J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Original Article

Volume 9, Number 2, February 2017, pages 104-116

More Use of Peritoneal Dialysis Gives Significant Savings: A Systematic Review and Health Economic Decision Model

Figure 1. Model structure. HD: hemodialysis; PD: peritoneal dialysis; CAPD: continuous ambulatory peritoneal dialysis; APD: automated peritoneal dialysis.

Figure 3. (a) Cost-effectiveness acceptability curve (societal perspective). (b) Cost-effectiveness acceptability curve (societal perspective) for the internal comparison within the HD group. HD: hemodialysis; PD: peritoneal dialysis; WTP: willingness to pay.

**Table 1.** Summary of Variables Used in the Base Case Analysis
	Definition	Value (SE)	Source/note
SE: standard error; QALY: quality-adjusted life year; HD: hemodialysis; PD: peritoneal dialysis. ^aIncluding costs associated with additional training for nurses in the satellite unit, EUR1,610 per patient per year. ^bInitial cost. ^cIncluding costs associated with line rental for broadband and telemedicine equipment. ^dHD home patients were treated at the hospital in the training period (about 6 weeks) which infrastructure costs were estimated to be EUR1,143 (initial cost). ^eTravel cost associated with complications and initial of treatment were presented in Supplementary 8 (www.jocmr.org). ^fIt was assumed that PD patients and HD home patients visit the hospital 12 - 15 times per year. ^gValue of loss time because of travel during training period (6 weeks) was calculated to be EUR5,917 (initial cost). ^hWe assumed that 30-50% of patients were accompanied by another person when visiting the medical center. ⁱWe assumed that 10-30% of patients were accompanied by another person when visiting the medical center.
Probabilities (range of 5 years)	PD to HD	0.05 - 0.14	Norwegian Renal Registry [11]
HD to PD	0.01 - 0.03
Dialysis to transplant	0.07 - 0.13
Dialysis to death	0.10 - 0.23
Efficacy estimate	All-cause mortality: PD vs. HD hospital; HD home vs. HD satellite	1.11 (0.33) 0.60 (0.31)	Based on the results of our systematic review (Supplementary 4, www.jocmr.org)
QALY weight	Patients on dialysis	0.54 (0.105)	Sennfalt et al, 2005 [19]
Infection	-0.19 (0.010)	Sennfalt et al, 2005 [19]
Acute myocardial infarction	-0.27 (0.03)	Lund and Wisloff, 2012 [20]
Angina	-0.22 (0.03)	Lund and Wisloff, 2012 [20]
Sepsis	-0.28 (0.12)	Korosec et al, 2006 [21]
Costs per patient per year in EUR (EUR 1.00 ≈ NOK 7.47)		HD hospital	HD self-care	HD satellite	HD home	PD
Personnel costs	31,914	23,871	31,940^a	3,502	5,417	Based on the average healthcare staff salary per month from Statistics Norway (Supplementary 5, www.jocmr.org)
Dialysis supplies	85,800	85,800	85,800	408,320	273,570	PD: based on actual price in Norway in 2012 HD: based on data from three major hospitals in Norway Home HD: based on the price list provided by Oslo University Hospital
Dialysis supplies-training^b		825		10,140	5,600	Assumption
Medication	105,685	84,235	105,685	96,420	26,282	Based on data reported by the Norwegian renal registry, Norwegian Medicines Agency (Supplementary 6, www.jocmr.org)
Laboratory test	18,124	18,124	18,124	18,124	15,855	Based on data provided by Oslo University Hospital
Complications	24,330	23,590	20,840	18,885	30,570	Norwegian Medicine Agency Wisloff et al, 2012 [13, 14]
Capital costs	44,840	44,840	44,840	5,000	6,210	Nyhus et al, 2007 [12], Oslo University Hospital
Infrastructure costs	74,030	74,030	102,640	6,565^d	6,565	Nyhus et al, 2007 [12]
Telemedicine^c			27,600			Bjorvatn, 2004 [15], assumption
Home care				27,405	89,425	[16, 17]
Transport costs^e	227,310	227,310	165,700	160,000^f	110,000^f	Based on data obtained from dialysis centres across the country
Staff travel			10,800			Bjorvatn, 2004 [15]
Value of leisure time; patient	287,330	287,330	287,330	27,630^{f, g}	27,630^f	Assumption [18]
Value of leisure time; companion	114,930^h	57,470ⁱ	114,930^h	5,530ⁱ	11,050 ^h	Assumption [18]

