jkstn The Journal of the Korean Society for Transplantation J Korean Soc Transplant 1598-1711 The Korean Society for Transplantation 10.4285/jkstn.2015.29.4.200 jkstn-29-200 Original Article Quality of Life among End-stage Renal Disease Treatments and Economic Evaluation of Renal Transplantation and Hemodialysis Treatments JeonKyung-OckR.N. 1 SonSun-YoungR.N. 2 HahmMyung-IlPh.D. 3 KimSoon-IlM.D. 4 Organ Transplant Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Transplant Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Seoul, Department of Healthcare Management, Soonchunhyang University College of Medical Science, Seoul, Korea Asan, Department of Surgery and the Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea Corresponding authors: Soon-Il Kim Department of Surgery and the Research Institute for Transplantation, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: 82-2-2228-2118, Fax: 82-2-313-8289 E-mail: soonkim@yuhs.ac Myung-Il Hahm Department of Healthcare Management, Soonchunhyang University College of Medical Science, 22 Soonchunhyang-ro, Asan 31538, Korea Tel: 82-41-530-3035, Fax: 82-41-530-3085 E-mail: hmi@sch.ac.kr 01 2015 10 12 2015 29 4 200 208 28072015 02102015 26102015 Copyright © the Korean Society for Transplantation, 2015 2015 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background

Although renal transplantation is known as the best treatment for patients with end-stage renal disease, there are few of literature to identify economic evaluation of renal replacement therapies in Korea. This study was conducted to determine the cost-effectiveness of renal replacement treatments, particularly renal transplantation and hemodialysis.

 Methods

We used the quality adjusted life year (QALY) calculated from survey data, which was collected from 124 patients who underwent kidney transplantation and 90 patients who were receiving hemodialysis. Medical costs were collected from five hospitals in Korea. The ERA-EDTA registry data (European Renal Association-European Dialysis and Transplant Association) were used for transition probability. A Markov model was used for predicting the cost-utility of transplantation and hemodialysis over the 10-year period.

 Results

Renal transplantation offers lower cost and better outcome compared to hemodialysis. QALY per year of transplantation patients is higher than that of hemodialysis patients (transplantation 0.9465 vs. hemodialysis 0.8297). Cost per QALY gained is 15,566,000 won in transplantation patients whereas 32,765,000 won per QALY gained in hemodialysis patients was required.

 Conclusions

Although cost of first year after transplantation was expensive, over 2 years, transplantation was more effective and less costly than hemodialysis. The results suggest that transplantation is more cost-effective than hemodialysis in Korea.

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General characteristics of study subjects to measure the quality adjusted life year

Characteristic Transplantation Dialysis P-value
Total 124 (57.9) 90 (42.1)  
Sex      
　 Female 57 (46.0) 53 (58.9) 0.084
　 Male 67 (54.0) 37 (41.1)  
Age (yr)      
　 20∼29 6 (4.8) 6 (6.7) 0.321
　 30∼39 12 (9.7) 14 (15.5)  
　 40∼49 29 (23.4) 26 (28.9)  
　 50∼59 48 (38.7) 24 (26.7)  
　 60∼69 29 (23.4) 20 (22.2)  
　 Continuous a 51.1±10.3 49±12.3 0.174
Income (thousand won)      
　 ＜1,000 8 (7.3) 29 (34.1) ＜0.001
　 1,000≤&＜2,000 21 (19.3) 14 (16.5)  
　 2,000≤&＜3,000 29 (26.6) 16 (18.8)  
　 3,000≤&＜5,000 37 (33.9) 19 (22.4)  
　 5,000≤ 14 (12.9) 7 (8.2)  
Education (yr)      
　 ＜9 3 (2.4) 6 (6.9) 0.075
　 9≤&＜12 11 (8.9) 7 (8.0)  
　 12≤&＜14 51 (41.1) 46 (52.9)  
　 14≤ 59 (47.6) 28 (32.2)  
Job      
　 Unemployed 3 (2.8) 3 (4.1) 0.411
　 Housewives 24 (22.2) 22 (29.7)  
　 Non-manual 51 (47.2) 26 (35.1)  
　 Manual 30 (27.8) 23 (31.1)  
Universal health coverage      
　 Health insurance 107 (90.7) 71 (80.7) 0.062
　 Medical aid 11 (9.3) 17 (19.3)  
Private insurance      
　 Yes 15 (12.4) 21 (23.9) 0.048
　 No 106 (87.6) 67 (76.1)  
Region      
　 Metropolitan 65 (52.4) 59 (65.6) 0.066
　 Urban 52 (41.9) 30 (33.3)  
　 Rural 7 (5.7) 1 (1.1)  

Data are presented as number (%) or mean±SD.

