Frequent dialysis may benefit but at what cost?

More frequent hemodialysis sessions might improve the health of patients with end-stage renal disease (ESRD), but under reasonable assumptions of expected benefit, the overall costs are likely to increase, according to a study appearing in the September 2008 issue of the Journal of the American Society Nephrology (JASN). The findings indicate that strategies are needed to reduce the costs of delivering hemodialysis if patients receive hemodialysis more than three times a week. Despite ongoing therapy with current in-center hemodialysis procedures, which involve three sessions a week for three to four hours at a clinic per session, patients with ESRD experience relatively poor health and high mortality rates. Published studies suggest that more frequent hemodialysis for patients may improve their quality and length of life and cut down on hospitalizations and other costs. In recent years, several hemodialysis centers around the world have explored this strategy, and two ongoing clinical trials in the United States are currently comparing frequent and conventional hemodialysis.

To assess the potential effects of hemodialysis frequency on life expectancy and costs, Dr. Glenn Chertow of the Stanford University School of Medicine in Stanford, CA, and his colleagues from Stanford's Graduate School of Business and the Wharton School at the University of Pennsylvania examined data from a national registry that is representative of the US hemodialysis population. Using a sophisticated simulation model, they set out to determine if more frequent hemodialysis strategies could enhance longevity at a reasonable cost.

The investigators determined that a change from conventional in-center hemodialysis (three times per week, 3.5 hours per session) to a more frequent hemodialysis strategy might be expected to increase life expectancy by between two and 24 months depending on the frequency (four, five, or six times per week, across a range of session lengths from two to 4.5 hours per session). However, more frequent hemodialysis would be considerably more expensive than the current protocol.

Dr. Chertow's group found that it was possible for more frequent hemodialysis to break even in total lifetime costs by reducing the cost for each hemodialysis session. For a frequency of four times per week, four hours per session, the cost reduction needs to be 32%. For a frequency of five sessions per week, 2.5 hours per session, a cost reduction of 43% is required.

"These results imply that frequent in-center hemodialysis strategies are unlikely to be cost neutral unless increasing the frequency of in-center hemodialysis exerts much more favorable effects on outcomes and associated costs than assumed here," the authors concluded. "The cost of more frequent in-center hemodialysis may be prohibitive unless the benefits are overwhelming and/or the costs of delivering hemodialysis could be significantly reduced," they explained.

Source: American Society of Nephrology