MO800: A Systematic Literature Review on the Costs and Healthcare Resource Utilization Associated With Dialysis And Anemia Management by Dialysis Modality in Patients With End-Stage Kidney Disease

BACKGROUND AND AIMS

End-stage kidney disease (ESKD) is associated with a high clinical and economic burden. Dialysis modalities include in-center hemodialysis (ICHD) and home dialysis [home hemodialysis (HHD) or peritoneal dialysis (PD)]. The prevalence of anemia in ESKD is estimated to be > 50% and is associated with an increased risk of comorbidities and a lower quality of life [1]. Understanding the economic consequences of dialysis by modality of care, in the general ESKD population and the anemia-related ESKD population, is an essential aspect of the value of home dialysis. This study assessed the extent to which the economic burden of dialysis in ESKD and the management of anemia in ESKD have been characterized in the literature based on modality of care (HHD versus PD versus ICHD).

METHOD

A systematic literature review (SLR) was conducted to characterize costs and healthcare resource use (HCRU) in patients receiving ICHD, HHD or PD, and to further assess the impact of anemia. Data extracted included, but were not limited to, the cost of dialysis, hospitalizations, erythropoiesis-stimulating agents (ESAs) and other drug costs. Database searches were conducted in Embase, Medline, EconLit, Cochrane Library and University of York Center for Reviews and Dissemination (2011–21).

RESULTS

Searches identified 1105 records, of which 43 met the inclusion criteria (costs = 26, HCRU = 8, costs and HCRU = 9). Studies were conducted in Europe (n = 18), North America (n = 14), Asia (n = 7), Australia (n = 2), South America (n = 1) and mixed continents (n = 1). A total of 15 studies were observational/database analyses, and 28 were economic evaluations. Most studies compared costs, including direct (medical and pharmacy) and indirect, and/or HCRU for ICHD, HHD and PD (n = 22), while 11 compared ICHD and HHD and 10 compared ICHD and PD. A summary of results is reported in the Table 1. A total of 14 primary cost studies reported total dialysis costs and showed that ICHD was more expensive than HHD/PD per patient per year. A total of 16 economic models presented relevant outputs in the form of total dialysis costs. The majority of these (n = 13) reported that ICHD is more costly than HHD/PD, with 11 studies concluding that HHD/PD is cost-effective or even dominant compared with ICHD. HCRU was presented in 17 studies, with hospitalizations the most frequently reported (n = 12). Some studies reported that ICHD patients incurred more all-cause hospitalizations than HHD/PD patients, while others reported the opposite (especially for high-dose or frequent modalities). Four studies reported that patients receiving HHD/PD had more in-hospital days than ICHD. There was limited evidence for anemia-related outcomes, with only 11 studies showing either costs and/or HCRU relating to ESA or iron use (Table 1). Five studies reported that the use and dose of epoetin alfa or general ESAs were higher in ICHD patients than in HHD/PD patients (Fig. 1). Of these, one study reported the same trend for IV iron use but the opposite for darbepoetin alfa using baseline data. Four studies reported the same ESA costs for different modalities. An additional four studies reported a higher ESA cost for ICHD patients compared with HHD/PD, with three of the studies indicating that this is related to differences in dosage and use of ESAs. One economic evaluation modeled that ESA and iron costs were higher for HHD than ICHD, though not statistically significant (Table 1).

CONCLUSION

Most studies reported a higher total dialysis cost for ICHD compared with home dialysis, with evidence that home dialysis is cost-effective. There was a paucity of evidence characterizing anemia in ESKD. In this SLR, more ICHD patients used ESAs and at higher doses than HHD/PD patients, thus incurring a higher cost. Global interests highlight increasing home dialysis penetration; therefore, it is important to understand the cost differences and drivers of these differences in ESKD patients with anemia.

