TREATMENT STRATEGIES FOR INSULIN-DEPENDENT DIABETICS WITH ESRD - A COST-EFFECTIVENESS DECISION-ANALYSIS MODEL

Clinical decision analysis has become an important tool for evaluating specific clinical scenarios and exploring public health policy issues . A decision analysis model that incorporates patient preferences rega rding various outcomes, as well as cost, may be particularly informati ve in patients with type I diabetes and end stage renal disease (ESRD) . Such a model that includes pancreas transplantation as a treatment c hoice has not been performed and is presented in this study. The decis ion tree consisted of a choice between four possible treatment strateg ies: dialysis, kidney-alone transplant from a cadaver (KA-CAD) or livi ng donor (KA-LD), and simultaneous pancreas-kidney (SPK) transplant. T he analysis was based on a 5-year model, and the measures of outcome u sed in the model were cost and cost adjusted for quality of life. The measure of preference for quality of life was obtained using the ''Sta ndard Reference Gamble'' method in 17 SPK transplant recipients who un derwent transplantation between January, 1992 and June, 1996 at our ce nter. The measures for various outcome states (mean +/- 1 SD) were dia lysis-free/insulin-free = 1, dialysis-free/insulin-dependent = 0.6 (0. 4 to 0.8), dialysis-dependent/insulin-free = 0.5 (0.36 to 0.64), dialy sis-dependent/insulin-dependent = 0.4 (0.21 to 0.59), and death = 0. T he expected 5-year costs for each of the treatment strategies in the m odel were dialysis, $216,068; KA-CAD transplant, $214,678; KA-LD trans plant, $210,872; and SPK transplant, $241,207. The expected cost per q uality-adjusted year for each of the treatment strategies in the model were dialysis, $317,746; KA-CAD transplant, $156,042; KA-LD transplan t, $123,923; and SPK transplant, $102,422. SPK transplantation remaine d the optimal strategy after varying survival probabilities, costs, an d utilities over plausible ranges by means of one-way sensitivity anal ysis. In conclusion, according to the 5-year cost-utility model presen ted in this study, SPK transplantation is the most cost-effective trea tment strategy for a patient with type I diabetes and ESRD. From a pol icy standpoint, looking at the cost alone of pancreas transplantation is deceiving. In these patients, who may view various outcome states d ifferently, it would be important to take into account cost adjusted f or quality of life when evaluating this procedure. (C) 1998 by the Nat ional Kidney Foundation, Inc.