OBJECTIVES: The high cost of dialysis, coupled with the diminished patient quality of life, often results in the incremental cost-effectiveness ratio being above willingness-to-pay (WTP) thresholds of countries. Despite this, the life-saving dialysis treatment remains the standard of care globally, indicating an acceptance of these costs by the society. This study questions whether standard economic evaluations are suitable for assessing life-extending innovations in dialysis.

METHODS: A systematic literature review was performed per the Preferred Reporting Item for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify clinical and economic benefits of Hemodiafiltration (HDF) versus Hemodialysis (HD) in in-center patients from 2013 onwards. Databases searched included Embase, MEDLINE, EBM reviews, and EconLit. Only the economic evaluations identified were analyzed.

RESULTS: Five economic evaluations were included. Three studies found HDF cost-effective but only when excluding life extension-related dialysis costs. Two studies concluded HDF to be not cost-effective. One of these two studies did consider additional life-year costs in a secondary analysis; however, the analysis’ time-horizon was set to 5 years.

CONCLUSIONS: Standard economic evaluations may not be suitable for assessing life-extending innovations in dialysis. Due to the inherently high cost of dialysis, treatments with survival benefits incur significant general dialysis-related costs over the additional life years gained. If these costs are not excluded, such interventions are unlikely to show cost-effectiveness with a lifetime horizon at country-specific WTP thresholds (e.g., UK at £20–30,000). Since the determination of cost-effectiveness heavily depends on the WTP threshold, the question arises whether the WTP should be increased, or costs excluded from the analysis while keeping the WTP constant. To incentivize innovation, expanded cost-effectiveness analysis or multi-criteria decision analysis might offer a more comprehensive assessment of high-cost treatments, however more research is needed.