ORIGINAL ARTICLE
Cost-effectiveness analysis of dialysis andkidney transplants in Japan
Masahiro Kaminota
Department of Preventive Medicine and Public Health, School of Medicine, Keio University, Tokyo, Japan(Received for publication on December 11, 2000)

Abstract. Although kidney transplantation is considered to be more desirable than dialysis in terms of
cost-effectiveness and patients' quality of life, there have been very few cases of kidney transplants inJapan. This study was conducted to compare the cost-effectiveness of dialysis and kidney transplants
using Disability-Adjusted Life Years (DALYs) as an indicator of effectiveness. Most data necessary for
the DALYs analysis were obtained from publications. The disability weights for dialysis patients andkidney transplant patients were estimated based on a questionnaire emailed to medical of®cials of theJapanese Government. Expected duration of treatment was estimated from the survival rates of dialysis patients and the graft-survival rates of transplant patients using the Weibull model method. The
cost of dialysis and living-related donor (LRD) transplant included only medical expenditures andneglected all other costs, and the cost of cadaveric donor (CAD) transplant included the budget fororgan procurement and distribution in addition to medical expenditures. The analysis showed that
dialysis averted 138,019 DALYs/year, living-related donor transplant averted 5,740 DALYs/year, and
CAD transplant averted 1,892 DALYs/year. The cost-effectiveness ratio (C-E ratio) was 9,546 thousand yen/DALY for dialysis, 1,809 thousand yen/ DALY for LRD transplant, and 2,322 thousand yen/
DALY for CAD transplant. These results could be used for the decision making of the Government on
what resources should be allocated to the promotion of kidney transplantation. Also, the methodology
used in this study can be applied to cost-effectiveness analysis of other organ transplants. (Keio J Med
50 (2): 100±108, June 2001)
Key words: dialysis, kidney transplant, cost-effectiveness analysis, DALYs, Weibull model

Introduction
There are two major treatments for end-stage renal
diseases (ESRD): dialysis and a kidney transplant. In
Japan, there were 152,373 dialysis patients as of the endof 1995, and the number at that time had been expanding at more than 10,000 patients per year.1 With the
medical expenditures for dialysis in 1996 at 9,073.6
thousand yen/year/inpatient and 5,380.3 thousand yen/year/outpatient, according to The National Sakura
Hospital, the leading institution for ESRD treatment inJapan, huge medical resources were consumed by dialysis patients. On the other hand, although the medical
expenditures for kidney transplants in 1996 were much
lower, at only 5,319.5 thousand yen/year/patient for the®rst year and 1,736.2 thousand yen/year/patient for thefollowing years (The National Sakura Hospital ), there
Reprint requests to: Dr. Masahiro
kaminota@1992.jukuin.keio.ac.jp

Kaminota,

5-13-2-403

were only 604 kidney transplants executed in 1995: 172
cadaveric donor (CAD) transplants and 432 livingrelated donor (LRD) transplants.2 In addition, thedialysis patients still awaiting the chance for a kidneytransplant as of the end of 1994 totaled 22,129 (TheNational Sakura Hospital ).
Generally speaking, a kidney transplant is considered to be more cost-effective and more desirable forpatients' quality of life than dialysis, as shown by several studies.3±5 This study was conducted to compare
the cost-effectiveness of dialysis and kidney transplantation using Disability-Adjusted Life Years (DALYs),
which were developed as a time-based measure formortality and non-fatal health outcomes and have been
widely applied to assess technologies and interventions.6±12 The effectiveness of dialysis and kidney transplants can be estimated more precisely using DALYs,
Miyamae-cho,

100

Kofu-shi,

Yamanashi

400-0021,

Japan,

e-mail:Keio J Med 2001; 50 (2): 100±108101because the measure includes patients' quality of life
in addition to mortality aspects of disease.
Materials and Methods
Calculation of effectivenessThe effectiveness was estimated based on the
DALYs calculation described by Murray and Lopez.13
DALYs are composed of two elements: Years of Life
Loss (YLLs), which measures time lost due to premature mortality, and Years Lived with Disability (YLDs),
which measures burden of time lived with a disability
due to morbidity. DALYs can be calculated using thefollowing formula:
DALYs  YLLs  YLDs
YLLs 

