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Titolo	Intensifying dialysis: how far should we go and at what cost?
Autore	Lieven Annemans - Department of Public Health, Ghent University, Belgium
Referenza	Nephrol Dial Transplant 2008; doi: 10.1093/ndt/gfn680
Contenuto	Extract In a recent issue of JASN, Lee and colleagues presented the results of a simulation model estimating the cost-effectiveness of different modalities of centre-based dialysis, increasing frequency and/or duration. Their simulation shows that this intensified approach, even with?according to the authors?rather conservative assumptions about its benefit is associated with poor cost-effectiveness. None of the simulations resulted in a cost per quality adjusted life year (QALY) below $75 000. Generally, the societal threshold for the willingness to pay for gaining 1 QALY is around $50 000 as the authors confirm. In other words, the extra money spent on the increased frequency and/or increased duration does not result in a proportionally acceptable health benefit. Spending this money elsewhere (for instance on better prevention of nephropathy, or on alternative non-centre-based types of dialysis) would bring much more benefit to society. Hence, if I were a payer (whether it would be an insurer or NHS responsible) I would not pay for this care, based on these results. I would invest much more in alternative non-in-centre based types of dialysis. I could of course request additional information and allow the use of intensified dialysis in a research setting, hence reimbursing it conditionally upon more evidence to be expected. This will likely reduce uncertainty, but this also costs money. A possible way out is to calculate the value of information beforehand. This method, based on modelling techniques, focuses on the value of obtaining further information that will reduce uncertainty. If that value turns out to be lower than the cost of this further research, one may decide not to undertake this further research. Calculating this value of information may perhaps be a new challenge for Lee et al..
Data	12.01.2009

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