0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Articles |

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

Mary Beth Hamel, MD, MPH; Russell S. Phillips, MD; Roger B. Davis, ScD; Norman Desbiens, MD; Alfred F. Connors Jr., MD; Joan M. Teno, MD, MS; Neil Wenger, MD, MPH; Joanne Lynn, MD; Albert W. Wu, MD, MPH; William Fulkerson, MD; and Joel Tsevat, MD, MPH
[+] Article and Author Information

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.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1997;127(3):195-202. doi:10.7326/0003-4819-127-3-199708010-00003
Text Size: A A A

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.

Figures

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Submit a Comment

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)