Outcomes and cost-effectiveness of initiating dialysis and continuing aggressive care in seriously III hospitalized adults

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.