Ethgen Olivier, Schneider Antoine G, Bagshaw Sean M, Bellomo Rinaldo, Kellum John A
Economic Evaluation of Medical Innovation Research Unit, Department of Public Health Sciences, Faculty of Medicine, University of Liège, Liège, Belgium.
Division of Critical Care Medicine, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland.
Nephrol Dial Transplant. 2015 Jan;30(1):54-61. doi: 10.1093/ndt/gfu314. Epub 2014 Oct 17.
The obective of this study was to perform a cost-effectiveness analysis comparing intermittent with continuous renal replacement therapy (IRRT versus CRRT) as initial therapy for acute kidney injury (AKI) in the intensive care unit (ICU).
Assuming some patients would potentially be eligible for either modality, we modeled life year gained, the quality-adjusted life years (QALYs) and healthcare costs for a cohort of 1000 IRRT patients and a cohort of 1000 CRRT patients. We used a 1-year, 5-year and a lifetime horizon. A Markov model with two health states for AKI survivors was designed: dialysis dependence and dialysis independence. We applied Weibull regression from published estimates to fit survival curves for CRRT and IRRT patients and to fit the proportion of dialysis dependence among CRRT and IRRT survivors. We then applied a risk ratio reported in a large retrospective cohort study to the fitted CRRT estimates in order to determine the proportion of dialysis dependence for IRRT survivors. We conducted sensitivity analyses based on a range of differences for daily implementation cost between CRRT and IRRT (base case: CRRT day $632 more expensive than IRRT day; range from $200 to $1000) and a range of risk ratios for dialysis dependence for CRRT as compared with IRRT (from 0.65 to 0.95; base case: 0.80).
Continuous renal replacement therapy was associated with a marginally greater gain in QALY as compared with IRRT (1.093 versus 1.078). Despite higher upfront costs for CRRT in the ICU ($4046 for CRRT versus $1423 for IRRT in average), the 5-year total cost including the cost of dialysis dependence was lower for CRRT ($37 780 for CRRT versus $39 448 for IRRT on average). The base case incremental cost-effectiveness analysis showed that CRRT dominated IRRT. This dominance was confirmed by extensive sensitivity analysis.
Initial CRRT is cost-effective compared with initial IRRT by reducing the rate of long-term dialysis dependence among critically ill AKI survivors.
本研究的目的是进行一项成本效益分析，比较间歇性与连续性肾脏替代疗法（IRRT与CRRT）作为重症监护病房（ICU）中急性肾损伤（AKI）初始治疗方法的效果。
假设部分患者可能适合两种治疗方式中的任何一种，我们对1000例接受IRRT治疗的患者队列和1000例接受CRRT治疗的患者队列的生命年增益、质量调整生命年（QALY）和医疗成本进行了建模。我们采用了1年、5年和终身的时间范围。设计了一个针对AKI幸存者的具有两种健康状态的马尔可夫模型：透析依赖和非透析依赖。我们应用已发表估计值中的威布尔回归来拟合CRRT和IRRT患者的生存曲线，并拟合CRRT和IRRT幸存者中透析依赖的比例。然后，我们将一项大型回顾性队列研究报告的风险比应用于拟合的CRRT估计值，以确定IRRT幸存者中透析依赖的比例。我们基于CRRT和IRRT每日实施成本的一系列差异（基础情况：CRRT每天比IRRT贵632美元；范围为200美元至1000美元）以及CRRT与IRRT相比透析依赖的一系列风险比（范围为0.65至0.95；基础情况：0.80）进行了敏感性分析。
与IRRT相比，连续性肾脏替代疗法的QALY增益略高（分别为1.093和1.078）。尽管ICU中CRRT的前期成本较高（CRRT平均为4046美元，IRRT平均为1423美元），但包括透析依赖成本在内的5年总成本CRRT较低（CRRT平均为37780美元，IRRT平均为39448美元）。基础情况的增量成本效益分析表明CRRT优于IRRT。广泛的敏感性分析证实了这种优势。
与初始IRRT相比，初始CRRT具有成本效益，因为它降低了重症AKI幸存者长期透析依赖的发生率。
