The Economic Impact of Improving Phosphate Binder Therapy Adherence and Attainment of Guideline Phosphorus Goals in Hemodialysis Patients: a Medicare Cost-Offset Model

Ramakrishnan, Karthik; Braunhofer, Peter; Newsome, Britt A.; Lubeck, Deborah P.; Wang, Steven; Deuson, Jennifer; Claxton, Ami J.

doi:10.1007/s12325-014-0170-4

Cited by 11 publications

(7 citation statements)

References 15 publications

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“…A more liberal intake of plant-derived phosphate, together with attention to avoiding food additives, is probably compatible with good metabolic control and less need for phosphate binders, which account for a relevant portion of the pill burden in dialysis patients [160,161,162,163,164,165,166,167]. The awareness that hyperphoshatemia reflects a variety of nutritional and non-nutritional derangements can guide tailored interventions [167] (Figure 3).…”

Section: Diet and Dialysis: Four Paradoxesmentioning

confidence: 99%

The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach

et al. 2017

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The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients’ lives. In the early years of dialysis, potassium was identified as “the killer”, and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the “third era” finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the “magic numbers” of nutritional requirements (calories: 30–35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on “conventional” thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of “vascular healthy” food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.

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Section: Diet and Dialysis: Four Paradoxesmentioning

confidence: 99%

The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach

et al. 2017

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“…We did not find any publication on the cost‐effectiveness of other interventions for hyperphosphataemia management despite their increasing use in clinical practice, such as dietary interventions, exercise during dialysis and non‐dialysis times, dialysis prescription (long vs standard hour and frequent vs standard dialysis), and adherence‐promoting interventions. Economic evaluations of these interventions are needed, especially in the fields of dialysis prescription and adherence promotion, as they were effective in terms of decreased serum phosphorus55–57 and phosphate binders dose, an resulted in better survival, improved quality‐of‐life, and cost savings, among others. Several drawbacks were mentioned in the included articles, primarily pertaining to the lack of data in the following areas: long‐term effects of PB on survival and other health outcomes; cost impact and utility of hypercalcaemic events; utility of different PB and their side effects, adherence rates with different binders and their effects on outcomes and costs … Also, we could not identify any head‐to‐head comparison between calcium‐free binders.…”

Section: Discussionmentioning

confidence: 99%

“…We did not find any publication on the cost-effectiveness of other interventions Park 2011 37 Ruggeri 2014 39 Taylor 2008 41 Vegter 2011 43 Vegter 2012 44 1. Is the study population clearly [55][56][57] and phosphate binders dose, 57 an resulted in better survival, 56 improved quality-of-life, 58 and cost savings, 59 among others. Several drawbacks were mentioned in the included articles, primarily pertaining to the lack of data in the following areas: long-term effects of PB on survival and other health outcomes; cost impact and utility of hypercalcaemic events; utility of different PB and their side effects, adherence rates with different binders and their effects on outcomes and costs .…”

Section: Implications For Researchersmentioning

confidence: 99%

Economic evaluations of interventions to manage hyperphosphataemia in adult haemodialysis patients: A systematic review

et al. 2016

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This is an interesting systematic review of studies specifically addressing the economic evaluation of interventions to lower phosphate in dialysis patients. Only 12 studies provided information, all relating to phosphate binders. In general, the overall quality of these studies was suboptimal; therefore, firm conclusions were difficult to be drawn about which binders were best, although calcium-based binders seemed most cost-effective as first-line therapy. ABSTRACT:Managing hyperphosphataemia in haemodialysis patients is resourceintensive. A search for cost-effective interventions in this field is needed to inform decisions on the allocation of healthcare resources. NHSEED, MEDLINE, EMBASE and CINAHL were searched for full economic evaluations of hyperphosphataemia-managing interventions in adult haemodialysis patients, published between 2004 and 2014, in English, French, Dutch or German. Incremental cost-effectiveness ratios of the interventions were up-rated to 2013US$ using Purchasing Power Parity conversion rates and Consumer Price Indices. The quality of included studies was assessed using the Extended Consensus on Health Economic Criteria List. Twelve out of the 1681 retrieved records fulfilled the inclusion criteria. They reported only on one aspect of hyperphosphataemia management, which is the use of phosphate binders (calcium-based and calcium-free, in first-line and sequential use). No economic evaluations of other phosphorus-lowering interventions were found. The included articles derived from five countries and most of them were funded by pharmaceutical companies. The incremental costeffectiveness ratios of phosphate binders ranged between US$11 461 and US$157 760 per quality-adjusted life-year gained. Calcium-based binders (especially calcium acetate) appear to be the optimal cost-effective first-and second-line therapy in prevalent patients, while the calcium-free binder, lanthanum carbonate, might provide good value for money, as second-line therapy, in incident patients. The studies' overall quality was suboptimal. Drawing firm conclusions was not possible due to the quality heterogeneity and inconsistent results. Future high-quality economic evaluations are needed to confirm the findings of this review and to address other interventions to manage hyperphosphataemia in this population.

