Cost-effective care of end-stage renal disease: a billion dollar question.

We examined the survival time and costs of therapy for patients with end-stage renal disease. A computer simulation model of the current system was constructed to estimate the cost-effectiveness of home and center hemodialysis and live related as well as cadaver donor renal transplantation. Analysis of the simulation showed that live related donor transplantation was the least costly and had the greatest survival time, while center hemodialysis had the poorest cost-effectiveness. By simulating changes to the present system of care, we found that shifts from center dialysis to either home dialysis or cadaver donor transplantation would save $7000 to $8000 per life year, or $284 million per year for the existing end-stage renal disease population. However, if legislative changes fail to produce real shifts from center hemodialysis, costs will increase. We conclude that the substantial costs for end-stage renal disease can be contained by shifting from the widespread use of center hemodialysis.