Essential inputs for studies of cost-effectiveness analysis in melanoma

Not applicabl

Essential inputs for studies of cost-effectiveness analysis in melanoma

Health-related quality of life, measured in either ‘utilities’ or ‘disability weights’ is an essential component of cost-effectiveness analysis and burden of disease studies

Patients who choose not to dialyze

Introduction and aims: Some patients with Stage 5 chronic kidney disease (CKD) choose supportive non-dialytic management or conservative care in preference to dialysis. The aims of this study were to estimate the national proportion of incident CKD Stage 5 patients referred to Nephrologists who choose not to dialyse, and investigate their characteristics. Methods: A prospective national multi-centre study of information given to incident CKD Stage 5 patients in Australian renal units, identified between 1st July and 30th September 2009. Patients with CKD who had not been referred to a nephrologist were excluded. Multi-level logistic regression models were used to determine which patient and unit characteristics were associated with receiving information about the option of conservative care and determine which characteristics were associated with commencement of conservative care compared to renal replacement therapy. Results: Sixty-six (90%) of 73 Australian renal units participated in the study. 102 of 721 (14%) of incident CKD Stage 5 patients chose not to dialyse, mean age 79 years (standard deviation 8.7). Nine of 50 (18%) of renal units managing conservative patients had a formal conservative care pathway. In multivariable analysis, age (p<0.001), language (p=0.0396), time known to a nephrologist (p<0.001), and the presence of a support person (p<0.001) were associated with the presentation of information about conservative care options. After adjusting for the patient’s gender, insurance status, size of the renal unit and presence of a formal conservative care pathway, patients over 60 years, OR 3.78(95% CI 2.39-5.00), non-English speakers, OR 2.52(95% CI 1.08-5.90), and those known to a nephrologist for more than 3 months, OR 5.83(95% CI 2.90-11.71), were more likely to receive information about conservative care. In unadjusted analysis the absence of a support person was strongly associated with a lower likelihood of receiving information about conservative care, OR 0.54(95% CI 0.34-0.86) however this effect lessened when adjusted for other factors, OR 0.65 (95% CI 0.39-1.09). In the second multivariable analysis that compared commencement of conservative care to renal replacement therapy, age (p<0.0001), gender (p=0.0169) and earlier CKD stage when treatment options were presented (p=0.027) were associated with commencement of conservative care. Patients older than 60 years, OR 7.84(95% CI 2.78-22.06); females, OR 2.01(95% CI 1.13-3.59); and those receiving information about their treatment options in Stage 3/4 CKD compared to Stage 5, OR 2.41 (95% CI 1.25-4.64), were more likely to decline renal replacement therapy. Conclusions: A considerable proportion (14%), of Australian CKD Stage 5 patients managed by Nephrologists choose conservative care, despite a lack of formal care pathways. Earlier presentation of treatment options including conservative care, to an older CKD population may result in more informed patient decision making, with choices being more strongly aligned to patient preferences. Further research is required in this area as many nephrologists feel unprepared or uncomfortable in discussions with patients about palliative treatment.Rachael Morton is supported by National Health and Medical Research Council (NHMRC) grants #457281 and #571372. RMT is supported by NHMRC program grants #402764 and #633003

Home hemodialysis: a comprehensive review of patient-centered and economic considerations

