NDT Advance Access originally published online on June 25, 2007
Nephrology Dialysis Transplantation 2007 22(10):2867-2878; doi:10.1093/ndt/gfm367
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Economic evaluation of sevelamer in patients with end-stage renal disease
1Department of Community Health Sciences, 2Department of Medicine, Division of Nephrology, University of Calgary, Calgary, 3Institute of Health Economics, 4Department of Medicine, Division of Nephrology, 5Division of Critical Care Medicine and 6Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada
Correspondence and offprint requests to: Dr Marcello Tonelli, University of Alberta, Division of Nephrology and Immunology, 7-129 Clinical Science Building, 8440 112 Street, Edmonton, Alberta T6B 2b7 Canada. Email: mtonelli{at}ualberta.ca
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Abstract |
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Background. There is uncertainty about the most cost-effective way to treat hyperphosphataemia in patients with end-stage renal disease.
Methods. We performed an economic analysis which compared the use of sevelamer with calcium carbonate in a simulated cohort of North American dialysis patients, using the perspective of the health care purchaser and a lifetime horizon. Outcomes considered were quality-adjusted life years (QALYs) gained and health care costs. To account for uncertainty, we considered four separate modelling strategies, obtaining data on the relative effectiveness of sevelamer from the recent Dialysis Clinical Outcomes Revisited study.
Results. In the base analysis, the use of sevelamer was associated with a cost per QALY gained of CAN$157 500, compared with calcium carbonate. Assuming no survival or hospitalization advantage for sevelamer, use of sevelamer resulted in an incremental cost of CAN$17 000 per patient. In alternate models which assumed sevelamer to be more effective than calcium-based phosphate binders, the use of sevelamer was associated with a cost per QALY gained ranging from CAN$127 000–$278 100. Assuming that sevelamer resulted in a differential reduction in mortality in patients 
65 years of age, use of sevelamer in this subgroup was associated with a cost per QALY of CAN$105 500. Results were similar in groups defined by age 55 or by 45 years. Since dialysis is expensive, interventions for dialysis patients that improve survival without reducing the need for dialysis will be associated with a cost-utility ratio at least as great as that of dialysis itself. As such, we repeated the primary analysis excluding the costs of dialysis and transplantation and found that the cost per QALY gained for sevelamer was $77 600.
Conclusions. The cost per QALY gained for treating all dialysis patients with sevelamer exceeds what would usually be considered good value for the money. While the high cost per QALY was in part due to the inclusion of the costs of dialysis and transplant in the analysis, the cost per QALY gained remained relatively unattractive even when these costs were excluded. Although a lower cost per QALY gained is realized when only patients older than 65 years are treated, this strategy remains economically unattractive, particularly given the uncertainty of clinical benefit in this group.
Keywords: Sevelamer; Calcium; Hyperphosphatemia; Economic Evaluation
Received for publication: 7. 3.07
Accepted in revised form: 14. 5.07
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