KCe raerb Larbar  bar  b 2e

YLDs  Df

KCe rar  b 2

e

rba

f

e

f

r  b L  a1g rb Lar  ba

f

1

K
r

1

1g
e rL 

r  b L  a

1g 

1

K
r

1

1g

e rL 

where e is the natural logarithmic base, r is the discountrate, b is the age-weighting parameter, K is the age
weighting modulation factor, C is the adjustment constant equal to 0.16243, D is the disability weight, which
describes health states spanning from death D  1 toperfect health D  0, a in the YLLs formula is the age
at death, a in the YLDs formula is the age of onset ofthe disability, L in the YLLs formula is the remaining
years of life at death, and L in the YLDs formula is theduration of disability. In this analysis, a discount rater of 3% and the standard age weighting function(b  0:04 and K  1) adopted by the World Bank wereused.14 The other variables necessary for DALYs calculation were estimated as follows.
The annual incidence of dialysis was determined as
the number of new dialysis cases in 1995 and the annual
number of kidney transplants came from the number ofrecipients in 1995.1,2 Patients were grouped by age into
10 classes of 10 years each (0±9 to 90 years) for dialysis patients, and 6 classes of 10 years each (0±9 to 50
years) for kidney transplant patients (column A of
Table 1). The age distribution of kidney transplantpatients in 1995, which was not published, was assumed
to be same as that of patients from 1983 to 1994.15 In
addition, kidney transplant patients were divided into
two donor-related groups, LRD transplants and CAD
transplants. The annual incidences are shown in column
B of Table 1.

The disability weights (D) for the dialysis and kidneytransplant patients were estimated based on the questionnaire emailed to 95 of®cials, all of whom weredoctors engaged in health related policy making in
the Japanese Government. The Person Trade-Off
method13 was used as the protocol. Here, two alternatives are offered to subjects. Alternative 1 is toextend life for 1,000 individuals in normal health andalternative 2 is to extend life for X individuals in healthstate Y (e.g. patients undergoing dialysis or transplant).
X is varied until the respondent is indifferent to the
choice between the two alternatives, at which point thepreference for state Y is 1,000/X and the disability weight(D) is 1±1,000/X. The emailed questionnaire contained
an explanation of the Person Trade-Off method, de®nitions of physical conditions of dialysis and kidneytransplant patients, and a table of 7 disability classes
with 22 indicator conditions which were developed by
the WHO study group.13 The response rate of thequestionnaire was 45.3% (43/95). As a normal distribution was not obtained, the median data, 0.231 for dialysis patients and 0.100 for transplant patients, wereadopted for DALYs calculation (Table 2).
Expected duration (L in YLDs formula) was estimated using the Weibull model formula, RS(t) 
exp at b , where t is years after the onset of treatment, RS(t) is survival rate at the point of t, and a
and b are parameters. With survival rates at two pointsof time, for example 2 year and 5 year survival rates, aand b can be determined and a model curve of survival
rates can be drawn from the formula. The JapaneseSociety for Dialysis Therapy provides 12 survival rates
of dialysis patients spanning from 1 year to 12 years for7 age classes, 0±14, 15±29, 30±44, 45±59, 60±74, 75±89,
and 90 years.1 Two survival rates were chosen arbitrarily, and the Weibull curve ®t 12 actual data points
very well (Fig. 1). The Weibull curves were modi®edusing data from The Abridged Life Table for Japan(1995)16 to re¯ect the effect of aging. The area under
the curve, which can be determined by accumulating
survival rates from onset to extinction, shows average
duration from onset to death. As for the age classes of
75±89 and 90 years, the expected duration was estimated by simply summing up the 12 survival rates from
1 year to 12 years, because the 12-year survival rates forthese age classes were close to zero and it was not necessary to use the Weibull model estimation. Then, theexpected duration estimated for the 7 age classes wasconverted to 10 age classes by interpolation; for example, the expected duration for the 20±29 year class(midpoint: 25.0 years) was obtained from those for the
15±29 year class (midpoint: 22.5 years) and the 30±44year class (midpoint: 37.5 years) (column E of Table 1).
As for kidney transplants, using survival rates willlead to overestimation of the effectiveness of kidney

