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Cha-Silva AS, Gavaghan MB, Bergroth T, Alexander-Parrish R, Yang J, Draica F, Patel J, Garner DA, Stanford RH, Meier G, McLaughlin JM, Nguyen JL. Effectiveness of Nirmatrelvir-Ritonavir for the Prevention of COVID-19-Related Hospitalization and Mortality: A Systematic Literature Review. Am J Ther 2024; 31:e246-e257. [PMID: 38691664 PMCID: PMC11060058 DOI: 10.1097/mjt.0000000000001744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
BACKGROUND Nirmatrelvir/ritonavir (NMV/r) is an oral antiviral drug used to treat mild-to-moderate coronavirus disease 2019 (COVID-19) in patients aged 12 years or older at high risk of progression to severe disease (eg, hospitalization and death). Despite being the preferred option for outpatient treatment in the majority of countries worldwide, NMV/r is currently underutilized in real-world clinical practice. AREAS OF UNCERTAINTY As numerous real-world studies have described patient outcomes following treatment with NMV/r, this systematic literature review provides a comprehensive summary of evidence on NMV/r effectiveness against hospitalization and mortality further organized by clinically meaningful categories, such as acute versus longer-term follow-up, age, underlying health conditions, and vaccination status, to help inform health care decision making. DATA SOURCES We searched Embase and PubMed (December 22, 2021-March 31, 2023) and congress abstracts (December 1, 2021-December 31, 2022) for reports describing NMV/r effectiveness. THERAPEUTIC ADVANCES In total, 18 real-world studies met final selection criteria. The evidence showed that NMV/r significantly reduced postinfection risk of all-cause and COVID-19-related hospitalization and mortality in both acute (≤30 days) (21%-92%) and longer-term (>30 days) (1%-61%) follow-up. The reduction in postinfection risk was higher when treatment was received within 5 days of symptom onset. Real-world effectiveness of NMV/r treatment was observed regardless of age, underlying high-risk conditions, and vaccination status. CONCLUSION The systematic literature review findings demonstrated the effectiveness of NMV/r against hospitalization and mortality during the Omicron period among individuals at high risk of progression to severe COVID-19 disease.
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Affiliation(s)
| | | | | | | | - Jingyan Yang
- Pfizer, New York, NY
- Institute for Social and Economic Research and Policy, Columbia University, New York, NY; and
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Reddy VY, Zhong Y, McGovern AM, Amorosi SL, Gavaghan MB, Hertz DS, Low K, Freeman S, Holmes Jr DR. Comparative Costs to Medicare and Medicare Beneficiaries of Alternative AF Stroke Risk Reduction Strategies. Clinicoecon Outcomes Res 2024; 16:81-96. [PMID: 38374959 PMCID: PMC10875168 DOI: 10.2147/ceor.s440556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 11/28/2023] [Indexed: 02/21/2024] Open
Abstract
Background As healthcare costs are increasingly being shifted from payers to patients, it is important to understand the economic consequences of therapeutic strategies to both payers and patients. Objective To determine the relative costs to Medicare and Medicare beneficiaries (patients) of warfarin, non-vitamin K oral anticoagulants (NOACs), and left atrial appendage closure (LAAC) for stroke risk reduction in nonvalvular atrial fibrillation. Methods An economic model was developed to assess costs at 5 and 10 years. For warfarin and NOACs, inputs were derived from published meta-analyses; for LAAC with the Watchman device, inputs were derived from pooled 5-year PROTECT AF and PREVAIL trial results. The model captured therapy costs vs clinical event costs, including procedural complications and follow-up clinical outcomes. Costs were based on 2023 Medicare reimbursement and copayment rates. Results At 10 years, overall LAAC costs ($48,337) were lower than those of NOACs ($81,198) and warfarin ($52,359). Overall LAAC costs were lower than those of NOACs by year 5 and warfarin by year 9. At 5 years, patient LAAC costs were lowest at $4,764, compared to $7,146 and $6,453 for NOACs and warfarin, respectively. LAAC patient costs were lower than those of NOACs by year 3 and warfarin by year 4. Clinical events comprised 96% of overall warfarin costs vs 48% for LAAC and 40% for NOACs. Conclusion LAAC yielded the lowest overall and patient costs. Warfarin costs were largely driven by clinical events, which may represent an unplanned financial burden for patients. These considerations should be incorporated into shared decision-making discussions about stroke prophylaxis strategies.
