Desai Amar A, Baras Jacqueline, Berk Benjamin B, Nakajima Aya, Garber Alan M, Owens Douglas, Chertow Glenn M
Division of Nephrology, Stanford University School of Medicine, 780 Welch Rd, Ste 106, Palo Alto, California 94304, USA.
Arch Intern Med. 2008 Sep 8;168(16):1761-7. doi: 10.1001/archinte.168.16.1761.
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.
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).
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%.
Daily hemodialysis is a cost-effective strategy compared with alternate-day hemodialysis for patients with severe AKI in the ICU.
尽管有证据表明较高的血液透析剂量和/或频率可能与改善预后相关，但对于急性肾损伤（AKI）危重症患者采用每日血液透析策略的成本效益尚不清楚。
我们建立了一个马尔可夫模型，用于评估重症监护病房（ICU）中AKI患者每日血液透析与隔日血液透析的成本、生活质量、生存率及增量成本效益。我们采用社会视角，分析时间范围为终身。基于Schiffl等人2004年发表的临床试验报告的数据，我们将每日血液透析的疗效建模为死亡相对风险的降低。我们对成本、疗效和效用输入变量进行了单因素和双因素敏感性分析。主要结局指标是每质量调整生命年（QALY）的成本。
在一名60岁男性的基础病例中，预计每日血液透析可增加2.14个QALY，成本增加10,924美元。我们发现，与隔日血液透析相比，每日血液透析的成本效益为每获得一个QALY 5084美元。当每日血液透析组的维持血液透析率变化超过27%，以及两种方案出院后14天死亡率差异变化小于0.5%时，增量成本效益比变得更不理想（每获得一个QALY>50,000美元）。
对于ICU中患有严重AKI的患者，与隔日血液透析相比，每日血液透析是一种具有成本效益的策略。
