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  • Health technology assessment of the different dialysis modalities in Norway

Health technology assessment

Health technology assessment of the different dialysis modalities in Norway

Published Updated

The Health Technology Assessment compare efficacy, safety and cost-effectiveness of the different dialysis modalities.

The Health Technology Assessment compare efficacy, safety and cost-effectiveness of the different dialysis modalities.


About this publication

  • Year: 2013
  • By: Norwegian Knowledge Centre for the Health Services
  • Authors Pike E, Hamidi V, Ringerike T, Wisløff T, Desser A, Harboe I, Klemp M.
  • ISSN (digital): 1890-1298
  • ISBN (digital): 978-82-8121-830-7

Key message

During the last ten years, the number of dialysis patients has doubled in Norway.

After a request from The Norwegian Directorate of Health we performed a Health Technology Assessment comparing efficacy, safety and cost-effectiveness of the different dialysis modalities 1) Hemodialysis carried out in hospital, 2) self-care hemodialysis in hospital, 3) hemodialysis in satellite unit (nursing home, local medical centre), 4) hemodialysis at home and 5) peritoneal dialysis at home for patients with end-stage renal failure requiring dialysis in Norway. Our outcomes were mortality, complications that require special measures and quality of life.

Clinical findings

Of 21 possible comparisons only six had published data. For the comparisons with published data and low quality of the evidence, we found no significant differences in mortality, in quality of life or in infections significantly fewer hospitalisation days per patients per year in the hemodialysis hospital group versus the peritoneal dialysis at home group.

Economic evaluation

In our model analyses all dialysis modalities were almost equally effective. Hemodialysis at home was the most effective and cost-effective alternative compared to all other hemodialysis modalities from both healthcare and societal perspectives. Peritoneal dialysis was the least costly, and hence the most cost-effective alternative compared to all hemodialysis modalities. The results of our sensitivity analysis showed that cost data had the greatest impact on the results’ uncertainty.

Summary

Background

About 11 % of the Norwegian population has chronic kidney disease (CKD). Some of these persons develop end-stage renal failure with the need for renal replacement therapy (RRT). The number of dialysis patients in Norway has increased from 241 in 1990 to 1240 in 2012. With the expected demographic development of increased numbers of elderly people, people with high blood pressure, cardiovascular diseases and/or diabetes, one can anticipate a further increase in the number of people with chronic renal failure in need of RRT in the future.

Generally, there are two different types of dialysis: hemodialysis (HD) and peritoneal dialysis (PD). In Norway hemodialysis performed in hospitals (satellites included) is the most frequently used modality (84.2%), whereas peritoneal dialysis at home makes up for 15.8%. Only 11 patients (0.8%) received hemodialysis at home by the end of 2012 (1).

Upon a request from The Norwegian Directorate of Health we performed a Health Technology Assessment comparing efficacy, safety and cost-effectiveness of the different dialysis modalities in Norway. This request has its background in "The Norwegian action plan for the prevention and treatment  of chronic kidney disease” (2011-2015)".

With the increasing number of dialysis patients expected, there is a need to compare both cost-effectiveness and safety data for the different dialysis modalities used in Norway today.

Objective

Our objective was to perform a Health Technology Assessment comparing efficacy, safety and cost-effectiveness of the different dialysis modalities 1) Hemodialysis carried out in hospital, 2) self-care hemodialysis in hospital, 3) hemodialysis in satellite units (nursing home, local medical centre), 4) hemodialysis at home and 5) peritoneal dialysis at home for patients above 18 years with end-stage renal failure requiring dialysis in Norway. Our outcomes were mortality, complications that require special measures and quality of life.

Method

We performed a systematic literature search for systematic reviews, randomized controlled trials and controlled observational studies to find information about mortality, complications that require special measures and quality of life for the specified dialysis modalities. The quality of the evidence for each outcome was assessed by GRADE.We performed a cost-utility analysis (CUA) where relevant costs were expressed in 2012 Norwegian kroner (NOK), and effects were expressed in quality-adjusted life-years (QALYs). The analysis was carried out from both a societal and healthcare perspective.

