Optimal Initiation and Management of Dialysis Therapy
成果类型：
Article
署名作者：
Lee, Chris P.; Chertow, Glenn M.; Zenios, Stefanos A.
署名单位：
University of Pennsylvania; Stanford University; Stanford University
刊物名称：
OPERATIONS RESEARCH
ISSN/ISSBN：
0030-364X
DOI：
10.1287/opre.1080.0613
发表日期：
2008
页码：
1428-1449
关键词：
摘要：
Dialysis is the most common therapy for patients afflicted with chronic kidney failure. Currently, little is known about the relationship between the timing of dialysis initiation and the therapy's cost and effectiveness. This paper examines the cost-effective initiation of dialysis and compares standard initiation criteria from the clinical literature to computationally derived strategies. Comparisons make use of a simulation model that integrates submodels of disease progression, hospitalization, transplantation, cost, and quality of life. The simulation model is also used by an approximate dynamic programming (ADP) algorithm to derive approximately optimal strategies that maximize patient welfare. Patient welfare is measured from the society's perspective and is defined as the product of the expected discounted quality-adjusted life years (QALYs) and a value-of-life parameter, minus the expected total discounted medical expenditures. Also considered is an alternative formulation in which the goal is to minimize the expected total discounted medical expenditures without affecting patient QALYs relative to current medical practice. Numerical results show that: (i) standard early initiation strategies, where once started on dialysis patients are kept on a fixed weekly program, have a limited potential, and (ii) early dialysis at an incrementally increasing dose customized to each patient can yield a significant cost advantage. These findings demonstrate computationally intensive models of disease progression, and therapy effectiveness can identify novel strategies for managing expensive medical therapies and a more efficient use of scarce health-care resources.