Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Clin J Am Soc Nephrol. 2012 Jan;7(1):24-34. doi: 10.2215/CJN.07350711. Epub 2011 Nov 10.
This study aimed to determine whether opening a new clinic in a remote region would be a cost-effective means of improving care for remote-dwellers with CKD.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This study is a cost-utility analysis from a public payer's perspective over a lifetime horizon, using administrative data from a large cohort of adults with stage 3b-4 CKD in Alberta, Canada. The association between the distance from each simulated patient's residence and the practice location of the closest nephrologist and clinical outcomes (quality of care, hospitalization, dialysis, and death) were examined. A Markov 6-month cycle economic decision model was analyzed; estimates of the effect of a new clinic were based on the association between residence location, resource use, and outcomes. Costs are reported in 2009 Canadian dollars.
The costs for equipping and operating a clinic for 321 remote-dwelling patients were estimated at $25,000 and $250,000/yr, respectively. The incremental cost-utility ratios (ICURs) ranged from $4000 to $8000/quality-adjusted life-year under most scenarios. However, if reducing distance to nephrologist care does not alter mortality or hospitalization among remote-dwellers, the cost-effectiveness becomes less attractive. All other one-way sensitivity analyses had negligible effects on the ICUR.
Given the low costs of equipping and operating new clinics, and the very attractive ICUR relative to other currently funded interventions, establishing new clinics for remote-dwellers could play an important role in efficiently improving outcomes for patients with CKD. High-quality controlled studies are required to confirm this hypothesis.
本研究旨在确定在偏远地区开设新诊所是否能以具有成本效益的方式改善对居住在偏远地区的慢性肾脏病（CKD）患者的治疗。
设计、地点、参与者和测量方法：本研究从公共支付者的角度进行了一项终生成本-效用分析，使用了加拿大艾伯塔省一个大型成年 3b-4 期 CKD 队列的行政数据。研究考察了每个模拟患者居住地与最近肾病医生就诊地点之间的距离与临床结果（治疗质量、住院治疗、透析和死亡）之间的关联。采用 Markov 6 个月周期经济决策模型进行分析；对新诊所的效果估计基于居住地位置、资源利用和结果之间的关联。成本以 2009 年加元报告。
为 321 名居住在偏远地区的患者配备和运营诊所的成本估计分别为 25,000 加元和 250,000 加元/年。在大多数情况下，增量成本-效用比（ICUR）在每例质量调整生命年 4000 至 8000 加元之间。然而，如果减少与肾病医生的距离不能改变居住在偏远地区的患者的死亡率或住院率，那么成本效益就不那么有吸引力了。所有其他单项敏感性分析对 ICUR 的影响都可以忽略不计。
鉴于新诊所的设备和运营成本较低，以及与其他目前已资助的干预措施相比具有非常有吸引力的 ICUR，为居住在偏远地区的患者建立新诊所可以在提高 CKD 患者的治疗效果方面发挥重要作用。需要进行高质量的对照研究来证实这一假设。
