LONG-FORM ORAL ABSTRACTS-5: POLICY CHALLENGES OF CHRONIC NON-COMMUNICABLE DISEASES
The Ontario Renal Network (ORN) aims to increase home dialysis from its current rate (24%) to 40%, based on evidence for its equivalent or superior outcomes and lower costs, versus facility dialysis.
Most published studies report dialysis-specific costs, but not total costs for the complex health needs of dialysis patients. The ORN commissioned this study to understand total health care costs for all dialysis modalities.
Method(s):
All patients in Ontario (Canada’s most populous province) who initiated chronic dialysis at age >18 years from April 2006 to March 2012 were selected from the Canadian Organ Replacement Registry, and grouped by initial modality: facility hemodialysis (HD), home HD, facility short daily or slow nocturnal HD (SD/SN HD), or any peritoneal dialysis (PD).
Using linked administrative healthcare data, we estimated direct medical costs (2012 Canadian dollars) from the payer perspective for inpatient and outpatient hospital visits, including dialysis clinics, laboratory and diagnostic tests, physician services, outpatient prescription drugs, home care including dialysis, and long-term care, for one and five years after dialysis initiation by modality group, adjusted for age, co-morbidity, and sex. Patients were censored at kidney transplant or end of follow-up (March 31, 2013), with a maximum observation time of 7.2 years.
Result(s):
The mean age of the cohort (N=9,302) was 66 years; 60% were male. Most (75.2%) initiated facility HD, 23.5% began PD, <1% initiated home HD or facility SD/SN HD. Home HD patients were youngest (mean age=50 years) with less co-morbidity, compared with other modality groups.
Mean adjusted costs for home HD and PD were similar (one-year = $50,506 and $43,123; five-year = $377,467 and $374,648), and much lower than other modalities. Mean facility HD costs were $102,979, and $515,650 for one and five years, respectively. Mean facility SD/SN HD were highest in the first year ($164,257) and similar to facility HD at five year ($482,453).
Conclusion(s):
Total health care costs for dialysis patients are high, (eg., one-year costs for cancer patients = $26,000). Our one-year costs for total health care are approximately twice as much as the dialysis-specific costs reported in previous studies, indicating the importance of non-dialysis costs. Our findings that home HD and PD are economical alternatives to facility HD provide some evidence for policy initiatives to increase home dialysis.
Method(s): We built the China LCPM using a well-established lung cancer microsimulation model. The China LCPM can project population outcomes associated with health interventions for smoking-related diseases in China. Smoking intensity and cessation rates from literature were used as model inputs. Model outputs were then calibrated to match smoking prevalence estimates from the China Health and Nutrition Survey (CHNS) and Chinese lung cancer mortality rates from the International Agency for Research on Cancer (IARC). Using the calibrated model, we estimated deaths attributable to smoking if intensive tobacco control measures and CT-based lung cancer screening were implemented from 2016-2050 in China. We defined an “intensive” tobacco control program as a program which could double the current, low smoking cessation rate of 2-3% per year. For lung cancer screening, we adapted eligibility criteria established by the U.S. Centers for Medicare & Medicaid Services.
Result(s): By 2050, we projected that an intensive tobacco control program would prevent approximately 0.9 million lung cancer deaths, 1.5 million other smoking-attributable deaths, and 43.6 million life-years lost in China. CT-based lung cancer screening in China would prevent an additional 1.2 million lung cancer deaths and 16.9 million life-years lost. The China LCPM estimated that males will contribute 74% of the lung cancer death burden in 2015. A program combining tobacco control and screening would reduce the cumulative lung cancer deaths between 2016- 2050 by 14.3%; for females, this value is projected to be 5.7%.
Conclusion(s): More than half of males in China are current smokers. Evidence from western countries tells us that an unprecedented number of smoking-attributable deaths will occur as the Chinese population ages. In China, a combination of intensive tobacco control measures and CT-based lung cancer screening, beginning in 2016, would prevent 3.6 million smoking-attributable deaths, including 2.1 million lung cancer deaths, by 2050. Effective health policies to mitigate the substantial disease burden caused by smoking in China may have a substantial, future public health impact. Our China LCPM is a comprehensive simulation platform that can provide instrumental information to policy makers about smoking-related diseases.
