BAP LA-SER Outcomes, LA-SER Group, Azcárraga, Oviedo, Asturias, Spain.
BMC Health Serv Res. 2012 Aug 16;12:257. doi: 10.1186/1472-6963-12-257.
A cost-effectiveness analysis of timely dialysis referral after renal transplant failure was undertaken from the perspective of the Public Administration. The current Spanish situation, where all the patients undergoing graft function loss are referred back to dialysis in a late manner, was compared to an ideal scenario where all the patients are timely referred.
A Markov model was developed in which six health states were defined: hemodialysis, peritoneal dialysis, kidney transplantation, late referral hemodialysis, late referral peritoneal dialysis and death. The model carried out a simulation of the progression of renal disease for a hypothetical cohort of 1,000 patients aged 40, who were observed in a lifetime temporal horizon of 45 years. In depth sensitivity analyses were performed in order to ensure the robustness of the results obtained.
Considering a discount rate of 3 %, timely referral showed an incremental cost of 211 €, compared to late referral. This cost increase was however a consequence of the incremental survival observed. The incremental effectiveness was 0.0087 quality-adjusted life years (QALY). When comparing both scenarios, an incremental cost-effectiveness ratio of 24,390 €/QALY was obtained, meaning that timely dialysis referral might be an efficient alternative if a willingness-to-pay threshold of 45,000 €/QALY is considered. This result proved to be independent of the proportion of late referral patients observed. The acceptance probability of timely referral was 61.90 %, while late referral was acceptable in 38.10 % of the simulations. If we however restrict the analysis to those situations not involving any loss of effectiveness, the acceptance probability of timely referral was 70.10 %, increasing twofold that of late referral (29.90 %).
Timely dialysis referral after graft function loss might be an efficient alternative in Spain, improving both patients' survival rates and health-related quality of life at an affordable cost. Spanish Public Health authorities might therefore promote the inclusion of specific recommendations for this group of patients within the existing clinical guidelines.
本研究从公共行政角度出发，对肾移植失败后及时透析转归的成本效益进行了分析。将当前西班牙所有移植肾功能丧失患者均延迟至透析的现状与所有患者均及时转归的理想情况进行了对比。
建立了一个马尔可夫模型，该模型共定义了 6 种健康状态：血液透析、腹膜透析、肾移植、晚期透析转归血液透析、晚期透析转归腹膜透析和死亡。模型对一组 1000 名年龄为 40 岁的假想患者队列的肾病进展情况进行了模拟，观察时间为 45 年。为确保结果稳健，进行了深入的敏感性分析。
考虑到 3%的贴现率，与晚期透析转归相比，及时透析转归的增量成本为 211 欧元。但这一成本增加是由于观察到的生存获益增加所致。增量有效性为 0.0087 质量调整生命年（QALY）。在比较两种方案时，得到了每 QALY 24390 欧元的增量成本效益比，这意味着如果将意愿支付阈值设定为 45000 欧元/QALY，及时透析转归可能是一种有效的替代方案。该结果独立于观察到的晚期透析转归患者的比例。及时透析转归的接受概率为 61.90%，而晚期透析转归的接受概率为 38.10%。但如果我们将分析仅限于不涉及任何有效性损失的情况，那么及时透析转归的接受概率将增加至 70.10%，是晚期透析转归（29.90%）的两倍。
在西班牙，移植肾功能丧失后及时透析转归可能是一种有效的替代方案，既可以提高患者的生存率，又可以提高患者的健康相关生活质量，而且成本也可负担。因此，西班牙公共卫生部门可能会推动在现有的临床指南中为这组患者纳入具体的建议。
