Cost-effectiveness achieved through changing the composition of renal replacement therapy in Japan

Figures & data

Figure 1.  Markov state diagram for renal replacement therapy (RRT) for new end-stage kidney disease (ESKD) patients. Schematic representation of the decision model showing a Markov state diagram of the post-hospitalization course for patients with chronic kidney disease (CKD) receiving renal replacement therapy (RRT) in Japan. Circles indicate various health states; arrows, transitions between the various states.

Table 1.  Base-case values used in the Markov model for RRT in Japan.

Morkov state	Transition probability			References
ESKD (end-stage kidney disease)
Living donor transplant	0.30%			2
Hemodialysis (HD)	94.40%			2,13
Peritoneal dialysis (PD)	5.30%			2,13
Peritoneal dialysis (PD)
Combination therapy with PD and HD	9.18%			15
Hemodialysis (HD)	16.33%			15
Living donor transplant	4.70%			14
Death	6.95%			13
Combination therapy with PD and HD (HD + PD)
Hemodialysis (HD)	25.51%			15
Living donor transplant	4.70%			14
Death	6.95%			13
Hemodialysis (HD)
Living donor transplant	1.98%			14
Deceased donor transplant	0.02%			13
Death	9.40%			13
	1-year	Subsequent years
Living donor transplant
Peritoneal dialysis (PD)	0.10%	0.10%		2,13,16
Hemodialysis (HD)	0.20%	0.33%		2,13,16
Resumption of dialysis	1.60%	2.79%		2,13,16
Death	4.70%	1.53%		16
Deceased donor transplant
Peritoneal dialysis (PD)	0.24%	0.03%		2,13,16
Hemodialysis (HD)	0.48%	0.05%		2,13,16
Resumption of dialysis	6.88%	0.74%		2,13,16
Death	9.60%	2.40%		16
Resumption of dialysis
Death	4.80%			13
Morkov state	Utility			References
ESKD	0.54			17
Peritoneal dialysis (PD)	0.53			18
Hemodialysis (HD)	0.44			18
PD + HD	0.53			18
Living donor transplant	0.71			18
Deceased donor transplant	0.57			19
Resumption of dialysis	0.44			18
Morkov state	Cost ($)			References
ESKD	8,861			20
Peritoneal dialysis (PD)  (1-year of introduced to PD)	8,684
(Subsequent years)	68,989
PD + HD  (1-year of introduced to PD + HD)	8,821
(Subsequent years)	67,073
Hemodialysis (HD)  (1-year of introduced to HD)	7,294
(Subsequent years)	40,065
Living donor transplant  (Incremental cost of transplant year)	57,383			21
(Subsequent years)	20,898			21
Deceased donor transplant  (Incremental cost of transplant year)	76,184			21
(Subsequent years)	20,898			21
Resumption of dialysis	40,065

Table 2.  Base-case analysis (no discount).

Case	Cost ($)	Difference in cost	QALY	Difference in QALY	Cost/QALY	ICER ($/QALY)
Base composition of RRT; The current composition of RRT	349,152		4.099		85,180
Alternative 1; Likelihood of starting with PD increased by 2.3-times	350,394	1242	4.505	0.406	77,779	3,059
Alternative 2; Likelihood of a pre-emptive living donor transplant increased by 2.4-times	342,031	−7121	4.464	0.365	76,620	−19,510	Dominant*
Alternative 3; Likelihood of a living donor transplant increased by 2.4-times	341,002	−8150	4.871	0.772	70,007	−10,557	Dominant*
Alternative 4; Likelihood of a deceased donor transplant increased by 22-times	342,104	−7048	4.480	0.381	76,363	−18,499	Dominant*

*Dominant: less costly and more effective.

RRT, renal replacement therapy; QALY, quality-of-life years; ICER, incremental cost-effectiveness ratio.

Table 3.  Base-case analysis: discounted at 3%.

Case	Cost ($)	Difference in cost	QALY	Difference in QALY	Cost/QALY	ICER ($/QALY)
Base composition of RRT; The current composition of RRT	297,723		3.544		84,008
Alternative 1; Likelihood of starting with PD increased by 2.3-times	299,415	1692	3.854	0.310	77,689	5,458
Alternative 2; Likelihood of a pre-emptive living donor transplant increased by 2.4-times	291,884	−5839	3.820	0.276	76,409	−21,156	Dominant*
Alternative 3; Likelihood of a living donor transplant increased by 2.4-times	291,358	−6365	4.128	0.584	70,581	−10,899	Dominant*
Alternative 4; Likelihood of a deceased donor transplant increased by 22-times	292,062	−5661	3.830	0.286	76,256	−19,794	Dominant*

*Dominant: less costly and more effective.