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“…Future research, ideally based on long-term observation, should focus on a possible association of reduced pill burden with improved compliance and adherence and resulting clinical effects, an aspect that could not be considered in this analysis due to a lack of data, but which has been addressed elsewhere [ 33 ]. The existence of differences in adherence between different phosphate binders and associated effects on clinical outcomes should be assessed in a real-life setting.…”

Section: Discussionmentioning

confidence: 99%

Cost Effectiveness of Sucroferric Oxyhydroxide Compared with Sevelamer Carbonate in the Treatment of Hyperphosphataemia in Patients Receiving Dialysis, from the Perspective of the National Health Service in Scotland

et al. 2015

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BackgroundHyperphosphataemia is common and harmful in patients receiving dialysis. Treatment options include noncalcium-based phosphate binders such as sevelamer carbonate (SC) and sucroferric oxyhydroxide (PA21).ObjectiveThe aim of this study was to determine the health economic impact of PA21-based strategies compared with SC-based strategies, from the perspective of the Scottish National Health Service (NHS).MethodsA Markov model was constructed based on data from a randomised clinical trial comparing PA21 and SC. Model input parameters were derived from published literature, national statistics and unpublished sources. Costs (price year 2012) and effects were discounted at 3.5 %. Analysis with a lifelong time horizon yielded the incremental cost-effectiveness ratio (ICER), expressed as cost or savings per quality-adjusted life-year (QALY) gained or forgone. Deterministic and probabilistic sensitivity analysis was performed to explore uncertainties around assumptions and model input parameters.ResultsIn the base-case analysis, phosphorus reductions for PA21 and SC were 1.93 and 1.95 mg/dL. Average undiscounted survival was estimated to be 7.61 years per patient in both strategies. PA21 patients accrued less QALYs (2.826) than SC patients (2.835), partially due to differential occurrence of side effects. Total costs were ₤13,119 and ₤14,728 for PA21 and SC, respectively (difference per patient of ₤1609). By using PA21 versus SC, one would save ₤174,999 (or ₤123,463 when including dialysis and transplantation costs) for one QALY forgone. A scenario modelling the nonsignificant reduction in mortality (relative risk 0.714) observed in the trial yielded an ICER for PA21 of ₤22,621 per QALY gained. In probabilistic sensitivity analysis of the base-case, PA21 was dominant in 11 %, and at least cost-effective in 53 %, of iterations, using a threshold of ₤20,000 per QALY gained.ConclusionsThe use of PA21 versus SC in hyperphosphataemic patients being intolerant of calcium-based phosphate binders may be cost saving and yields only very limited disadvantages in terms of quality-adjusted survival. PA21 appears to be cost-effective from the perspective of the Scottish NHS.

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The Economic Impact of Improving Phosphate Binder Therapy Adherence and Attainment of Guideline Phosphorus Goals in Hemodialysis Patients: a Medicare Cost-Offset Model

Abstract: Increasing phosphate binder adherence and improving phosphorus control were associated with increased cost savings in total Medicare costs and inpatient costs.

Cited by 11 publications

References 15 publications

The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach

The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach

Economic evaluations of interventions to manage hyperphosphataemia in adult haemodialysis patients: A systematic review

Cost Effectiveness of Sucroferric Oxyhydroxide Compared with Sevelamer Carbonate in the Treatment of Hyperphosphataemia in Patients Receiving Dialysis, from the Perspective of the National Health Service in Scotland

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