 |
 |
|
Home |
Current Issue |
Past Issues |
In the Clinic |
ACP Journal Club |
CME |
Collections |
Audio/Video |
Mobile |
Subscribe |
Tools |
Help |
ACP Online
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1 August 1997 | Volume 127 Issue 3 | Pages 195-202
Background: Renal failure requiring dialysis in the setting of hospitalization for serious illness is a poor prognostic sign, and dialysis and aggressive care are sometimes withheld.
Objective: To evaluate the clinical outcomes and cost-effectiveness of initiating dialysis and continuing aggressive care for seriously ill hospitalized patients.
Design: Prospective cohort study and cost-effectiveness analysis.
Setting: Five geographically diverse teaching hospitals.
Patients: 490 patients (median age, 61 years; 58% women) enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) in whom dialysis was initiated.
Measurements: Survival, functional status, quality of life, and health care costs. Life expectancy was estimated by extrapolating survival data (up to 4.4 years of follow-up) using a declining exponential function. Utilities (quality-of-life weights) were estimated by using time-tradeoff questions. Costs were based on data from SUPPORT and published Medicare data.
Results: Median duration of survival was 32 days, and only 27% of patients were alive after 6 months. Survivors reported a median of one dependency in activities of daily living, and 62% rated their quality of life as "good" or better. Overall, the estimated cost per quality-adjusted life-year saved by initiating dialysis and continuing aggressive care rather than withholding dialysis and allowing death to occur was $128 200. For the 103 patients in the worst prognostic category, the estimated cost per quality-adjusted life-year was $274 100; for the 94 patients in the best prognostic category, the cost per quality-adjusted life-year was $61 900.
Conclusions: For the few patients who survived, clinical outcomes were fairly good. With the exception of patients with the best prognoses, however, the cost-effectiveness of initiating dialysis and continuing aggressive care far exceeded $50 000 per quality-adjusted life-year, a commonly cited threshold for cost-effective care.
Author and Article Information
For the SUPPORT Investigators.
ARTICLE
Outcomes and Cost-effectiveness of Initiating Dialysis and Continuing Aggressive Care in Seriously Ill Hospitalized Adults
From Beth Israel Deaconess Medical Center, Boston, Massachusetts; University of Tennessee College of Medicine, Chattanooga, Tennessee; University of Virginia School of Medicine, Charlottesville, Virginia; George Washington University, Washington, D.C.; University of California, Los Angeles, School of Medicine, Los Angeles, California; Johns Hopkins University, Baltimore, Maryland; Duke University Medical Center, Durham, North Carolina; and University of Cincinnati Medical Center, Cincinnati, Ohio.
Note: The opinions and findings in this manuscript are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or their Board of Trustees.
Grant Support: In part by the Robert Wood Johnson Foundation.
Requests for Reprints: Mary Beth Hamel, MD, MPH, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.
Current Author Addresses: Drs. Hamel, Phillips, and Davis: Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, LY-330, Boston, MA 02215.
This article has been cited by other articles:
|
|
 |
|
  A. A. Desai, J. Baras, B. B. Berk, A. Nakajima, A. M. Garber, D. Owens, and G. M. Chertow Management of Acute Kidney Injury in the Intensive Care Unit: A Cost-effectiveness Analysis of Daily vs Alternate-Day Hemodialysis Arch Intern Med, September 8, 2008; 168(16): 1761 - 1767. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. M. Bagshaw Short- and long-term survival after acute kidney injury Nephrol. Dial. Transplant., July 1, 2008; 23(7): 2126 - 2128. [Full Text] [PDF]
|
|
|
|
|
|