RRT, renal replacement therapy; QALY, quality-of-life years; ICER, incremental cost-effectiveness ratio.

Table 4.  One-way sensitivity analysis.

Parameter		Sensitivity analysis range			Alternatives	Cost ($)		QALY		ICER ($/QALY)
		Low	High					Low	High	Low	High
HD utility		0.41	0.47	95%CI	Base composition of RRT	297,723		3.843	4.304
					Alternative 1	299,415		4.103	4.508	6,508	8,294
					Alternative 2	291,184		4.069	4.486	Dominant	Dominant
					Alternative 3	291,358		4.317	4.680	Dominant	Dominant
					Alternative 4	292,062		4.071	4.480	Dominant	Dominant
PD utility		0.50	0.56	95%CI	Base composition of RRT	297,723		3.545	3.553
					Alternative 1	299,415		3.856	3.875	5,441	5,255
					Alternative 2	291,184		3.821	3.829	Dominant	Dominant
					Alternative 3	291,358		4.128	4.136	Dominant	Dominant
					Alternative 4	292,062		3.831	3.840	Dominant	Dominant
Living donor transplant utility		0.68	0.74	95%CI	Base composition of RRT	297,723		3.554	3.560
					Alternative 1	299,415		3.989	4.050	3,890	3,453
					Alternative 2	291,184		3.952	4.012	Dominant	Dominant
					Alternative 3	291,358		4.400	4.524	Dominant	Dominant
					Alternative 4	292,062		3.957	4.015	Dominant	Dominant
Deceased donor transplant utility		0.50	0.64	95%CI	Base composition of RRT	297,723		3.544	3.545
					Alternative 1	299,415		3.854	3.856	5,458	5,441
					Alternative 2	291,184		3.820	3.821	Dominant	Dominant
					Alternative 3	291,358		4.128	4.130	Dominant	Dominant
					Alternative 4	292,062		3.842	3.867	Dominant	Dominant
						Low	High			Low	High
PD cost	(Subsequent years)	41,521	96,457	95%CI	Base composition of RRT	294,571	302,216	3.544
					Alternative 1	292,166	309,749	3.854		Dominant	24,300
					Alternative 2	288,732	296,377	3.820		Dominant	Dominant
					Alternative 3	288,577	295,167	4.128		Dominant	Dominant
					Alternative 4	288,910	296,555	3.830		Dominant	Dominant
HD cost	(Subsequent years)	21,371	58,758	95%CI	Base composition of RRT	202,342	489,578	3.544
					Alternative 1	214,352	466,661	3.854		38,742	Dominant
					Alternative 2	203,706	463,426	3.820		4,942	Dominant
					Alternative 3	211,953	438,257	4.128		16,457	Dominant
					Alternative 4	204,973	460,191	3.830		9,199	Dominant
Living donor transplant cost	(Subsequent years)	10,449	31,346	±50%	Base composition of RRT	297,129	299,120	3.544
					Alternative 1	293,672	314,904	3.854		Dominant	50,916
					Alternative 2	286,180	307,151	3.820		Dominant	29,098
					Alternative 3	279,625	322,758	4.128		Dominant	40,476
					Alternative 4	286,677	306,608	3.830		Dominant	26,182
Deceased donor transplant cost	(Subsequent years)	10,449	31,346	±50%	Base composition of RRT	297,675	297,860	3.544
					Alternative 1	299,372	299,538	3.854		5,474	5,413
					Alternative 2	291,838	292,011	3.820		Dominant	Dominant
					Alternative 3	291,315	291,474	4.128		Dominant	Dominant
					Alternative 4	291,064	294,836	3.830		Dominant	Dominant
Discount cost		0%	6%		Base composition of RRT	248,715	349,152	3.544
					Alternative 1	251,434	350,394	3.854		8,771	4,006
					Alternative 2	237,623	342,031	3.820		Dominant	Dominant
					Alternative 3	244,344	341,002	4.128		Dominant	Dominant
					Alternative 4	244,722	342,104	3.830		Dominant	Dominant

Base composition of RRT: current composition of RRT; Alternative 1: likelihood of starting with PD increased by 2.3 times; Alternative 2: likelihood of a preemptive living donor transplant increased by 2.4 times; Alternative 3: likelihood of a living donor transplant increased by 2.4 times; Alternative 4: likelihood of a deceased donor transplant increased by 22 times; RRT: renal replacement therapy; QALY: quality of life years; ICER: incremental cost-effectiveness ratio; CI: confidence interval.