102
Table 1

Kaminota M: Cost-effectiveness of dialysis and transplants
Data Used for Estimation of EffectivenessDialysisAge(years)Annual Incidence(1995)(persons)

Average Ageof Onset(years)Lost Duration ofLife at Onset(years)Expected
Duration(years)Average Ageof Death(years)Lost Duration ofLife at Death(years)

A

B

C

D

E

F (C  E)

G

0±9
10±19
20±29
30±39
40±49
50±59
60±69
70±79
80±89
90

25
118
606
1,201
3,163
5,587
7,416
5,389
2,032
92

5
15
25
35
45
55
65
75
85
95

75.1
65.2
55.5
45.7
36.2
27.1
18.7
11.3
5.9
2.8

50.2
46.8
41.2
28.9
19.2
11.6
7.2
4.7
3.0
2.5

55.2
61.8
66.2
63.9
64.2
66.6
72.2
79.7
88.0
97.5

26.9
21.3
17.8
19.6
19.3
17.4
13.3
8.5
4.8
2.2

Total

25,629

±

±

±

±

±

Annual Incidence(1995)(persons)

Average Ageof Onset(years)Lost Duration ofLife at Onset(years)Expected
Duration(years)Average Ageof Rejection(years)Lost Duration ofLife at Rejection(years)

A

B

C

D

E

F (C  E)

G

0±9
10±19
20±29
30±39
40±49
50

11
49
131
160
59
22

5
15
25
35
45
55

75.1
65.2
55.5
45.7
36.2
27.1

20.4
25.6
9.9
15.6
11.2
16.2

25.4
40.6
34.9
50.6
56.2
71.2

55.1
40.3
45.9
31.1
26.0
14.0

Total

432

±

±

±

±

±

Annual Incidence(1995)(persons)

Average Ageof Onset(years)Lost Duration ofLife at Onset(years)Expected
Duration(years)Average Ageof Rejection(years)Lost Duration ofLife at Rejection(years)

A

B

C

D

E

F (C  E)

G

0±9
10±19
20±29
30±39
40±49
50

2
4
26
71
58
11

5
15
25
35
45
55

75.1
65.2
55.5
45.7
36.2
27.1

9.3
15.1
12.7
12.8
10.6
12.7

14.3
30.1
37.7
47.8
55.6
67.7

65.9
50.5
43.1
33.6
26.6
16.6

Total

172

±

±

±

±

±

LRD TransplantAge(years)CAD TransplantAge(years)LRD Transplant: living-related donor transplant, CAD Transplant: cadaveric donor transplant.

Keio J Med 2001; 50 (2): 100±108
Table 2

103

Results of Questionnaire on Disability Weight
Dialysis

Transplant

Minimum
First Quartile
MedianThird Quartile
Maximum

0.000
0.139
0.231
0.333
0.700

0.000
0.034
0.100
0.233
0.667

Mean

0.261

0.148

Response Rate: 45.3% (43/95).

Fig. 2 Model for DALYs calculation. Effectiveness is equivalent to
the difference between ``DALYs without treatment'' and ``DALYs
with treatment''. ``DALYs with treatment'' are a summation of YLDs
caused by the disability during treatment, and YLLs caused by thedeath after treatment. ``DALYs without treatment'' was YLLs causedby the death just after the onset.

Fig. 1 Survival rate curves estimated by the Weibull model (dialysis
patients, age 0±14). Twelve data plots (o) show survival rate data
provided by The Japanese Society for Dialysis Therapy. The broken
line (---------) was drawn using the Weibull model formula, and thesolid line (ÐÐÐ) was obtained by correcting for the aging effectusing The Abridged Life Table for Japan (1995). The expected duration from the onset to death was obtained by calculating the areasurrounded by the solid line and the two axes.