Table 1. Summary of Variables Used in the Base Case Analysis

Definition

Value (SE)

Source/note

SE: standard error; QALY: quality-adjusted life year; HD: hemodialysis; PD: peritoneal dialysis. ^aIncluding costs associated with additional training for nurses in the satellite unit, EUR1,610 per patient per year. ^bInitial cost. ^cIncluding costs associated with line rental for broadband and telemedicine equipment. ^dHD home patients were treated at the hospital in the training period (about 6 weeks) which infrastructure costs were estimated to be EUR1,143 (initial cost). ^eTravel cost associated with complications and initial of treatment were presented in Supplementary 8 (www.jocmr.org). ^fIt was assumed that PD patients and HD home patients visit the hospital 12 - 15 times per year. ^gValue of loss time because of travel during training period (6 weeks) was calculated to be EUR5,917 (initial cost). ^hWe assumed that 30-50% of patients were accompanied by another person when visiting the medical center. ⁱWe assumed that 10-30% of patients were accompanied by another person when visiting the medical center.

Probabilities (range of 5 years)

PD to HD

0.05 - 0.14

Norwegian Renal Registry [11]

HD to PD

0.01 - 0.03

Dialysis to transplant

0.07 - 0.13

Dialysis to death

0.10 - 0.23

Efficacy estimate

All-cause mortality: PD vs. HD hospital; HD home vs. HD satellite

1.11 (0.33)
0.60 (0.31)

Based on the results of our systematic review (Supplementary 4, www.jocmr.org)

QALY weight

Patients on dialysis

0.54 (0.105)

Sennfalt et al, 2005 [19]

Infection

-0.19 (0.010)

Sennfalt et al, 2005 [19]

Acute myocardial infarction

-0.27 (0.03)

Lund and Wisloff, 2012 [20]

Angina

-0.22 (0.03)

Lund and Wisloff, 2012 [20]

Sepsis

-0.28 (0.12)

Korosec et al, 2006 [21]

Costs per patient per year in EUR (EUR 1.00 ≈ NOK 7.47)

HD hospital

HD self-care

HD satellite

HD home

Personnel costs

31,914

23,871

31,940^a

3,502

5,417

Based on the average healthcare staff salary per month from Statistics Norway (Supplementary 5, www.jocmr.org)

Dialysis supplies

85,800

408,320

273,570

PD: based on actual price in Norway in 2012
HD: based on data from three major hospitals in Norway
Home HD: based on the price list provided by Oslo University Hospital

Dialysis supplies-training^b

825

10,140

5,600

Assumption

Medication

105,685

84,235

105,685

96,420

26,282

Based on data reported by the Norwegian renal registry, Norwegian Medicines Agency (Supplementary 6, www.jocmr.org)

Laboratory test

18,124

15,855

Based on data provided by Oslo University Hospital

Complications

24,330

23,590

20,840

18,885

30,570

Norwegian Medicine Agency
Wisloff et al, 2012 [13, 14]

Capital costs

44,840

5,000

6,210

Nyhus et al, 2007 [12], Oslo University Hospital

Infrastructure costs

74,030

102,640

6,565^d

6,565

Nyhus et al, 2007 [12]

Telemedicine^c

27,600

Bjorvatn, 2004 [15], assumption

Home care

27,405

89,425

[16, 17]

Transport costs^e

227,310

165,700

160,000^f

110,000^f

Based on data obtained from dialysis centres across the country

Staff travel

10,800

Bjorvatn, 2004 [15]

Value of leisure time; patient

287,330

27,630^{f, g}

27,630^f

Assumption [18]

Value of leisure time; companion

114,930^h

57,470ⁱ

114,930^h

5,530ⁱ

11,050 ^h

Assumption [18]