J. F. Dasta, S. L. Kane-Gill, A. J. Durtschi, D. S. Pathak, and J. A. Kellum Costs and outcomes of acute kidney injury (AKI) following cardiac surgery Nephrol. Dial. Transplant., June 1, 2008; 23(6): 1970 - 1974. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. S. Patel and J. L. Holley Withholding and Withdrawing Dialysis in the Intensive Care Unit: Benefits Derived from Consulting the Renal Physicians Association/American Society of Nephrology Clinical Practice Guideline, Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis Clin. J. Am. Soc. Nephrol., March 1, 2008; 3(2): 587 - 593. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F Keller, G Allert, H Baitsch, G Sponholz, and Ethics in Medicine Working Group at the University Discourse ethics in practical medicine Med. Humanit., December 1, 2006; 32(2): 99 - 103. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. E. Hall Religious Attendance: More Cost-Effective Than Lipitor? J Am Board Fam Med, March 1, 2006; 19(2): 103 - 109. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Uchino, J. A. Kellum, R. Bellomo, G. S. Doig, H. Morimatsu, S. Morgera, M. Schetz, I. Tan, C. Bouman, E. Macedo, et al. Acute Renal Failure in Critically Ill Patients: A Multinational, Multicenter Study JAMA, August 17, 2005; 294(7): 813 - 818. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Y Rady and D. J Johnson Admission to intensive care unit at the end-of-life: is it an informed decision? Palliative Medicine, December 1, 2004; 18(8): 705 - 711. [Abstract] [PDF]
|
|
|
|
 |
|
 J. D. Cowan Hospital charges for a community inpatient palliative care program American Journal of Hospice and Palliative Medicine, May 1, 2004; 21(3): 177 - 190. [Abstract] [PDF]
|
|
|
|
 |
|
 Y. Yazdanpanah Costs associated with combination antiretroviral therapy in HIV-infected patients J. Antimicrob. Chemother., April 1, 2004; 53(4): 558 - 561. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. V. Kshirsagar, C. Poole, A. Mottl, D. Shoham, N. Franceschini, G. Tudor, M. Agrawal, C. Denu-Ciocca, E. Magnus Ohman, and W. F. Finn N-Acetylcysteine for the Prevention of Radiocontrast Induced Nephropathy: A Meta-Analysis of Prospective Controlled Trials J. Am. Soc. Nephrol., March 1, 2004; 15(3): 761 - 769. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. E. Cox, S. S. Carson, and A. K. Biddle Cost-effectiveness of Ultrasound in Preventing Femoral Venous Catheter-associated Pulmonary Embolism Am. J. Respir. Crit. Care Med., December 15, 2003; 168(12): 1481 - 1487. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T M Arnesen and O F Norheim Quantifying quality of life for economic analysis: time out for time trade off Med. Humanit., December 1, 2003; 29(2): 81 - 86. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. M.R. Spiegel, L. Targownik, G. S. Dulai, and I. M. Gralnek The Cost-Effectiveness of Cyclooxygenase-2 Selective Inhibitors in the Management of Chronic Arthritis Ann Intern Med, May 20, 2003; 138(10): 795 - 806. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S.-C. Bae, M. Corzillius, K. M. Kuntz, and M. H. Liang Cost-effectiveness of low dose corticosteroids versus non-steroidal anti-inflammatory drugs and COX-2 specific inhibitors in the long-term treatment of rheumatoid arthritis Rheumatology, January 1, 2003; 42(1): 46 - 53. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. L. Bosch, J. A. Kaufman, M. T. Beinfeld, M. E. A. P. M. Adriaensen, D. C. Brewster, and G. S. Gazelle Abdominal Aortic Aneurysms: Cost-effectiveness of Elective Endovascular and Open Surgical Repair Radiology, November 1, 2002; 225(2): 337 - 344. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Understanding Costs and Cost-Effectiveness in Critical Care . Report from the Second American Thoracic Society Workshop on Outcomes Research Am. J. Respir. Crit. Care Med., February 15, 2002; 165(4): 540 - 550. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P.E. Stevens, N.A. Tamimi, M.K. Al-Hasani, A.I. Mikhail, E. Kearney, R. Lapworth, D.I. Prosser, and P. Carmichael Non-specialist management of acute renal failure QJM, October 1, 2001; 94(10): 533 - 540. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. J. Smith and B. E. Hillner Ensuring Quality Cancer Care by the Use of Clinical Practice Guidelines and Critical Pathways J. Clin. Oncol., June 1, 2001; 19(11): 2886 - 2897. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. A. Freedberg, E. Losina, M. C. Weinstein, A. D. Paltiel, C. J. Cohen, G. R. Seage, D. E. Craven, H. Zhang, A. D. Kimmel, and S. J. Goldie The Cost Effectiveness of Combination Antiretroviral Therapy for HIV Disease N. Engl. J. Med., March 15, 2001; 344(11): 824 - 831. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Klahr and S. B. Miller Acute Oliguria N. Engl. J. Med., March 5, 1998; 338(10): 671 - 675. [Full Text] [PDF]
|
|
Article
