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A Cost-effectiveness Analysis of Daily vs Alternate-Day Hemodialysis

Amar A. Desai, MD, MPH; Jacqueline Baras, BA; Benjamin B. Berk, MD, MS; Aya Nakajima, MBA; Alan M. Garber, MD, PhD; Douglas Owens, MD, MS; Glenn M. Chertow, MD, MPH

Arch Intern Med. 2008;168(16):1761-1767.

Background  Although evidence suggests that a higher hemodialysis dose and/or frequency may be associated with improved outcomes, the cost-effectiveness of a daily hemodialysis strategy for critically ill patients with acute kidney injury (AKI) is unknown.

Methods  We developed a Markov model of the cost, quality of life, survival, and incremental cost-effectiveness of daily hemodialysis, compared with alternate-day hemodialysis, for patients with AKI in the intensive care unit (ICU). We employed a societal perspective with a lifetime analytic time horizon. We modeled the efficacy of daily hemodialysis as a reduction in the relative risk of death on the basis of data reported in the 2004 clinical trial published by Schiffl et al. We performed 1- and 2-way sensitivity analyses across cost, efficacy, and utility input variables. The main outcome measure was cost per quality-adjusted life-year (QALY).

Results  In the base case for a 60-year-old man, daily hemodialysis was projected to add 2.14 QALYs and $10 924 in cost. We found that the cost-effectiveness of daily hemodialysis compared with alternate-day hemodialysis was $5084 per QALY gained. The incremental cost-effectiveness ratio became less favorable (>$50 000 per QALY gained) when the maintenance hemodialysis rate of the daily hemodialysis group was varied to more than 27% and when the difference in 14-day postdischarge mortality between the alternatives was varied to less than 0.5%.

Conclusion  Daily hemodialysis is a cost-effective strategy compared with alternate-day hemodialysis for patients with severe AKI in the ICU.

Author Affiliations: Division of Nephrology (Drs Desai and Chertow), Center for Health Policy and Primary Care and Outcomes Research (Drs Desai, Garber, and Owens), School of Medicine (Ms Baras and Dr Berk), and Graduate School of Business (Ms Nakajima), Stanford University, Stanford, California; and Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California (Drs Garber and Owens).

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