A COST COMPARISON OF OPTIMAL VERSUS SUB-OPTIMAL PRE-DIALYSIS CARE IN CANADA BASED ON THE STARRT TRIAL

Purpose:

Suboptimal transition from chronic kidney disease (CKD) to end stage renal disease (ESRD) results in poor clinical outcomes and substantial economic burden to health care systems and patients.  The objective of this study was to estimate and compare the average total cost per patient requiring CKD management that initiates renal replacement therapy (RRT), stratified by their preparation status: 1.) Optimally Prepared (RRT initiation as outpatients and via AV Fistula or Graft), 2.) Sub-Optimally Prepared (RRT initiation as inpatients or via central venous catheter).

Method:

The Study To Assess Renal Replacement Therapy (STARRT), a Canadian, multicentre, retrospective study, designed to assess various factors related to pre-dialysis care and patient status at the time of dialysis initiation, was used to estimate and compare the average direct medical cost for patients in each group. Patients in the STARRT trial were retrospectively followed for up to 6 months following the start of dialysis. Unit costs for resources were obtained from participating hospitals, the literature, and/or standard costing sources (i.e., provincial fee schedules). The analysis was performed from the perspective of Canadian health care facilities and reported in 2010 Canadian Dollars (CAD). Descriptive statistical analyses were performed to determine the mean, standard deviation, and median for resources utilized. 

Result:

Data from a total of 339 patients, who started chronic RRT at 10 Canadian centres were collected.  The mean patient age was 63±16 years. Sixty-two percent of these patients were males. One hundred and thirty four patients were Optimally Prepared (39.5%) and 205 patients (60.5%) were Sub-Optimally Prepared.  The Optimally Prepared group ($52,225) had a statistical significant (p ≤0.001) lower total average cost during the study period than the Sub-Optimally Prepared group ($68,733).  Cost drivers for the difference between the two groups included the various dialyses and the number of hospitalizations and the lengths of stay.  The average length of stay in hospital for the Optimally Prepared group was 6.5 (± 29.5) days compared to 19.5 (± 31.9) days for the Sub-Optimally Prepared group (p=0.01). 

Conclusion:

In addition to the reported improved clinical outcomes, patients Optimally Prepared for RRT have significantly reduced costs, resulting in a potential decrease in the total economic burden of RRT.