A systematic review of economic models comparing in-centre haemodialysis interventions: challenges for demonstrating cost-effectiveness in the context of high background dialysis costs.

The objective was to determine whether in-centre haemodialysis (ICHD) interventions that improve health outcomes can demonstrate cost effectiveness at different willingness-to-pay (WTP) thresholds, and how this is influenced by the inclusion of dialysis costs in additional life years. A systematic literature review (SLR) was performed to identify studies comparing the cost-effectiveness of ICHD modalities or add-ons to ICHD. Incremental costs from included studies were standardised to US Dollars and plotted onto cost-effectiveness planes (CEPs) along with incremental quality-adjusted life years (QALYs) to compare the cost effectiveness of relevant interventions at different WTP thresholds. Nineteen analyses were included from 13 studies. Interventions that improved health outcomes were considered cost effective at a WTP threshold of $37,484 (£30,000) per QALY in 7/19 analyses, including three analyses that excluded dialysis costs incurred in additional life years. At a WTP threshold of $150,000 per QALY, interventions were cost effective in 16/19 analyses. In a scenario comparing the cost effectiveness of haemodiafiltration (HDF) with conventional ICHD, only 1/9 analyses reported HDF to be cost effective at a WTP threshold of $37,484 per QALY gained; a study that excluded dialysis costs accrued in additional life years. At a WTP threshold of $150,000 per QALY, HDF was cost effective in 8/9 analyses. Inclusion of dialysis costs accrued in additional years of life makes demonstration of cost effectiveness challenging for interventions that improve outcomes. It should be considered whether the inclusion of such costs is appropriate, or whether higher WTP thresholds should apply for dialysis innovations.