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Renal Replacement Therapy in Critical Care

Disclaimer

Policy Forum Options Series

The Policy Forum is a pan-Canadian committee of senior health care decision-makers who are tasked with the development of evidence-based joint policy initiatives related to the implementation, management, and decommissioning of health technologies. The Policy Forum was created in response to the Health Technology Strategy 1.0, and its subsequent implementation strategy, approved by the Conference of Deputy Ministers in May 2004 and April 2005 respectively. Members of the Policy Forum include senior officials involved in health policy from each of the 14 federal, provincial and territorial health ministries, as appointed by the Deputy Ministers of Health. Also included are two non-voting members: one from Industry Canada and the other from the Interprovincial and Territorial Medical Directors group. The Canadian Agency for Drugs and Technologies in Health (CADTH) serves as the secretariat for the Policy Forum.

This is the first options paper produced by the Policy Forum and it has served to test the process for the development of joint health technology policy initiatives. The analysis presented in this document is based primarily on evidence from a health technology assessment (HTA) produced by CADTH.1   An expert review panel was struck to obtain input from nephrologists, intensivists, and program managers from across the country.

The intended audience for this options document includes decision-makers at regional health authorities, renal program managers, critical care unit managers, and clinicians treating acute renal failure in critical care settings. The purpose of this document is to assist these individuals in making evidence-based decisions about the provision of renal replacement therapies in critical care settings. This document is not intended to serve as a clinical guideline.

Issue

To reduce hospital-based acute care spending while promoting positive clinical outcomes by determining which of the two most commonly used renal replacement therapies for acute renal failure in critically ill adult patients is most appropriate.

Key Research Findings from CADTH HTA

  • The systematic review did not reveal statistically significant differences in clinical outcomes between intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). Economic models suggested that IHD could be cost-saving or lead to additional downstream costs. Cost-effectiveness is influenced by small differences in patient survival and need for long-term dialysis.
  • IHD reduces acute-care costs. Given current CRRT usage rates of 26% to 68%, selectively funding IHD when either technology is appropriate would save $2.1 million to $6.1 million in annual acute-care costs across Canada.
  • The benefit from CRRT is yet to be proven. Compared with IHD, observed differences in clinical outcomes after CRRT (dialysis dependence at study end, number of hospitalization days) were not statistically significant, but had wide confidence intervals, suggesting that meaningful clinical differences could exist.