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Affiliation(s)
- Vivek Y Reddy
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yue Zhong
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Alysha M McGovern
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Stacey L Amorosi
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, USA
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Kamae I, Zhong Y, Hara H, Inoue K, Yasaka M, Reddy VY, Holmes DR, Sakurai M, Gavaghan MB, Amorosi SL, McGovern AM, Priest V, Inoue S, Shibahara H, Akehurst RL. Cost-effectiveness of left atrial appendage closure with Watchman for non-valvular atrial fibrillation patients in Japan. J Med Econ 2023; 26:1357-1367. [PMID: 37819734 DOI: 10.1080/13696998.2023.2266275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023]
Abstract
AIMS Left atrial appendage closure (LAAC) has been demonstrated to be cost-saving relative to oral anticoagulants for stroke prophylaxis in patients with non-valvular atrial fibrillation (NVAF) in the United States and Europe. This study assessed the cost-effectiveness of LAAC with the Watchman device relative to warfarin and direct oral anticoagulants (DOACs) for stroke risk reduction in NVAF from a Japanese public healthcare payer perspective. METHODS A Markov model was developed with 70-year-old patients using a lifetime time horizon. LAAC clinical inputs were from pooled, 5-year PROTECT AF and PREVAIL trials; warfarin and DOAC inputs were from published meta-analyses. Baseline stroke and bleeding risks were from the SALUTE trial on LAAC. Cost inputs were from the Japanese Medical Data Vision database. Probabilistic and one-way sensitivity analyses were performed. RESULTS Over the lifetime time horizon, LAAC was less costly than warfarin (savings of JPY 1,878,335, equivalent to US $17,600) and DOACs (savings of JPY 1,198,096, equivalent to US $11,226). LAAC also provided 1.500 more incremental quality-adjusted life years (QALYs) than warfarin and 0.996 more than DOACs. In probabilistic sensitivity analysis, LAAC was cost-effective relative to warfarin and DOACs in 99.98% and 99.73% of simulations, respectively. LAAC dominated (had higher cumulative QALYs and was less costly than) warfarin and DOACs in 89.94% and 83.35% of simulations, respectively. CONCLUSIONS Over a lifetime time horizon, LAAC is cost-saving relative to warfarin and DOACs for stroke risk reduction in NVAF patients in Japan and is associated with improved quality-of-life.
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Affiliation(s)
- Isao Kamae
- Graduate School of Public Policy, University of Tokyo, Tokyo, Japan
| | - Yue Zhong
- Heath Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Hidehiko Hara
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Koichi Inoue
- Cardiovascular Division, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Vivek Y Reddy
- Icahn School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Stacey L Amorosi
- Heath Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Alysha M McGovern
- Heath Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Virginia Priest
- Health Economics and Market Access, Boston Scientific Asia Pacific, Singapore
| | | | | | - Ronald L Akehurst
- BresMed Health Solutions, Sheffield, UK
- University of Sheffield, Sheffield, UK
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Shore ND, Gavaghan MB. Clinical and economic impact of blue light cystoscopy in the management of NMIBC at US ambulatory surgical centers: what is the site-of-service disparity? Urol Oncol 2022; 41:207.e9-207.e16. [PMID: 36564259 DOI: 10.1016/j.urolonc.