to determine the predictive factors for patients receiving education, making a decision, and receiving their preferred modality choice in UPS patients following a UPS educational program (UPS-EP).MethodsThe Offering Patients Therapy Options in Unplanned Start (OPTiONS) study examined the impact of the implementation of a specific UPS-EP, including decision support tools and pathway improvement on dialysis modality choice. Linear regression models were used to examine the factors predicting three key steps: referral and receipt of UPS-EP, modality decision making, and actual delivery of preferred modality choice. A simple economic assessment was performed to examine the potential benefit of implementing UPS-EP in terms of dialysis costs.ResultsThe majority of UPS patients could receive UPS-EP (214/270 patients) and were able to make a decision (177/214), although not all patients received their preferred choice (159/177). Regression analysis demonstrated that the initial dialysis modality was a predictive factor for referral and receipt of UPS-EP and modality decision making. In contrast, age was a predictor for referral and receipt of UPS-EP only, and comorbidity was not a predictor for any step, except for myocardial infarction, which was a weak predictor for lower likelihood of receiving preferred modality. Country practices predicted UPS-EP receipt and decision making. Economic analysis demonstrated the potential benefit of UPS-EP implementation because dialysis modality costs were associated with modality distribution driven by patient preference.ConclusionEducation and decision support can allow UPS patients to understand their options and choose dialysis modality, and attention needs to be focused on ensuring equity of access to educational programs, especially for the elderly. Physician practice and culture across units/countries is an important predictor of UPS patient management and modality choice independent of patient-related factors. Additional work is required to understand and improve patient pathways to ensure that modality preference is enacted. There appears to be a cost benefit of delivering education, supporting choice, and ensuring that the choice is enacted in UPS patients.

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Section: Discussionmentioning

confidence: 99%

Factors influencing access to education, decision making, and receipt of preferred dialysis modality in unplanned dialysis start patients

Machowska¹,

Alscher²,

Vanga³

et al. 2016

PPA

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“…It has been shown that UPS bears several disadvantages: besides an increased mortality and hospitalization rates, higher total costs have been recorded [4-6]. …”

Section: Introductionmentioning

confidence: 99%

Impact of an in-Hospital Patient Education Program on Choice of Renal Replacement Modality in Unplanned Dialysis Initiation

Schanz

Ketteler

Heck

et al. 2017

Kidney Blood Press Res

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Background/Aims: Up to 50% patients requiring dialysis receive an urgent, unplanned start (UPS) to renal replacement therapy (RRT). Most of these are initiated with an intravenous catheter and commenced and maintained on hemodialysis (HD). Although peritoneal dialysis (PD) could be an equipotent initial modality for RRT, it is used less frequently as long-term RRT in UPS patients. This multicenter-study aimed to evaluate the impact of a structured, in-hospital education program and factors influencing PD rates, especially in UPS patients. Methods: Three German nephrology departments collaborated to implement an in-hospital education program. Retrospective analysis included 336 subjects and compared the rates of HD and PD in consecutive patients who started RRT 12 months prior (two centers) and for 12 months after (three centers) implementing the education program. Results: PD rates increased significantly (p < 0.05) by 66% in all planned and unplanned dialysis starts after implementation of a structured, patient-centered education program. A highly significant (p < 0.0001) rise in utilization of PD was found, especially in UPS patients. In logistic regression analysis, PD modality choice was significantly influenced by age (p < 0.0001) and gender (p = 0.006). Conclusions: A structured, patient-centered in-hospital education program increases the frequency of PD in patients needing unplanned RRT. PD modality choice is significantly higher in young (p < 0.0001) and male (p = 0.006) patients.

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“…on a nonpreferred modality, with a nonpreferred access, or in hospital). 9 Cost estimates for optimal and suboptimal initiation of dialysis were taken from a multicenter retrospective study, and totaled $54,679 for patients who experience suboptimal dialysis initiations and $33,953 for optimally initiated patients. 9 The cost of a hospitalization event was assumed to be $11,640 based on estimates from the Agency for Healthcare Research and Quality.…”

Section: Methodsmentioning

confidence: 99%

“…8 Unfortunately, even among patients followed by a nephrologist and multidisciplinary care team, 50% or more experience a suboptimal initiation of dialysis. 9,10 Moreover, more than half of dialysis initiations involve a hospitalization or emergency department visit due to severe uremic symptoms, volume overload, or hyperkalemia. 7 Initiating dialysis earlier at a higher kidney function before patients are symptomatic and when there is less risk of suboptimal starts is not an ideal solution, as it increases health care costs without a clinical benefit.…”

mentioning

confidence: 99%

A Cost-Minimization Analysis of Nurse-Led Virtual Case Management in Late-Stage CKD

Ferguson

Hager

Whitlock

et al. 2020

Kidney International Reports

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Introduction: Interventions are needed to improve early detection of indications for dialysis before development of severe symptoms or complications. This may reduce suboptimal dialysis starts, prevent hospitalizations, and decrease costs. Our objectives were to explore assumptions around a nurse-led virtual case management intervention for patients with late-stage chronic kidney disease (CKD) with a 2-year Kidney Failure Risk Equation (KFRE) estimated risk of kidney failure $80% and to estimate how these assumptions affect potential cost savings. Methods: We performed a cost-minimization analysis by developing a decision analytic microsimulation model constructed from the perspective of the health payer. Our primary outcome was the break-even point, defined as the maximum amount a health payer could spend on the intervention without incurring any net financial loss or gain. The intervention group received remote telemonitoring, including daily measurement of several health metrics (blood pressure, oxygen saturation, and weight), and a validated symptom questionnaire accompanied by nurse-led case management, whereas the comparator group received usual care. We assumed patients received the intervention for a maximum of 2 years. Results: The break-even point was $7339 per late-stage CKD patient enrolled in the intervention. Based on the distribution of time receiving the intervention, we determined a maximum monthly intervention cost of $703.37. In probabilistic sensitivity analyses, we found that 75% of simulations produced break-even points between $3929 and $9460. Conclusion: Nurse-led virtual home monitoring interventions in patients with CKD at high risk of kidney failure have the potential for significant cost savings from the perspective of the health payer.

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The STARRT trial: a cost comparison of optimal vs sub-optimal initiation of dialysis in Canada

Abstract: The results of this study indicate, after adjusting for potential confounders, that optimally initiated patients for RRT have significantly lower healthcare-associated costs compared to sub-optimally initiated patients.

Cited by 14 publications

References 21 publications

Factors influencing access to education, decision making, and receipt of preferred dialysis modality in unplanned dialysis start patients

Factors influencing access to education, decision making, and receipt of preferred dialysis modality in unplanned dialysis start patients

Impact of an in-Hospital Patient Education Program on Choice of Renal Replacement Modality in Unplanned Dialysis Initiation

A Cost-Minimization Analysis of Nurse-Led Virtual Case Management in Late-Stage CKD

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