Comparison of antigen- and RT-PCR-based testing strategies for detection of SARS-CoV-2 in two high-exposure settings

Surveillance testing for infectious disease is an important tool to combat disease transmission at the population level. During the SARS-CoV-2 pandemic, RT-PCR tests have been considered the gold standard due to their high sensitivity and specificity. However, RT-PCR tests for SARS-CoV-2 have been shown to return positive results when performed to individuals who are past the infectious stage of the disease. Meanwhile, antigen-based tests are often treated as a less accurate substitute for RT-PCR, however, new evidence suggests they may better reflect infectiousness. Consequently, the two test types may each be most optimally deployed in different settings. Here, we present an epidemiological model with surveillance testing and coordinated isolation in two congregate living settings (a nursing home and a university dormitory system) that considers test metrics with respect to viral culture, a proxy for infectiousness. Simulations show that antigen-based surveillance testing coupled with isolation greatly reduces disease burden and carries a lower economic cost than RT-PCR-based strategies. Antigen and RT-PCR tests perform different functions toward the goal of reducing infectious disease burden and should be used accordingly.

Remote Monitoring of Automated Peritoneal Dialysis Patients: Assessing Clinical and Economic Value

BACKGROUND

For chronic kidney disease patients who progress to end-stage renal disease, survival is dependent on renal replacement therapy in the form of kidney transplantation or chronic dialysis. Peritoneal dialysis (PD), which can be performed at home, is both more convenient and less costly than hemodialysis that requires three 4-h visits per week to the dialysis facility and complicated equipment. Remote therapy management (RTM), technologies that collect medical information and transmit it to healthcare providers for patient management, has the potential to improve the outcomes of patients receiving automated peritoneal dialysis (APD) at home.

OBJECTIVE

Estimate through a simulation study the potential impact of RTM on APD patients use of healthcare resources and costs in the United States, Germany, and Italy.

METHODS

Twelve APD patient profiles were developed to reflect potential clinical scenarios of APD therapy. Two versions of each profile were created to simulate healthcare resource use, one assuming use of RTM and one with no RTM. Eleven APD teams (one nephrologist, one nurse) estimated resources that would be used.

RESULTS

Results from U.S., German, and Italian clinicians found that RTM could avoid use of 59, 49, and 16 resources over the 12 profiles, respectively. Estimated reduced utilization across the three countries ranged from one to two hospitalizations, one to four home visits, two to five emergency room visits, and four to eight unplanned clinic visits. Total savings across all scenarios were $23,364 in the United States, $11,477 in Germany, and $7,088 in Italy.

CONCLUSION

In a simulated environment, early intervention enabled by RTM reduced healthcare resource utilization and associated costs.

Cost-consequence analysis of different active flowable hemostatic matrices in cardiac surgical procedures

BACKGROUND

A recent retrospective comparative effectiveness study found that use of the FLOSEAL Hemostatic Matrix in cardiac surgery was associated with significantly lower risks of complications, blood transfusions, surgical revisions, and shorter length of surgery than use of SURGIFLO Hemostatic Matrix. These outcome improvements in cardiac surgery procedures may translate to economic savings for hospitals and payers.

OBJECTIVE

The objective of this study was to estimate the cost-consequence of two flowable hemostatic matrices (FLOSEAL or SURGIFLO) in cardiac surgeries for US hospitals.

METHODS

A cost-consequence model was constructed using clinical outcomes from a previously published retrospective comparative effectiveness study of FLOSEAL vs SURGIFLO in adult cardiac surgeries. The model accounted for the reported differences between these products in length of surgery, rates of major and minor complications, surgical revisions, and blood product transfusions. Costs were derived from Healthcare Cost and Utilization Project's National Inpatient Sample (NIS) 2012 database and converted to 2015 US dollars. Savings were modeled for a hospital performing 245 cardiac surgeries annually, as identified as the average for hospitals in the NIS dataset. One-way sensitivity analysis and probabilistic sensitivity analysis were performed to test model robustness.

RESULTS

The results suggest that if FLOSEAL is utilized in a hospital that performs 245 mixed cardiac surgery procedures annually, 11 major complications, 31 minor complications, nine surgical revisions, 79 blood product transfusions, and 260.3 h of cumulative operating time could be avoided. These improved outcomes correspond to a net annualized saving of $1,532,896. Cost savings remained consistent between $1.3m and $1.8m and between $911k and $2.4m, even after accounting for the uncertainty around clinical and cost inputs, in a one-way and probabilistic sensitivity analysis, respectively.

CONCLUSIONS

Outcome differences associated with FLOSEAL vs SURGIFLO that were previously reported in a comparative effectiveness study may result in substantial cost savings for US hospitals.