Internationally, the number of patients requiring treatment for end-stage kidney disease (ESKD) continues to increase, placing substantial burden on health systems and patients. Home hemodialysis (HD) has fluctuated in its popularity, and the rates of home HD vary considerably between and within countries although there is evidence suggesting a number of clinical, survival, economic, and quality of life (QoL) advantages associated with this treatment. International guidelines encourage shared decision making between patients and clinicians for the type of dialysis, with an emphasis on a treatment that aligned to the patients’ lifestyle. This is a comprehensive literature review of patient-centered and economic impacts of home HD with the studies published between January 2000 and July 2016. Data from the primary studies representing both efficiency and equity of home HD were presented as a narrative synthesis under the following topics: advantages to patients, barriers to patients, economic factors influencing patients, cost-effectiveness of home HD, and inequities in home HD delivery. There were a number of advantages for patients on home HD including improved survival and QoL and flexibility and potential for employment, compared to hospital HD. Similarly, there were several barriers to patients preferring or maintaining home HD, and the strategies to overcome these barriers were frequently reported. Good evidence reported that indigenous, low-income, and other socially disadvantaged individuals had reduced access to home HD compared to other forms of dialysis and that this situation compounds already-poor health outcomes on renal replacement therapy. Government policies that minimize barriers to home HD include reimbursement for dialysis-related out-of-pocket costs and employment-retention interventions for home HD patients and their family members. This review argues that home HD is a cost-effective treatment, and increasing the proportion of patients on this form of dialysis compared to hospital HD will result in a more equitable distribution of good health outcomes for individuals with ESKD

Renal unit characteristics and patient education practices that predict a high prevalence of home-based dialysis in Australia

Abstract AIM: The proportion of patients using home dialysis in Australia varies from 6% to 62% between renal units. The aim of this study was to determine if the variance is attributed to any underlying renal unit factors including pre-end stage education practices. METHODS: An online survey was distributed to all Australian units that offered home dialysis. Logistic regression was performed to estimate the effects of renal unit characteristics on the binary outcome of 1 h of pre-end stage education per patient, compared with ≤ 1 h predicted more than 10% of patients on HHD (OR 2.84, 95% CI 1.17-6.90). CONCLUSION: Our data suggest certain pre-end stage education practices are significantly associated with home dialysis rates above the national average. The consistent above average home dialysis rates witnessed in New South Wales appear to be the result of renal unit culture, education strategies and policies that support 'home dialysis first'. © 2014 Asian Pacific Society of Nephrology

Anti-coagulation, anti-platelets or no therapy in haemodialysis patients with atrial fibrillation: a decision analysis

BACKGROUND: Optimal treatment of atrial fibrillation (AF) in the haemodialysis population is uncertain due to the exclusion of this group from randomized trials. The risk-benefit profile for anticoagulation and anti-platelet therapy in haemodialysis differs from the general population due to platelet dysfunction from uraemia, altered pharmacokinetics and increased falls risk. METHODS: This decision analysis used a Markov-state transition model that took a patient perspective over a 5 year timeframe. The Markov model compared life-years gained and quality-adjusted life-years gained (QALY) for three AF treatment strategies: warfarin, aspirin and no treatment. The base case was a 70-year-old man on haemodialysis with non-valvular AF. RESULTS: In the base case, the total health outcomes in life-years and QALY were 2.37 and 1.47 respectively for warfarin, 2.38 and 1.61 respectively for aspirin, and 2.39 and 1.61 respectively for no treatment. Thus, warfarin led to 0.14 fewer QALY or 1.7 fewer months of life lived in full health, compared with either aspirin or no therapy. The finding that warfarin generated the lowest expected QALY was robust to one-way, two-way and probabilistic sensitivity analyses. CONCLUSIONS: Our results suggest that warfarin should not be the default choice for older haemodialysis patients with non-valvular AF as it provides the fewest QALY compared with aspirin or no therapy

Anti-coagulation, anti-platelets or no therapy in haemodialysis patients with atrial fibrillation: A decision analysis

Non

The impact of socio-economic status on melanoma clinical trial participation: an observational cohort study from Australia.

Low socio-economic status (SES) is reported to be a barrier to participation in cancer clinical trials due to out-of-pocket costs associated with trial participation, logistical barriers to attend screening services in different diagnostic and treatment centers, and associated cultural or linguistic barriers. One study of clinical trial participation in the ocular melanoma population, reported somewhat different results, whereby people of an older age (≥60 years), lower education level, and those with non-managerial jobs were more likely to participate in a clinical trial, than their younger, more educated counterparts. The aim of the present study was to determine whether SES was associated with participation in clinical trials for people with cutaneous melanoma