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 11/03/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION AND OBJECTIVE Management of non-muscle-invasive bladder cancer (NMIBC) significantly impacts healthcare resource utilization due to requirements for ongoing surveillance. White light cystoscopy (WLC) represents the traditional approach to NMIBC disease surveillance, though physicians utilizing WLC alone may fail to detect all cancerous lesions. The approval of blue light cystoscopy (BLC) as an adjunct to WLC enhances the urologist's ability to more readily detect cancerous tissue. A more complete resection will reduce recurrences and could result in reduced costs for the US healthcare system. This analysis quantifies the clinical and economic impact of the incorporation of BLC in the management of NMIBC in ambulatory surgical centers (ASCs) considering current Center for Medicare Services (CMS) patient-physician coverage and reimbursement. METHODS AND MATERIALS A budget impact model was developed to assess projected ASC costs for a cohort of 50 newly diagnosed bladder cancer patients over a 2-year follow-up comparing WLC alone vs. WLC + BLC. Treatment and surveillance intervals were based on AUA/SUO clinical guidelines. Clinical and cost metrics for staging and biopsy rates were assessed, with cost inputs based on Medicare reimbursement rates. RESULTS Use of WLC + BLC for NMIBC surveillance resulted in the identification of 5 additional NMIBC recurrences compared to WLC alone. There was an associated increased cost of performing BLC in an ASC setting, with a net increase in the total cost of care for NMIBC of $110 per cystoscopy over a 2-year period. If recurrences missed using WLC alone were to progress prior to detection, the model projects an increase in treatment costs borne by Medicare of $9,097 to $34,538 due to more intensive treatments required for the increased risk of recurrence. CONCLUSIONS Modeled results suggests that the Medicare program will incur increased costs, due to the gap between added costs per cystoscopy due to BLC. The current discrepancy in reimbursement disincentivizes community-based ASCs from adopting BLC, resulting in suboptimal patient care while increasing downstream treatment costs to Medicare, necessitated when missed disease progresses to higher stage/grade disease. The findings have important clinical implications for the optimal management of NMIBC and should inform healthcare policies that promote cost-effectiveness and enhanced patient outcomes.
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Affiliation(s)
- Neal D Shore
- Carolina Urologic Research Center, Myrtle Beach, SC.
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Williams SB, Gavaghan MB, Fernandez A, Daneshmand S, Kamat AM. Macro and microeconomics of blue light cystoscopy with CYSVIEW® in non-muscle invasive bladder cancer. Urol Oncol 2021; 40:10.e7-10.e12. [PMID: 34158205 DOI: 10.1016/j.urolonc.2021.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/14/2021] [Accepted: 05/20/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the estimated budget impact to practices that incorporate blue light cystoscopy (BLC) with hexaminolevulinate HCl (HAL) for the surveillance of non-muscle-invasive bladder cancer (NMIBC) in the clinic setting. With the introduction of advanced technologies in the clinic setting such as HAL, further cost comparative research is needed to justify HAL as a high value option. MATERIAL AND METHODS A budget impact model was developed from the facility perspective assessing projected costs at 2 years for a simulated facility with 50 newly diagnosed bladder cancer patients. Treatment and surveillance cystoscopy intervals were based on clinical guidelines. Clinical inputs, including tumor stage and grade at diagnosis, rates of recurrence and relative risk reduction when using BLC with HAL, were derived from published studies. Cost inputs were based on Medicare reimbursement rates and facility costs. RESULTS Use of BLC identified 9 additional recurrences over two years compared to white light cystoscopy alone. Use of flexible BLC for surveillance marginally increased costs to the practice, with a net difference of $0.76 per cystoscopy over 2 years. CONCLUSIONS From the office/clinic perspective, the model suggests that the use of flexible BLC for the surveillance of NMIBC may not impact cost per cystoscopy and identifies 9 recurrences over 2 years that would be missed using white light cystoscopy alone. These findings could have important implications in the management of NIMBC and help guide clinical practice guidelines that promote cost-effective care and improved patient outcomes.