**Table 2.** Results of the Base-Case Cost-Effectiveness Analyses Over a 5-Year Time Horizon From a Societal Perspective (Discounted) (EUR1.00 ≈ NOK7.47)
	Total costs (EUR)	Effects (QALYs)	Versus PD	Sequential ICER (EUR/QALY)
All HD strategies were compared to PD, because none of the more effective strategies were cost-effective compared to PD. QALY: quality-adjusted life year; ICER: incremental cost-effectiveness ratio; INHB: incremental net health benefit; HD: hemodialysis; PD: peritoneal dialysis.
PD	164,741	1.6825
HD home	228,362	1.8613	63,621	0.1788	355,822	355,822
Dominated strategies
HD hospital	317,501	1.7169	152,760	0.0344	4,440,698	Dominated by HD home
HD self-care	261,260	1.7170	96,519	0.0344	2,805785	Dominated by HD home
HD satellite	352,048	1.7181	187,308	0.0356	5,261,461	Dominated by HD home

Table 2. Results of the Base-Case Cost-Effectiveness Analyses Over a 5-Year Time Horizon From a Societal Perspective (Discounted) (EUR1.00 ≈ NOK7.47)

Total costs (EUR)

Effects (QALYs)

Versus PD

Sequential ICER (EUR/QALY)

Incremental cost (EUR)

Incremental effect (QALYs)

ICER (EUR/QALY)

All HD strategies were compared to PD, because none of the more effective strategies were cost-effective compared to PD. QALY: quality-adjusted life year; ICER: incremental cost-effectiveness ratio; INHB: incremental net health benefit; HD: hemodialysis; PD: peritoneal dialysis.

164,741

1.6825

HD home

228,362

1.8613

63,621

0.1788

355,822

Dominated strategies

HD hospital

317,501

1.7169

152,760

0.0344

4,440,698

Dominated by HD home

HD self-care

261,260

1.7170

96,519

0.0344

2,805785

Dominated by HD home

HD satellite

352,048

1.7181

187,308

0.0356

5,261,461

Dominated by HD home

**Table 3.** Cost-Saving With an Increased Proportion of Patients Starting on PD at the Expense of In-Center HD Over 5-Year Time Horizon From a Societal Perspective (EUR1.00 ≈ NOK7.47)
		Number of patients	Cost (in millions, EUR)	Cost-saving (in millions, EUR)
HD: hemodialysis; PD: peritoneal dialysis; EU: The European Union. ^aIn Norway PD in 2012 was actual 15.8%. ^bIn-center HD includes HD in hospital and satellites.
Norway	2017 (annual growth rate of 4%) PD: 15%^a In-center HD: 85%^b	1,284	227	1,510	398	37	435
Scenario PD: 30% In-center HD: 70%	1,057	453	1,510	328	75	403	32
EU	2017 (annual growth rate of 4%) PD: 10% In-center HD: 90%	328,500	36,500	365,000	101,923	6,013	107,936
Scenario 1 PD: 20% In-center HD: 80%	292,000	73,000	365,000	90,599	12,026	102,625	5,311
Scenario 2 PD: 30% In-center HD: 70%	255,500	109,500	365,000	79,274	18,039	97,313	10,623

Table 3. Cost-Saving With an Increased Proportion of Patients Starting on PD at the Expense of In-Center HD Over 5-Year Time Horizon From a Societal Perspective (EUR1.00 ≈ NOK7.47)

Number of patients

Cost (in millions, EUR)

Cost-saving (in millions, EUR)

Total

HD: hemodialysis; PD: peritoneal dialysis; EU: The European Union. ^aIn Norway PD in 2012 was actual 15.8%. ^bIn-center HD includes HD in hospital and satellites.

Norway

2017 (annual growth rate of 4%)
PD: 15%^a
In-center HD: 85%^b

1,284

227

1,510

398

435

Scenario
PD: 30%
In-center HD: 70%

1,057

453

1,510

328

403

2017 (annual growth rate of 4%)
PD: 10%
In-center HD: 90%

328,500

36,500

365,000

101,923

6,013

107,936

Scenario 1
PD: 20%
In-center HD: 80%

292,000

73,000

365,000

90,599

12,026

102,625

5,311

Scenario 2
PD: 30%
In-center HD: 70%

255,500

109,500

365,000

79,274

18,039

97,313

10,623