THE HEMODIALYSIS PRESCRIPTION AND COST-EFFECTIVENESS

Case-mix adjusted mortality rates for patients undergoing hemodialysis for ESRD increased during the 1980s, despite the introduction of adva nced dialysis technologies. Variations in dialysis practices suggest t hat excess mortality may be caused by inadequate uremic-toxin clearanc es. Cost-effectiveness analysis was used to assess whether attempts to improve uremic-toxin clearance are cost effective, assuming that thes e therapies are clinically effective. The medical literature was surve yed by the use of MEDLINE to assess the likelihood of clinical outcome s on the basis of the type of treatment given to the patient. Options considered in the model were delivered fractional urea clearance (Kt/V ), dialysis-treatment duration, type of dialyzer membrane, dialysate, and ultrafiltration. Clinical outcomes included in the model were surv ival, severity of uremic symptoms, hospital days per year, and intradi alytic hypotension and symptoms. Lifetime costs were calculated from d ata collected from a northern California dialysis center and abstracte d from the literature. In the base-case scenario, it was assumed that increasing Kt/V to levels greater than 1 was effective in reducing mor bidity and mortality. Under these assumptions, outpatient cost increas ed significantly, but the cost effectiveness of Kt/V equal to 1.5 was less than $50,000 per quality-adjusted life-year saved. These calculat ions indicate that, if higher levels of Kt/V prove clinically effectiv e, they are also cost effective.