MO800: A Systematic Literature Review on the Costs and Healthcare Resource Utilization Associated With Dialysis And Anemia Management by Dialysis Modality in Patients With End-Stage Kidney Disease
Authors: Rastogi Anjay , Schiavo Sofia , Makhija Dilip , Benjumea Darrin , Gidey Saba , Mcewan Phil , Rabar Silvia , Berner Todd 
Published: May 2022

Abstract

BACKGROUND AND AIMS
End-stage kidney disease (ESKD) is associated with a high clinical and economic burden. Dialysis modalities include in-center hemodialysis (ICHD) and home dialysis [home hemodialysis (HHD) or peritoneal dialysis (PD)]. The prevalence of anemia in ESKD is estimated to be &gt; 50% and is associated with an increased risk of comorbidities and a lower quality of life [1]. Understanding the economic consequences of dialysis by modality of care, in the general ESKD population and the anemia-related ESKD population, is an essential aspect of the value of home dialysis. This study assessed the extent to which the economic burden of dialysis in ESKD and the management of anemia in ESKD have been characterized in the literature based on modality of care (HHD versus PD versus ICHD).

METHOD
A systematic literature review (SLR) was conducted to characterize costs and healthcare resource use (HCRU) in patients receiving ICHD, HHD or PD, and to further assess the impact of anemia. Data extracted included, but were not limited to, the cost of dialysis, hospitalizations, erythropoiesis-stimulating agents (ESAs) and other drug costs. Database searches were conducted in Embase, Medline, EconLit, Cochrane Library and University of York Center for Reviews and Dissemination (2011–21).

RESULTS
Searches identified 1105 records, of which 43 met the inclusion criteria (costs = 26, HCRU = 8, costs and HCRU = 9). Studies were conducted in Europe (n = 18), North America (n = 14), Asia (n = 7), Australia (n = 2), South America (n = 1) and mixed continents (n = 1). A total of 15 studies were observational/database analyses, and 28 were economic evaluations. Most studies compared costs, including direct (medical and pharmacy) and indirect, and/or HCRU for ICHD, HHD and PD (n = 22), while 11 compared ICHD and HHD and 10 compared ICHD and PD. A summary of results is reported in the Table 1. A total of 14 primary cost studies reported total dialysis costs and showed that ICHD was more expensive than HHD/PD per patient per year. A total of 16 economic models presented relevant outputs in the form of total dialysis costs. The majority of these (n = 13) reported that ICHD is more costly than HHD/PD, with 11 studies concluding that HHD/PD is cost-effective or even dominant compared with ICHD. HCRU was presented in 17 studies, with hospitalizations the most frequently reported (n = 12). Some studies reported that ICHD patients incurred more all-cause hospitalizations than HHD/PD patients, while others reported the opposite (especially for high-dose or frequent modalities). Four studies reported that patients receiving HHD/PD had more in-hospital days than ICHD. There was limited evidence for anemia-related outcomes, with only 11 studies showing either costs and/or HCRU relating to ESA or iron use (Table 1). Five studies reported that the use and dose of epoetin alfa or general ESAs were higher in ICHD patients than in HHD/PD patients (Fig. 1). Of these, one study reported the same trend for IV iron use but the opposite for darbepoetin alfa using baseline data. Four studies reported the same ESA costs for different modalities. An additional four studies reported a higher ESA cost for ICHD patients compared with HHD/PD, with three of the studies indicating that this is related to differences in dosage and use of ESAs. One economic evaluation modeled that ESA and iron costs were higher for HHD than ICHD, though not statistically significant (Table 1).

CONCLUSION
Most studies reported a higher total dialysis cost for ICHD compared with home dialysis, with evidence that home dialysis is cost-effective. There was a paucity of evidence characterizing anemia in ESKD. In this SLR, more ICHD patients used ESAs and at higher doses than HHD/PD patients, thus incurring a higher cost. Global interests highlight increasing home dialysis penetration; therefore, it is important to understand the cost differences and drivers of these differences in ESKD patients with anemia.