Rizk Rana, Hiligsmann Mickaël, Karavetian Mirey, Evers Silvia M A A
a Department of Health Services Research , CAPHRI, Care and Public Health Research Institute, Maastricht University , Maastricht , The Netherlands.
b Department of Health Sciences, College of Natural and Health Sciences , Zayed University , Dubai , United Arab Emirates.
J Med Econ. 2017 Oct;20(10):1024-1038. doi: 10.1080/13696998.2017.1347877. Epub 2017 Jul 13.
To assess the cost-effectiveness of nutrition education by dedicated dietitians (DD) for hyperphosphatemia management among hemodialysis patients.
This was a trial-based economic evaluation in 12 Lebanese hospital-based units. In total, 545 prevalent patients were cluster randomized to DD, trained hospital dietitian (THD), and existing practice (EP) groups. During Phase I (6 months), DD (n = 116) received intensive education by DD trained on renal nutrition, THD (n = 299) received care from trained hospital dietitians, and EP (n = 130) received usual care from untrained hospital dietitians. Patients were followed-up during Phase II (6 months).
At baseline, EP had the lowest weekly hemodialysis time, and DD had the highest serum phosphorus and malnutrition-inflammation score. The additional costs of the intervention were low compared with the societal costs (DD: $76.7, $21,007.7; EP: $4.6, $18,675.4; THD: $17.4, $20,078.6, respectively). Between Phases I and II, DD showed the greatest decline in services use and societal costs (DD: -$2,364.0; EP: -$1,727.7; THD: -$1,105.7). At endline, DD experienced the highest decrease in adjusted serum phosphorus (DD: -0.32; EP: +0.16; THD: +0.04 mg/dL), no difference in quality-adjusted life-years (QALY), and the highest societal costs. DD had a cost-effectiveness ratio of $7,853.6 per 1 mg decrease in phosphorus, compared with EP; and was dominated by THD. Regarding QALY, DD was dominated by EP and THD. The results were sensitive to changes in key parameters.
The analysis depended on numerous assumptions. Interpreting the results is limited by the significant baseline differences in key parameters, suggestive of higher baseline societal costs in DD.
DD yielded the greatest effectiveness and decrease in societal costs, but did not affect QALY. Regarding serum phosphorus, DD was likely to be cost-effective compared with EP, but had a low cost-effectiveness probability compared with THD. Regarding QALY, DD was not likely to be cost-effective. Assessing the long-term cost-effectiveness of DD, on similar groups, is recommended.
评估由专业营养师（DD）开展营养教育对血液透析患者高磷血症管理的成本效益。
这是一项在黎巴嫩12个医院科室进行的基于试验的经济评估。总共545例现患患者被整群随机分为专业营养师组、经过培训的医院营养师组（THD）和常规治疗组（EP）。在第一阶段（6个月），专业营养师组（n = 116）接受由接受过肾脏营养培训的专业营养师进行的强化教育，经过培训的医院营养师组（n = 299）接受经过培训的医院营养师的护理，常规治疗组（n = 130）接受未经培训的医院营养师的常规护理。在第二阶段（6个月）对患者进行随访。
基线时，常规治疗组每周血液透析时间最短，专业营养师组血清磷和营养不良 - 炎症评分最高。与社会成本相比，干预的额外成本较低（专业营养师组：76.7美元，21,007.7美元；常规治疗组：4.6美元，18,675.4美元；经过培训的医院营养师组：17.4美元，20,078.6美元）。在第一阶段和第二阶段之间，专业营养师组的服务使用和社会成本下降幅度最大（专业营养师组：-2,364.0美元；常规治疗组：-1,727.7美元；经过培训的医院营养师组：-1,105.7美元）。在研究结束时，专业营养师组调整后的血清磷下降幅度最大（专业营养师组：-0.32；常规治疗组：+0.16；经过培训的医院营养师组：+0.04mg/dL），质量调整生命年（QALY）无差异，社会成本最高。与常规治疗组相比，专业营养师组每降低1mg磷的成本效益比为7,853.6美元；且被经过培训的医院营养师组主导。关于QALY，专业营养师组被常规治疗组和经过培训的医院营养师组主导。结果对关键参数的变化敏感。
分析依赖于众多假设。由于关键参数存在显著的基线差异，这表明专业营养师组的基线社会成本较高，因此对结果的解释受到限制。
专业营养师组产生了最大的效果并降低了社会成本，但未影响QALY。关于血清磷，与常规治疗组相比，专业营养师组可能具有成本效益，但与经过培训的医院营养师组相比，其成本效益概率较低。关于QALY，专业营养师组不太可能具有成本效益。建议对相似群体评估专业营养师组的长期成本效益。