transplants, since kidney transplant patients whoseorgans are rejected could survive with dialysis and thus
raise the survival rate considerably. To eliminate suchbias, graft-survival rates were used to estimate theexpected duration for a kidney transplant assuming thattransplant patients died just after the rejections. The
Japan Society for Transplantation provides 10 graftsurvival rates of kidney transplants by donor category(LRD transplant and CAD transplant) spanning from1-year to 10-years for 8 age classes, 0±4, 5±9, 10±19,
20±29, 30±39, 40±49, 50±59, and 60 years.15 To adjust
the age-classes, the graft-survival rate for the 0±9 class
was obtained from the data of the 0±4 and 5±9 year
classes, and the data of the 50±59 and 60 year classes
were recalculated to determine a 50 year class.
The midpoint of each age class was used for averageage of onset (a in YLDs formula) as shown in column C
of Table 1. Average age of death of dialysis patientsand average age of rejection of transplant patients (a inYLLs formula) were obtained by summation of theaverage age of onset and expected duration (column F
of Table 1).
The Abridged Life Table for Japan (1995)16 was used
to estimate the lost duration of life at the age of onset
and death (or rejection) (L in YLLs formula). Lost
duration of life at onset is shown in column D of
Table 1, and lost duration of life at death (or rejection)is shown in column G of Table 1.
Effectiveness is equivalent to ``DALYs averted bytreatment'', which is the difference between ``DALYs
without treatment'' and ``DALYs with treatment''.
DALYs without treatment were estimated by calculating DALYs of ESRD patients in a hypothetical world
where ESRD patients die just after the onset. DALYs
without treatment have only the YLLs element since
ESRD patients die at the onset without a disability period. On the other hand, DALYs with treatment are asummation of YLDs caused by the disability of disease
lasting for the years of expected duration, and YLLs
caused by the death coming after the expected duration(Fig. 2). The element of YLLs was discounted to thepresent value at the time of onset using a discount rateof 3%. For example, if the age of the patient at onset is
20 years old and the expected duration is 30 years, thepresent value of YLLs from death of a 50-year-old
person will be as follows:(YLLs from death of 50-year-old person)
1  r 30(r: discount rate of 3%)

104

Kaminota M: Cost-effectiveness of dialysis and transplants

Estimation of cost
Average health insurance payments for ESRD
treatments provided by The National Sakura Hospitalwere used for cost estimation, because the insurance
payments are almost uniform among institutions under
universal health insurance coverage in Japan.
Cost of dialysis included only the medical expenditures neglecting all other costs, such as transportation cost and opportunity cost of time during
dialysis. Medical expenditures for dialysis as ofApril 1996 were 9,073.6 thousand yen/year/inpatientand 5,380.3 thousand yen/year/outpatient. As the proportion of inpatient dialysis was 13.8%, according
to the survey of the Ministry of Health and Welfare,17 the ®gure 5,888.4 thousand yen/year/patient(9; 073:6  13:8%  5; 380:3  86:2%) was used for theestimation of dialysis cost.
The medical expenditures for kidney transplants
were 5,319.5 thousand yen/year/patient for the ®rst year
and 1,736.2 thousand yen/year/patient for the following
years. In addition to the medical expenditures, the costof CAD transplant included the budget for the kidneytransplant information system, which was used for kidney procurement and distribution necessary for CAD
transplants. As the budget for kidney transplants was
706,000 thousand yen/year and the annual incidence of
CAD transplants was 172 in 1995, the operation cost of
the kidney transplant information system per patientwas estimated as 4,105 thousand yen (706,000/172). The
cost necessary for the second and following years was
discounted to the present value at the point of onset
using a discount rate of 3%, then summed up throughthe total process of treatment.
Results
Column L of Table 3 shows the effectiveness per patient (EPP), which is the gap between DALYs without
treatment (column K of Table 3) and DALYs withtreatment (column J of Table 3). The EPP of dialysis
was higher than that of transplant in ®ve age classes,
0±9, 10±19, 20±29, 30±39, and 40±49 years. Column M
of Table 3 shows the total effectiveness, which corresponds to EPP (column L of Table 3) multiplied by incidence (column B of Table 1). The total effectivenessof dialysis was 138,019 DALYs and was much greaterthan that of transplants (5,740 DALYs for LRD transplants and 1,892 DALYs for CAD transplants).
The cost per patient is shown in column N of Table 4
and the total cost is shown in column O of Table 4.
The cost per dialysis patient was greater than that pertransplant patient. For example, in the case of the 10±
19 year age class, the cost was 151,523 thousand yen for

