Outcomes and Cost-effectiveness of Initiating Dialysis and Continuing Aggressive Care in Seriously Ill Hospitalized Adults

  1. Mary Beth Hamel, MD, MPH;
  2. Russell S. Phillips, MD;
  3. Roger B. Davis, ScD;
  4. Norman Desbiens, MD;
  5. Alfred F. Connors Jr., MD;
  6. Joan M. Teno, MD, MS;
  7. Neil Wenger, MD, MPH;
  8. Joanne Lynn, MD;
  9. Albert W. Wu, MD, MPH;
  10. William Fulkerson, MD; and
  11. Joel Tsevat, MD, MPH
  1. For the SUPPORT Investigators. 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.

    Abstract

    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.

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    1. Ann Intern Med August 1, 1997 vol. 127 no. 3 195-202
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