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Affiliation(s)
- Stephen B Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Division of Urology, Galveston, TX.
| | | | | | - Siamak Daneshmand
- Department of Urology, University of Southern California, Urology and GU Oncology Los Angeles, Los Angeles, CA
| | - Ashish M Kamat
- Department of Urology, MD Anderson Cancer Center, Houston, TX
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Reddy VY, Akehurst RL, Gavaghan MB, Amorosi SL, Holmes DR. Cost-Effectiveness of Left Atrial Appendage Closure for Stroke Reduction in Atrial Fibrillation: Analysis of Pooled, 5-Year, Long-Term Data. J Am Heart Assoc 2019; 8:e011577. [PMID: 31230500 PMCID: PMC6662368 DOI: 10.1161/jaha.118.011577] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background Recent publications reached conflicting conclusions about the cost‐effectiveness of left atrial appendage closure (LAAC) with the Watchman device (Boston Scientific, Marlborough, MA) for stroke risk reduction in nonvalvular atrial fibrillation (AF). This analysis sought to assess the cost‐effectiveness of LAAC relative to both warfarin and nonwarfarin oral anticoagulants (NOACs) using pooled, long‐term data from the randomized PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) and PREVAIL (Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long‐Term Warfarin) trials. Methods and Results A Markov model was constructed from a US payer perspective with a lifetime (20‐year) horizon. LAAC clinical event rates and stroke outcomes were from pooled PROTECT AF and PREVAIL trial 5‐year data. Warfarin and NOAC inputs were derived from published meta‐analyses. The model was populated with a cohort of 10 000 patients, aged 70 years, at moderate stroke and bleeding risk. Sensitivity analyses were performed. LAAC was cost‐effective relative to warfarin by year 7 ($48 674/quality‐adjusted life‐year) and dominant (more effective and less costly) by year 10. LAAC became cost‐effective and dominant compared with NOACs by year 5. Over a lifetime, LAAC provided 0.60 more quality‐adjusted life‐years than warfarin and 0.29 more than NOACs. In sensitivity analyses, LAAC was cost‐effective relative to warfarin and NOACs in 98% and 95% of simulations, respectively. Conclusions Using pooled, 5‐year PROTECT AF and PREVAIL trial data, LAAC proved to be not only cost‐effective, but cost saving relative to warfarin and NOACs. LAAC with the Watchman device is an economically viable stroke risk reduction strategy for patients with AF seeking an alternative to lifelong anticoagulation.
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Affiliation(s)
- Vivek Y Reddy
- 1 Icahn School of Medicine at Mount Sinai New York NY
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Reddy VY, Akehurst RL, Amorosi SL, Gavaghan MB, Hertz DS, Holmes DR. Cost-Effectiveness of Left Atrial Appendage Closure With the WATCHMAN Device Compared With Warfarin or Non-Vitamin K Antagonist Oral Anticoagulants for Secondary Prevention in Nonvalvular Atrial Fibrillation. Stroke 2018; 49:1464-1470. [PMID: 29739915 PMCID: PMC5976225 DOI: 10.1161/strokeaha.117.018825] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 02/01/2018] [Accepted: 02/15/2018] [Indexed: 12/13/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Once a patient with atrial fibrillation experiences an embolic event, the risk of a recurrent event increases 2.6-fold. New treatments have emerged as viable treatment alternatives to warfarin for stroke risk reduction in secondary prevention populations. This analysis sought to assess the cost-effectiveness of left atrial appendage closure (LAAC) compared with warfarin and the non–vitamin K antagonist oral anticoagulants dabigatran 150 mg, apixaban and rivaroxaban in the prevention of stroke in nonvalvular atrial fibrillation patients with a prior stroke or transient ischemic attack. Methods— A Markov model was constructed using data from the secondary prevention subgroup analyses of the non–vitamin K antagonist oral anticoagulant and LAAC pivotal trials. Costs were from 2016 US Medicare reimbursement rates and the literature. The cost-effectiveness analysis was conducted from a US Medicare perspective over a lifetime (20 years) horizon. The model was populated with a cohort of 10 000 patients aged 70 years with a CHA2DS2-VASc score of 7 (annual stroke risk=9.60%) and HAS-BLED score of 3 (annual bleeding risk=3.74%). Results— LAAC achieved cost-effectiveness relative to dabigatran at year 5 and warfarin and apixaban at year 6. At 10 years, LAAC had more quality-adjusted life years (4.986 versus 4.769, 4.869, 4.888, and 4.810) and lower costs ($42 616 versus $53 770, $58 774, $55 656, and $58 655) than warfarin, dabigatran, apixaban, and rivaroxaban, respectively, making LAAC the dominant (more effective and less costly) stroke risk reduction strategy. LAAC remained the dominant strategy over the lifetime analysis. Conclusions— Upfront procedure costs initially make LAAC higher cost than warfarin and the non–vitamin K antagonist oral anticoagulants, but within 10 years, LAAC delivers more quality-adjusted life years and has lower total costs, making LAAC the most cost-effective treatment strategy for secondary prevention of stroke in atrial fibrillation.