dialysis, 35,240 thousand yen for LRD transplant, and29,146 thousand yen for CAD transplant.
Table 5 shows the Cost-Effectiveness ratios (C-E
ratios) of dialysis and kidney transplants. The C-E
ratios were 9,546 thousand yen/ DALY for dialysis, 1,809
thousand yen/ DALY for LRD transplants, and 2,322
thousand yen/ DALY for CAD transplants. As the C-E
ratios of the same age classes were compared, the C-E
ratio of dialysis was 3 to 4 times higher than that oftransplantation.
Sensitivity Analysis
Sensitivity analysis of discount rate, age weight, anddisability weight was carried out. As shown in Fig. 3,
the C-E ratios were insensitive to discount rate. Figure
4 shows how the C-E ratios of dialysis varied when K,
the age weighting modulation factor, changed from 0
to 1. Larger K worsened the C-E ratios for elderly
patients, especially for patients 70 years and older. Figure 5 shows how the C-E ratios varied with the disability weight obtained from the questionnaire. Although
the C-E ratio of dialysis worsened more markedly thanthe C-E ratios of transplants when applying larger disability weight data, there was no effect on the order ofthe magnitudes of the C-E ratios among dialysis, LRD
transplants, and CAD transplants.
Discussion
Weibull model estimation of expected duration
It takes a long time to determine the duration of
diseases by means of disease registration, since treatment outcome would not be clear even after decades offollow-up, especially for chronic diseases. The Weibull
model is a useful method to estimate a decades-longsurvival rate and the duration of a disease, and has
been applied in several studies.17,18 Although the Weibull model needs survival rate data only at two points oftime, the curves drawn by this method ®t the actual
surveillance data quite well. However, since the Weibull model does not re¯ect the effect of aging, the rangeof error becomes wider as the duration increases. In
this study, the Life Table data was used to adjust forsuch an error. Although it is a convenient method toestimate duration of chronic diseases, the validity ofthis modi®cation should be inspected more carefully.
In this analysis, discontinuity was observed in the
expected duration of LRD transplants: the duration of
the 20±29 year age class was unexpectedly short (9.9years) compared to those of the adjacent age classes,
25.6 years for the 10±19 year class and 15.6 years forthe 30±39 year class. This may be due to the small
sample size of the graft survival rate data from The

Keio J Med 2001; 50 (2): 100±108
Table 3

105

Results of Effectiveness Estimation

DialysisAge(years)DALYs with Dialysis per patient
YLLs(DALYs)YLDs(DALYs)Total(DALYs)DALYs w/o
Dialysisper patient(DALYs)A

H

I

J (H  I)

K

0±9
10±19
20±29
30±39
40±49
50±59
60±69
70±79
80±89
90

3.2
2.7
2.5
4.1
5.4
6.0
4.9
3.1
1.6
0.6

7.6
7.8
6.9
5.1
3.4
2.0
1.1
0.6
0.3
0.2

10.7
10.4
9.4
9.2
8.8
7.9
6.0
3.7
1.9
0.8

35.7
36.0
31.9
26.0
19.8
14.1
9.1
5.1
2.3
0.9

25.0
25.6
22.5
16.7
11.0
6.2
3.1
1.4
0.4
0.1

624
3,023
13,62020,10934,911
34,43323,144
7,321
825
8

Total

±

±

±

±

±

138,019

Effectivenessper patient(DALYs)

Total
Effectiveness(DALYs)

Effectivenessper patient(DALYs)
L (K

J)

Total
Effectiveness(DALYs)M (L  B)

LRD TransplantAge(years)DALYs with Transplant per patient
YLLs(DALYs)YLDs(DALYs)Total(DALYs)DALYs w/oTransplant
per patient(DALYs)A

H

I

J (H  I)