To quantify and compare the performance of all published clinical prediction rules (CPRs) for pulmonary embolism (PE) to a Bayes-Price-La Place Clinical Learning Machine (BPLCLM).
Method(s):
The study population is 310 (65 PEs) consecutive patients referred for CT angiogram of the chest to rule out PE. All relevant clinical findings for each patient are entered into a tailored database that supports the development and evaluation of Bayes’ Rule parameters. The first 201 patients are used to determine the prior odds based upon the presenting findings for each diagnosis and the likelihood ratios for all clinical findings for each diagnosis. Predictor variables (PVs) that are utilized have a level of significance > .95, face validity, and enhance the ability to discriminate in the development set. PVs may be a single clinical finding or a group of clinical findings with either an “and” or “or” relationship; PVs may not be a clinical judgement. The sum of the probability for all diagnoses is proportionally constrained to sum to 1. The last 109 patients are used to calculate a P(PE) for each patient with each CPR and the BPLCLM. ROC curves are generated for each method.
Result(s):
| Clinical Prediction Method | ROC Area |
| Charlotte Score | .66 |
| Miniati Regression Equation | .74 |
| PERC Score | .61 |
| Revised Geneva Score | .59 |
| Simplified Revised Geneva Score | .55 |
| Simplified Wells Score | .60 |
| Wells & Charlotte Scores | .63 |
| Wells & PERC Scores | .62 |
| Wells Score | .61 |
| BPLCLM | .92 |
Conclusion(s): The BPLCLM has significantly more capacity to discriminate between patients with and without PE than any published CPRs. The enhanced performance of the BPLCLM is due to the adjustment of the prior odds based upon the presenting findings and utilization of all PVs that have been found to be relevant to the patient’s situation. If the BPLCLM function were to be incorporated into electronic medical record systems it would enhance the ecology of clinical decision making. Bayes rule is to clinical decision making, as the Pythagorean Theorem is to architecture and Newton’s Second Law of Motion is engineering; violation of the equation in their respective domains leads to falling buildings, crashing vehicles; and costly, risky, low-value health care.
This study aimed to evaluate the cost-effectiveness of haemodialysis (HD) and two forms of peritoneal dialysis (continuous ambulatory peritoneal dialysis [CAPD] and automated peritoneal dialysis [APD]) for patients with end-stage renal disease (ESRD) in Singapore.
Method(s):
A Markov model was developed for patients who started dialysis with HD, CAPD or APD in a time horizon of 10 years. Event data (death, hospitalization, and transplantation) was taken from a hospital database and the national renal registry; health utility data came from published studies of Singaporean dialysis patients, and costs data was obtained from a local hospital and dialysis services providers. Outcome measures were 10-year costs (in 2015 Singaporean dollars [SG$]), quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs).
The base-case was a hypothetical cohort of 60-year-old non-diabetic ESRD patients who started dialysis with one of the three modalities and had no contradictions to any modality. We performed base-case cost-effectiveness analysis, one-way sensitivity analysis, and probabilistic sensitivity analysis with Monte Carlo simulation. A high-risk group of 60-year-old diabetic ESRD patients was also analyzed.
Result(s):
The base-case analysis showed that the QALYs were 3.38 with CAPD, 3.60 with APD and 4.82 with HD and the total costs were SG$169,872 for CAPD, 201,509 for APD and 306,827 for HD. The analysis of high risk group showed that the QALYs were 2.59 with CAPD, 2.64 with APD and 3.81 with HD. The total costs were SG$144,972 for CAPD, 169,282 for APD and 271,446 for HD.
For both base-case and high-risk groups, CAPD and HD had extended dominance over APD. The ICER of HD versus CAPD was SG$95,204 per QALY for base-case and 103,727 for high-risk group, respectively.
One-way sensitivity analyses showed that the ICER of HD versus CAPD was most sensitive to the utility for HD for base-case and high-risk groups. Probabilistic sensitivity analysis demonstrated that the probability of CAPD being the optimal choice was 37.5% for the base-case and 42.8% for the high-risk group at a willingness-to-pay threshold of SG$60,000 (US$43,000) per QALY.
Conclusion(s):
CAPD may be a cost-effective therapy compared with HD and APD in ESRD patients in Singapore. These findings are potentially useful to all stakeholders of the dialysis services in Singapore.