OBJECTIVES : End-stage renal disease (ESRD) remains a substantial cost burden that currently affects less than 1% of US adults, while steadily accounting for approximately 7% of overall Medicare fee-for-service spending over the past 15 years. Home dialysis has been associated with lower costs and better health outcomes compared to in-center dialysis. The objective of this study was to assess the cost utility of the proposed End-Stage Renal Disease Treatment Choices Model (ETC) from a health system and societal perspective.

METHODS : A Markov model simulated a cohort of patients transitioning between health states representing in-home or in-center dialysis, renal transplant, and death to compare the ETC model to in-center dialysis. Costs were estimated from the societal and healthcare perspective for the 2018 US Medicare population in 1-year cycles over a lifetime time horizon with a 3% discount rate for all health outcome and cost inputs. The outcomes measured were life-years, quality-adjusted life years (QALYs), costs, and incremental cost effectiveness ratio (ICER). One-way sensitivity analyses were conducted to determine the drivers of the base case results.

RESULTS : Implementation of ETC resulted in an incremental change of 0.09 life-years, 0.08 QALYs, and $5,467 in costs from the healthcare perspective and an incremental change of 0.09 life-years, 0.15 QALYs and -$7,240 in costs from the societal perspective. From the healthcare system perspective, the ICER was $67,528/QALY from the healthcare perspective, which was most sensitive to annual home dialysis costs and patient utility. From a societal perspective, the implementation of ETC dominated in-center dialysis with cost-savings and higher incremental QALYs across results from deterministic and one-way sensitivity analyses.

CONCLUSIONS : Our model suggests implementation of ETC may provide clinical benefit to patients while being cost-effective or even cost-saving compared to in-center dialysis among patients requiring RRT for the management of ESRD.