A simulation model to estimate the cost and effectiveness of alternative dialysis initiation strategies

Background. Patients with end-stage renal disease (ESRD) require dialysis to maintain survival. The optimal timing of dialysis initiation in terms of cost-effectiveness has not been established. Methods. We developed a simulation model of individuals progressing towards ESRD and requiring, dialysis. It can be used to analyze dialysis strategies and scenarios. It was embedded in an optimization frame worked to derive improved strategies. Results. Actual (historical) and simulated survival curves and hospitalization rates were virtually indistinguishable. The model overestimated transplantation costs (10%) but it was related to confounding by Medicare coverage. To assess the model's robustness' we examined several dialysis strategies while input parameters were perturbed. Under all 38 scenarios, relative rankings remained unchanged. An improved policy for a hypothetical patient was derived using an optimization algorithm. Conclusion. The model produces reliable results and is robust. It enables the cost-effectiveness analysis of dialysis strategies.