K

0±9
10±19
20±29
30±39
40±49
50

17.3
10.6
19.5
10.5
9.6
4.0

1.9
2.6
1.3
1.6
1.0
1.1

19.2
13.1
20.7
12.0
10.7
5.1

35.7
36.0
31.9
26.0
19.8
14.1

16.5
22.9
11.1
14.0
9.2
9.0

177
1,131
1,465
2,233
536
198

Total

±

±

±

±

±

5,740

Effectivenessper patient(DALYs)

Total
Effectiveness(DALYs)

L (KJ)

M (L  B)

CAD TransplantAge(years)DALYs with Transplant per patient
YLLs(DALYs)YLDs(DALYs)Total(DALYs)DALYs w/oTransplant
per patient(DALYs)A

H

I

J (H  I)

K

0±9
10±19
20±29
30±39
40±49
50

27.5
18.5
16.7
12.4
10.1
5.4

0.8
1.8
1.5
1.4
1.0
0.9

28.4
20.3
18.2
13.8
11.1
6.3

35.7
36.0
31.9
26.0
19.8
14.1

7.3
15.7
13.6
12.2
8.8
7.8

12
67
352
865
510
86

Total

±

±

±

±

±

1,892

L (K

J)

M (L  B)

LRD Transplant: living-related donor transplant. CAD Transplant: cadaveric donor transplant. YLLs: years of life loss. YLDs: years lived withdisability.

106
Table 4

Kaminota M: Cost-effectiveness of dialysis and transplants

Japan Society for Transplantation rather than methodological problems.

Results of Cost Estimation

DialysisAge(years)Cost per patient(thousand yen)

Total Cost
(thousand yen)N

O (NB)

0±9
10±19
20±29
30±39
40±49
50±59
60±69
70±79
80±89
90

156,355
151,523
142,357
116,052
87,70058,69738,86525,96317,36914,322

3,908,869
17,879,694
86,268,081
139,378,604
277,395,654
327,940,847
288,224,033
139,915,248
35,293,026
1,317,649

Total

±

1,317,521,706

A

Cost per patient(thousand yen)

Total Cost
(thousand yen)N

O (NB)

0±9
10±19
20±29
30±39
40±49
50

30,53735,24018,66825,55020,437
26,277

327,851
1,738,561
2,452,835
4,088,525
1,196,344
577,663

Total±

10,381,779

A

Cost per patient(thousand yen)

Total Cost
(thousand yen)N

O (NB)

0±9
10±19
20±29
30±39
40±49
50

21,98529,14626,363
26,45523,71826,40135,423
123,274
679,646
1,880,844
1,380,531
292,455

Total±

4,392,173A

The sensitivity analysis of age weighting showed that
effectiveness for the elderly was greatly dependent
upon the age weighting modulation factor (K). If healthpolicy decisions are made based on cost-effectivenessanalysis using DALYs, the value of K will greatly
in¯uence the destiny of the elderly. As the value of K
may vary among societies, surveys to determine K
might be necessary before DALYs analysis could be
put into practical use. In the case of Japan, K seems tobe almost zero when considering the Government's
positive attitude on the welfare policy for the elderly.
Disability weight

CAD TransplantAge(years)Although discounting future health is still controversial, it is strongly supported by some arguments: theopportunity cost argument, the time paradox argument,
and the disease eradication paradox argument.13,20,21
The discount rate could in¯uence the consequences ofanalysis; generally, a higher discount rate is more advantageous to C-E ratios of curative procedures than tothose of preventive procedures, because effectivenessof curative procedures occurs earlier and is affected
little by discount rate. In this study, the sensitivity
analysis was carried out and showed that discount rate
had little effect on the C-E ratios of dialysis and kidneytransplants.
Age weighting

LRD TransplantAge(years)Discounting

LRD Transplant: living-related donor transplant. CAD Transplant:
cadaveric donor transplant.