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Affiliation(s)
- Vivek Y Reddy
- From the Icahn School of Medicine at Mount Sinai Medical Center, New York, NY (V.Y.R.)
| | - Ronald L Akehurst
- BresMed, Sheffield, United Kingdom (R.L.A.).,School of Health and Related Research, University of Sheffield, United Kingdom (R.L.A.)
| | - Stacey L Amorosi
- Health Economics Center of Excellence, Boston Scientific, Marlborough, MA (S.L.A.)
| | | | | | - David R Holmes
- Cardiovascular Medicine, Mayo Clinic, Rochester, MN (D.R.H.)
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Garfield SS, Gavaghan MB, Armstrong SO, Jones JS. The cost-effectiveness of blue light cystoscopy in bladder cancer detection: United States projections based on clinical data showing 4.5 years of follow up after a single hexaminolevulinate hydrochloride instillation. Can J Urol 2013; 20:6682-6689. [PMID: 23587507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Several studies, including the recently published phase III study by Stenzl and colleagues have demonstrated that hexaminolevulinate hydrochloride, when used with blue light fluorescence cystoscopy, improves detection of non-muscle invasive bladder tumors compared to white light cystoscopy and transurethral resection of bladder tumors (TURB) alone. MATERIALS AND METHODS The objective of this study was to conduct a detailed assessment of the cost-effectiveness of using hexaminolevulinate hydrochloride with blue light cystoscopy as an adjunct to white light versus white light cystoscopy alone at time of initial TURB in the United States. A probabilistic decision tree model, using TreeAge Pro 2011 software, was developed using base case scenario cost and utility estimates. RESULTS Incorporation of hexaminolevulinate hydrochloride into diagnostic cystoscopy results in lower costs over 5 years ($25,921) as compared to those patients who initially receive white light cystoscopy ($30,581). Those patients who initially receive hexaminolevulinate hydrochloride blue light TURB also experience a lower overall cancer burden. CONCLUSIONS Hexaminolevulinate hydrochloride may be cost effective when used at first TURB for patients with suspected new or recurrent non-muscle invasive bladder cancer.
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Komenda P, Gavaghan MB, Garfield SS, Poret AW, Sood MM. An economic assessment model for in-center, conventional home, and more frequent home hemodialysis. Kidney Int 2011; 81:307-13. [PMID: 21993583 PMCID: PMC3258566 DOI: 10.1038/ki.2011.338] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
More intensive and/or frequent hemodialysis may provide clinical benefits to patients with end-stage renal disease; however, these dialysis treatments are more convenient to the patients if provided in their homes. Here we created a standardized model, based on a systematic review of available costing literature, to determine the economic viability of providing hemodialysis in the home that arrays costs and common approaches for assessing direct medical and nonmedical costs. Our model was based on data from Australia, Canada, and the United Kingdom. The first year start-up costs for all hemodialysis modalities were higher than in subsequent years with modeled costs for conventional home hemodialysis lower than in-center hemodialysis in subsequent years. Modeled costs for frequent home hemodialysis was higher than both in-center and conventional home hemodialysis in the United Kingdom, but lower than in-center hemodialysis and higher than conventional home hemodialysis in Australia and Canada in subsequent years. The higher costs of frequent compared to conventional home hemodialysis were because of higher consumable usage due to dialysis frequency. Thus, our findings reinforce the conclusions of previous studies showing that home-based conventional and more frequent hemodialysis may provide clinical benefit at reasonable costs.
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Affiliation(s)
- Paul Komenda
- Department of Medicine, Section of Nephrology, University of Manitoba, Manitoba Renal Program, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada.
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