Skyrocketing Costs of Dialysis May Require Difficult Decisions

Norra MacReady

November 09, 2009

November 9, 2009 (San Diego, California) — Even modest improvements in the survival of patients with end-stage renal disease undergoing dialysis may lead to billions of dollars in extra costs that society must be prepared to assume, Philip McFarlane, MD, PhD, said here at Renal Week 2009: American Society of Nephrology 2009 Annual Meeting.

These projections may force policymakers and the public into making some difficult decisions in the years ahead, said Dr. McFarlane, a clinical investigator in the Division of Nephrology at the University of Toronto in Ontario. “No matter how you slice it, the numbers remain very large.”

Within 10 years, the additional costs could exceed $5 million for a relatively small dialysis unit caring for approximately 170 people, Dr. McFarlane explained. Projected onto a large national program, such as the one in the United States, that could translate into an increase of more than $14 billion.

Currently, more than 360,000 people in the United States are undergoing dialysis, according to the US Renal Data Service. Medicare spends approximately $73,000 annually per dialysis patient.

Dr. McFarlane’s figures come from a Markov decision analysis model he developed with his coauthor, David C. Mendelssohn, MD. The model accounted for expected growth in the incidence of end-stage renal disease and inflation and assumed that survival of patients undergoing hemodialysis would improve by 22%, given the findings of recent clinical trials. It also assumed that within 10 years the population of a 100-patient dialysis unit would swell to 179 patients, when even longer survival thanks to medical advances is factored in. That would mean an additional 58 patient-years of survival and an additional $5,171,000 in costs. On a national scale, this amounts to an increase of 157,640 patient-years of survival.

The cost per life-years in the model ranged from $77,250 to $88,660.

The projections are for dialysis only: they do not include the cost of transplantation or other interventions that could prolong survival even more, Dr. McFarlane said. “The new interventions will have to be free, or we will have to find the money somewhere else.”

Already “dialysis may be the most expensive thing that society is willing to pay for to keep someone alive,” he pointed out. “It is already recognized as being too expensive for many countries to offer.

“If this is as much as society is willing to pay, we need to know that, because moving forward we will have to displace other costs” to keep supporting dialysis, he explained.

This analysis does not include the cost of hospitalization, said Susan Hedayati, MD, MHSc, assistant professor of internal medicine-nephrology at the University of Texas Southwestern Medical Center in Dallas. “Wouldn’t some interventions lead to some cost savings by decreasing morbidity and the need for hospitalization?” asked Dr. Hedayati, who was not involved in this research.

The savings will have to come from somewhere, Dr. McFarlane said. In an interview with Medscape Nephrology, he cited more use of home dialysis and higher rates of transplantation as 2 possible ways of lowering the costs of conventional hemodialysis.

Still, society will be facing some tough questions. “Dialysis is already recognized as being not sustainable in many countries. If we make it more expensive, are we prepared at the societal level to bear those costs? That’s not at all apparent to me.”

Dr. MacFarlane and Dr. Hedayati have disclosed no relevant financial relationships.

Renal Week 2009: American Society of Nephrology (ASN) 2009 Annual Meeting: Abstract SA-FC347. Presented October 31, 2009.

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