Disability weights for dialysis patients and kidneytransplant patients were determined by questionnaire.
The respondents to the survey seemed to be well quali®ed in the sense that they had suf®cient knowledge regarding medicine and policy making. Although there
were some inappropriate responses, such as the disability weight of ``0'' for ESRD patients, such responses
seem to be rather natural since the design of the Person
Trade-Off method itself contains ethical problems
which never would be accepted by some people. However, the medium data being used for the analysis
were quite reasonable with reference to the table of
22 indicator conditions, which was attached to thequestionnaire.
Cost-effectiveness of dialysis and transplantThis study suggests that a kidney transplant is much
more cost effective than dialysis in all age classes. As
stated above, this relationship would not change with

Keio J Med 2001; 50 (2): 100±108

107

Table 5Results of Cost-effectiveness Ratio

Age(years)Dialysis(thousand yen/DALY)LRD Transplant(thousand yen/DALY)CAD Transplant(thousand yen/DALY)A

P (O/M)

P (O/M)

P (O/M)

0±9
10±19
20±29
30±39
40±49
50±59
60±69
70±79
80±89
90

6,259
5,915
6,334
6,931
7,946
9,524
12,453
19,11242,755
170,834

1,851
1,537
1,675
1,831
2,232
2,913
±
±
±
±

2,992
1,852
1,932
2,174
2,706
3,399
±
±
±
±

Total

9,546

1,809

2,322

LRD Transplant: living-related donor transplant. CAD Transplant: cadaveric donor transplant.

Fig. 3

Sensitivity analysis by discount rates (age 10±19).

Fig. 4

Sensitivity analysis by age weight (dialysis).

discount rate and disability weight. As for limitations of
this study, the study was based on statistical data ofpractical treatments, and therefore matching of patients

Fig. 5

Sensitivity analysis by disability weight (age 10±19).

among treatments was not considered. It is possible thatthe difference of patients' conditions affected the valuesof the C-E ratio. Nevertheless, the results suggest thatthe difference of C-E ratio between dialysis and transplants is large enough to allow disregarding thepatients' conditions.
On the other hand, this result does not mean that atransplant is superior to dialysis in all aspects. As shownin column L of Table 3, we can expect dialysis to produce a higher EPP than a transplant. This means that
dialysis is favorable to extend life longer easily compared to a kidney transplant, which has a considerable
risk of rejection. Also, we cannot neglect the fact that
dialysis averts a much greater number of DALYs thandoes a kidney transplant, as shown in column M ofTable 3 (138,019 DALYs for dialysis, 5,740 DALYs
for LRD transplants, and 1,892 DALYs for CAD
transplants).

108

Kaminota M: Cost-effectiveness of dialysis and transplants

Application to the health policy in Japan
If the C-E ratios of health interventions are less thanthe price, which the society is willing to spend to avert 1
DALY (call this the S value), such interventions should
be made. The S value is considered to be at least equal
to the gross domestic product (GDP) per capita, because averting 1 DALY is equivalent to gaining 1 person year in perfect health, which would increase theGDP per capita. The GDP in Japan was 462 trillion
yen, and the GDP per capita was 3,716 thousand yen in
1995. Therefore LRD transplants (1,809 thousand yen/
DALY) and CAD transplants (2,322 thousand yen/
DALY) can be judged to be cost-effective. Then,should we continue dialysis, for which the C-E ratio is9,546 thousand yen/DALY? The decision would depend on the background of a country, such as history,social solidarity, and political situation. If we makedecisions from a utilitarian standpoint, dialysis might begiven up completely or be limited to young patients.
However, such a policy would never be accepted by theJapanese society, where egalitarianism has permeatedthe whole system; all people have a right to access tohealth services equally regardless of wealth, age, or sex
under universal health insurance coverage. The possible Government policy derived from this study would
therefore not be suppression of dialysis, but rather
promotion of kidney transplants. At least, the resultsof this study can be used for decision making of what
resources should be allocated to promote kidney transplantation.
Although the Government's health policy at present
is rarely formed based on cost-effectiveness analysis
in Japan, rapidly increasing medical expenditures will
someday lead to a realization that we have to manage the health care system with scarce resources andchoose cost-effective treatment using cost-effectivenessanalysis.
Acknowledgments: I thank Dr. Christopher Murray who instructed
me in DALYs when I was in the MPH course at Harvard School of
Public Health in 1997±8. Part of this study was done as MPH course
work. I would like to thank Professor Takefumi Kondo, Professor
Kazuyuki Omae, and Dr. Takamoto Uemura of the Department ofPreventive Medicine and Public Health, School of Medicine, Keio
University, for their comments on drafts of this article.

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