Cost-consequence analysis of two different active flowable hemostatic matrices in spine surgery patients

OBJECTIVES

A recently published retrospective analysis comparing two different active flowable hemostatic matrices (FLOSEAL and SURGIFLO Kit with Thrombin) showed significantly increased resource use and complications (surgery time, risk of blood product transfusion, and amount of matrix used) with SURGIFLO use compared to FLOSEAL in major spine surgery, and also significantly increased surgical time with SURGIFLO use in severe spine surgery. This analysis was developed as a follow-up to this prior analysis, to evaluate the cost-consequence of using FLOSEAL vs SURGIFLO in major and severe spine surgery.

METHODS

A cost consequence model was constructed from a US hospital provider perspective. Model parameters combined clinical inputs from the published retrospective analysis with supplemental analyses on annual spine surgery volume using the 2012 National Inpatient Sample (NIS) database. Cost of hemostatic matrices, blood product transfusion, and operating room time were identified from published literature. Various one-way and probabilistic sensitivity analyses were performed.

RESULTS

The base case for a medium volume hospital showed that, compared to SURGIFLO, patients receiving FLOSEAL required three fewer blood product transfusions and saved 27 h of OR time, resulting in annual savings of $151 per major and $574 per severe spine surgery. Additional scenarios for high and low volume hospitals supported cost savings in the base case. Probabilistic sensitivity analysis revealed FLOSEAL was cost-saving in 76% of simulations in major spine and 97% of iterations in severe spine surgery.

CONCLUSIONS

This economic analysis indicates that use of FLOSEAL instead of SURGIFLO hemostatic matrices to induce hemostasis in both major and severe spine surgery could potentially lead to sizable cost savings in US hospitals, regardless of spinal surgery case-mix.

Cost-effectiveness of Chloride-liberal versus Chloriderestrictive Intravenous Fluids among Patients Hospitalized in the United States

Background: Patients developing acute kidney injury (AKI) during critical illness or major surgery are at risk for renal sequelae such as costly and invasive acute renal replacement therapy (RRT) and chronic dialysis (CD). Rates of renal injury may be reduced with use of chloride-restrictive intravenous (IV) resuscitation fluids instead of chloride-liberal fluids. Objectives: To compare the cost-effectiveness of chloride-restrictive versus chloride-liberal crystalloid fluids used during fluid resuscitation or for the maintenance of hydration among patients hospitalized in the US for critical illnesses or major surgery. Methods: Clinical outcomes and costs for a simulated patient cohort (starting age 60 years) receiving either chloride-restrictive or chloride-liberal crystalloids were estimated using a decision tree for the first 90-day period after IV fluid initiation followed by a Markov model over the remainder of the cohort lifespan. Outcomes modeled in the decision tree were AKI development, recovery from AKI, progression to acute RRT, progression to CD, and death. Health states included in the Markov model were dialysis free without prior AKI, dialysis-free following AKI, CD, and death. Estimates of clinical parameters were taken from a recent meta-analysis, other published studies, and the US Renal Data System. Direct healthcare costs (in 2015 USD) were included for IV fluids, RRT, and CD. US-normalized health-state utilities were used to calculate quality-adjusted life years (QALYs). Results: In the cohort of 100 patients, AKI was predicted to develop in the first 90 days in 36 patients receiving chloride-liberal crystalloids versus 22 receiving chloride-restrictive crystalloids. Higher costs of chloride-restrictive crystalloids were offset by savings from avoided renal adverse events. Chloride-liberal crystalloids were dominant over chloride-restrictive crystalloids, gaining 93.5 life-years and 81.4 QALYs while saving $298 576 over the cohort lifespan. One-way sensitivity analyses indicated results were most sensitive to the relative risk for AKI development and relatively insensitive to fluid cost. In probabilistic sensitivity analyses with 1000 iterations, chloride-restrictive crystalloids were dominant in 94.7% of iterations, with incremental cost-effectiveness ratios below $50 000/QALY in 99.6%. Conclusions: This analysis predicts improved patient survival and fewer renal complications with chloriderestrictive IV fluids, yielding net savings versus chloride-liberal fluids. Results require confirmation in adequately powered head-to-head randomized trials.

Stearylated cycloarginine nanosystems for intracellular delivery – simulations, formulation and proof of concept

Novel cationic agent liposomes performed better in silico translating in higher cellular uptake with reduced toxicity.