How effective is cost effectiveness for dialysis patients?

Alexandros Mallios

Attendees at the 2023 Charing Cross (CX) Symposium (25–27 April, London, UK) renal interventions session were treated to two presentations exploring the issue of cost effectiveness in renal care—and whether it should take priority over outcomes. In the corner of cost effectiveness was Jeremy Crane (Hammersmith Hospital, London, UK), but before him came Alexandros Mallios (Hôpital Paris Saint-Joseph, Paris, France), who insisted that outcomes should come first.

Mallios began by opining that, in an ideal world, the question of whether outcomes should be the priority would demand only a very short presentation—one in which he simply answered “yes”. He then posed another question: how are the best outcomes defined? For the government, he suggested, the best outcome might be the cheapest, while for the nephrologist it might be the one that gets him safely back to his office without a call from the nurse that there’s a problem. Surgeons might have their own definitions, too—but what about the patient?

Having presented all of these options, Mallios then questioned why there should be a conflict between outcomes and cost effectiveness. He stated: “Best results and cost effectiveness can be compatible as long as the system provides incentives and rewards the right kind of care—although in most countries it does not currently do so”.

Offering a hypothetical in which a surgeon follows guidelines and creates a non-dominant radiocephalic fistula, he suggested such a patient could feasibly need a series of percutaneous transluminal angioplasty (PTA) procedures as their fistula repeatedly fails to mature—with a total treatment cost of €20,000, by Mallios’ estimation of the cost in France.

This, he suggested, achieves neither cost effectiveness nor the best outcomes compared to other procedures that perhaps have a higher initial cost. In the audience participation section following Mallios’ presentation, Karen Stevenson (Glasgow, United Kingdom) put it that “failure is expensive”—though she added that some patients prefer a short-term and others a long-term treatment strategy—and adopting those strategies may mean using different procedures.

Speaking finally on cost effectiveness, Mallios concluded: “I’m convinced that the benefits of doing a fistula that works for a long time, and which offers a good quality of life to patients, are multiple—if not always measurable.”

Jeremy Crane

Next came Crane, who wryly described his path to the podium to advocate for cost effectiveness as a “walk of shame”. Once he got there, however, he nevertheless built the case for “bang for buck” in kidney care. Cost effectiveness he defined as “the value of a healthcare intervention”—it is “about the ability to provide the best outcomes possible while also be financially viable”, which means getting the most possible out of the available resources.

Turning to how cost effectiveness is measured, Crane then raised quality-adjusted life years (QALYs) as the main metric of an intervention’s offer of disease limitation. He also highlighted non-monetary benefits as a component of cost-benefit analyses. The measurement of cost effectiveness is “in essence” the same across healthcare systems, he added, but there is variation between public and private healthcare systems.

“Why is this so particularly applicable to vascular access for dialysis?” he asked next. The answer, he said, was the “growing demand worldwide” for dialysis care, and said that a combination of aging populations and increasing diabetes rates have combined with better dialysis provision in some countries to increase numbers of patients.

New technologies such as the VasQ device (Laminate Medical), Crane said, could improve cost effectiveness by improving outcomes in dialysis access. Cost effectiveness “should not come at the expense of patient safety,” but he concluded that it “will play a pivotal role in helping more patients receive successful dialysis as the years roll on”.


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