Continuous value of age.

Self-evaluated health status and QALY of respondents with EQ-5D among ESRD patients

Variable Total Transplantation Dialysis P-value
Total 214 124 (57.9) 90 (42.1)  
Mobility       0.004
　 Level 1. No problem 178 111 (89.5) 67 (74.4)  
　 Level 2. Some problem 32 13 (10.4) 19 (21.1)  
　 Level 3. Severe problem 4 0 4 (4.5)  
Self care       0.329
　 Level 1. No problem 202 119 (96.8) 83 (92.2)  
　 Level 2. Some problem 6 2 (1.6) 4 (4.5)  
　 Level 3. Severe problem 5 2 (1.6) 3 (3.3)  
Usual activities       ＜0.001
　 Level 1. No problem 152 106 (85.5) 46 (51.1)  
　 Level 2. Some problem 59 18 (14.5) 41 (45.6)  
　 Level 3. Severe problem 3 0 3 (3.3)  
Pain/discomfort       ＜0.001
　 Level 1. No problem 143 100 (80.6) 43 (47.8)  
　 Level 2. Some problem 63 23 (18.6) 40 (44.4)  
　 Level 3. Severe problem 8 1 (0.8) 7 (7.8)  
Anxiety/depression       0.005
　 Level 1. No problem 151 98 (79.0) 53 (58.9)  
　 Level 2. Some problem 59 25 (20.2) 34 (37.8)  
　 Level 3. Severe problem 4 1 (0.8) 3 (3.3)  
QALY per year 214 0.9465±0.0879 0.8297±0.2214 ＜0.001
EQ-VAS 214 78.9±13.7 68.0±21.0 ＜0.001

Data are presented as number (%) or mean±SD.

Abbreviations: QALY, quality adjusted life year; EQ-5D, EuroQ0l–5 dimension; ESRD, end-stage renal disease; EQ-VAS, EuroQol-visual analogue scale.

The cost-effectiveness of transplantation and hemodialysis in ESRD patients (unit 1,000 won)

　 Strategy Cost Incremental cost Effectiveness (QALY) Incremental effectiveness (QALY) C/E ICER (1,000 won/QALY)
Transplantation 97,053 – 6.23 – 15,566/1 QALY Dominant (less costly
            & more effective)
Dialysis 133,447 36,394 4.07 −2.16 32,765/1 QALY –

Abbreviations: ESRD, end-stage renal disease; QALY, quality adjusted life year; C/E, cost effectiveness ratio; ICER, incremental cost effectiveness ratio.

Results of sensitivity analysis by discount rate (unit 1,000 won)

Discount rate (%) Strategy Cost Incremental cost Effectiveness (QALY) Incremental effectiveness (QALY) C/E ICER (1,000 won/QALY)
3 Transplantation 102,073 – 6.77 – 15,080 Dominant (less costly and more effective)
  Dialysis 142,706 40,633 4.37 −2.40 32,658  
5 Transplantation 97,053 – 6.23 – 15,566 Dominant (less costly and more effective)
  Dialysis 133,447 36,394 4.07 −2.16 32,765  
7 Transplantation 92,637 – 5.77 – 16,056 Dominant (less costly and more effective)
  Dialysis 125,304 32,667 3.81 −1.96 32,871  

Abbreviations: QALY, quality adjusted life year; C/E, cost effectiveness ratio; ICER, incremental cost effectiveness ratio.

Results of sensitivity analysis by operation cost (unit 1,000 won)

Operation cost Strategy Cost Incremental cost Effectiveness (QALY) Incremental effectiveness (QALY) C/E Incremental C/E (ICER)
10,035 Transplantation 92,033 – 6.23 – 14,761 Dominant (less costly and more effective)
  Dialysis 133,447 41,414 4.07 −2.16 32,765  
20,070 Transplantation 97,053 – 6.23 – 15,566 Dominant (less costly and more effective)
  Dialysis 133,447 36,394 4.07 −2.16 32,765  
30,105 Transplantation 102,073 – 6.23 – 20,456 Dominant (less costly and more effective)
  Dialysis 133,447 31,374 4.07 −2.16 32,765  

Abbreviations: QALY, quality adjusted life year; C/E, cost effectiveness ratio; ICER, incremental cost effectiveness ratio.