Cost Effectiveness of Dialysis Modalities: A Systematic Review of Economic Evaluations

Background and Objective The economic burden of providing maintenance dialysis to those with end-stage kidney disease continues to increase. Home dialysis, including both haemodialysis and peritoneal dialysis, is commonly assumed to be more cost effective than facility dialysis, with some countries adopting a home-first policy in an attempt to reduce costs. However, the cost effectiveness of this approach is uncertain. The aim of this study is to review all published cost-effectiveness analyses comparing all alternative dialysis modalities for people with end-stage kidney disease. Methods We conducted a systematic review of MEDLINE, the National Health Service Economic Evaluation Database, and Health Technology Assessment Database from the Centre of Reviews and Dissemination, The Cochrane Library and Econlit from January 2000 to December 2017. Published economic evaluations were included if they provided comparative information on the costs and health outcomes of alternative dialysis modalities. Results The review identified 16 economic evaluations comparing dialysis modalities from both high- and low-income countries. The majority (69%) were undertaken solely from the perspective of the payer or service provider, 14 (88%) included a cost-utility analysis and eight (50%) were modelled evaluations. The studies addressed costs and health outcomes of multiple dialysis modalities, with many reporting average cost effectiveness rather than incremental cost effectiveness. Almost all evaluations suggest home dialysis to be less costly and to offer comparable or better health outcomes than in-centre haemodialysis. However, the quality-of-life benefit for each modality was poorly defined and inconsistent in terms of magnitude and direction of differences between modalities and across studies. Other issues include exclusion of competing modalities and use of arbitrary assumptions with regard to the mix of modalities. Conclusions The ability to identify the mix of dialysis modalities that provides best outcomes for patients and health budgets is uncertain particularly given the lack of societal perspectives and inconsistencies between published studies.