In order to assess the cost-effectiveness of different dialysis modalities, a decision analytic model was developed in TreeAge pro ® 2012. The model is of the Markov type, in which a cohort of patients is followed over a given period of time. A Markov model was considered appropriate as end stage renal failure (ESRF) is a chronic condition requiring continuous treatment.

The results were expressed as mean incremental cost-effectiveness ratio (ICER) and mean incremental net health benefit.

Uncertainties in model parameters were handled by performing one-way (tornado diagram) and probabilistic sensitivity analyses, designed as a Monte Carlo simulation, with 1000 iterations.

Results

In this HTA we have systematically reviewed and summarized the clinical results from 18 publications reporting results from two randomized controlled studies and 17 observational studies.

We have further performed an economic evaluation to examine the relative cost-effectiveness in a Norwegian setting of different dialysis modalities from both healthcare and societal perspectives in patients with end stage renal disease.

Clinical findings

Of 21 possible comparisons only six had published data.

For the comparisons with published data and low quality of the evidence, we found:no significant differences in mortality, in quality of life or in infections significantly fewer hospitalisation days per patient per year in the hemodialysis hospital group versus the peritoneal at home dialysis group.

Economic evaluation

From a healthcare perspective: Hemodialysis at home was more effective and less costly (the dominant modality) relative to hemodialysis at hospital and hemodialysis in satellite. Hemodialysis at home was more costly and more effective than self-care hemodialysis and peritoneal dialysis although the incremental cost-effectiveness ratios (ICER; NOK 1,651,099 and NOK 4,344,526, respectively) were clearly above the suggested threshold for cost-effectiveness of NOK 588,000 per QALY gained.

From a societal perspective: Hemodialysis at home dominated all other hemodialysis modalities (i.e. hemodialysis in hospital,  self-care hemodialysis and hemodialysis in satellite). Hemodialysis at home was more costly and more effective relative to peritoneal dialysis, but the ICER (NOK 2,657,211) was above the suggested threshold.

The results of our sensitivity analysis showed that cost data had the greatest impact  on the results’ uncertainty.

Discussion

Most of our documentation regarding effectiveness of the different dialysis modalities came from controlled observational studies. Since observational studies lack randomization they are normally deemed to have a greater potential for varying patient characteristics across groups at baseline. We have therefore only assessed studies where the groups did not differ significantly in comorbidity at baseline.

For this HTA we were asked specifically to focus on the type of dialysis performed and the delivery location. Consequently, we could not examine differences in dialysis frequency, dialysis adequacy, residual function or dialysis equipment, all of which could possibly have influenced our results.Lack of data comparing different hemodialysis modalities (with regard to treatment location) was the most important limitation of this study. This limitation was relevant to all parameters, i.e. effect, complications, quality of life and costs.

Little research exists examining the costs of different dialysis modalities in Norway, making it difficult to obtain reliable cost information for the different modalities, particularly home and satellite, and with regard to geographical conditions and existing infrastructure in different regions. Although we have tried to conduct our analyses based on best available data, and have incorporated uncertainty around cost estimates in the sensitivity analysis, the cost estimates need to be treated with some caution.

In several cases, efficacy parameters used in the model are based on meta-analyses with no significant results. In health economic evaluation it is a common practice to include no significant differences since effect estimates from clinical studies themselves are considered to be the most likely outcome, and because it is assumed that the probability distributions represent the actual uncertainty.

Conclusion

In our model analyses all dialysis modalities were almost equally effective. When effects are combined with cost, hemodialysis at home was the most cost-effective alternative among the hemodialysis modalities. Peritoneal dialysis was the least expensive and hence the most cost-effective alternative compared to all hemodialysis modalities.