Évaluation médico-économique des stratégies de prise en charge de l’insuffisance rénale chronique terminale en France

Abstract

End-stage renal disease is a chronic state that may continue for many years before death. Patients may receive various modalities of renal replacement therapy that vary over time, which we describe as a treatment trajectory. The French health insurance system pays dialysis facilities and professionals various fixed fees according to the dialysis modalities they provide; fees are highest for hospital-based haemodialysis care, which treats around 58% of all dialysis patients. As in other European countries, a variety of dialysis modalities are used in France, and their weight and distribution differ from region to region. This study hypothesizes that some patients currently treated in hospital-based haemodialysis could be treated with another RRT modality without any increase in mortality risk. The aim of this study was to propose new care strategies so as to evaluate the medico-economic impact of replacing some hospital-based HD care by various other modalities for French health insurance. Care strategies were modelled using a statistical tool that predicts course and trajectories of a hypothetical cohort of news patients over a 15-year period. The results confirmed that the development of kidney transplantation in six sub-cohorts (according to age and diabetes status) is an efficient strategy, compared to all evaluated strategies. Strategies considering joint development of peritoneal dialysis and hospital-based haemodialysis are efficient for patients over 45 years but their feasibility has to be evaluated. Other alternative strategies also need to be considered because they are as effective and less costly than the current care practices.