Date Published: February 28, 2019
Publisher: Public Library of Science
Author(s): Nurul-Ain Mohd-Tahir, Shu-Chuen Li, Harald Mischak.
Renin-angiotensin system inhibitors (RAS) drugs have a proteinuria-reducing effect that could prevent the progression of kidney disease in diabetic patients. Our study aimed to assess the budget impact based on healthcare payer perspective of increasing uptake of RAS drugs into the current treatment mix of standard anti-hypertensive treatments to prevent progression of kidney disease in patient’s comorbid with hypertension and diabetes.
A Markov model of a Malaysian hypothetical cohort aged ≥30 years (N = 14,589,900) was used to estimate the total and per-member-per-month (PMPM) costs of RAS uptake. This involved an incidence and prevalence rate of 9.0% and 10.53% of patients with diabetes and hypertension respectively. Transition probabilities of health stages and costs were adapted from published data.
An increasing uptake of RAS drugs would incur a projected total treatment cost ranged from MYR 4.89 billion (PMPM of MYR 27.95) at Year 1 to MYR 16.26 billion (PMPM of MYR 92.89) at Year 5. This would represent a range of incremental costs between PMPM of MYR 0.20 at Year 1 and PMPM of MYR 1.62 at Year 5. Over the same period, the care costs showed a downward trend but drug acquisition costs were increasing. Sensitivity analyses showed the model was minimally affected by the changes in the input parameters.
Mild impact to the overall healthcare budget has been reported with an increased utilization of RAS. The long-term positive health consequences of RAS treatment would reduce the cost of care in preventing deterioration of kidney function, thus offsetting the rising costs of purchasing RAS drugs. Optimizing and increasing use of RAS drugs would be considered an affordable and rational strategy to reduce the overall healthcare costs in Malaysia.
Diabetes and cardiovascular diseases are among the major chronic diseases in the Asia Pacific region and the numbers of cases are expected to grow rapidly over the coming years . In this region, within a ten year time span between 1990 and 2010, the disability-adjusted-life-years of cardiovascular disease and diabetes increased by 22.6% and 69% respectively . The prevalence of these diseases steadily increased from 1996 to 2015 in Malaysia with data from the National Health and Morbidity Survey reported the 2015 prevalence of diabetes at 17.5% and hypertension at 30.3% .
The use of RAS in patients comorbid with diabetes and hypertension had shown to be effective in reducing proteinuria (the earliest clinical evidence of nephropathy), and cardiovascular events in many clinical trials [4, 6, 7, 9–16]. Consequently, most hypertension guidelines have recommended the use of RAS as first line therapy for diabetic patients. Additionally, studies had shown the use of RAS to be cost-effective and/or cost-saving in preventing the progression of kidney function deterioration in patients with diabetes and hypertension, especially if started at the early stage of kidney disease [4, 6, 7, 9–16]. Considering these positive clinical and economic impacts, the RAS uptake is possibly still low and may need to be optimized in Malaysia. This was shown indirectly from an audit of diabetes management in Asian patients treated by specialists. The audit reported that the incidence of neuropathy was still high (~33%) in diabetic patients in Asia with a significant proportion of patients had unsatisfactory control of blood pressure and glycemic level .
This budget impact model showed that optimizing RAS utilization would have a small impact to the overall healthcare budget. However, the long-term positive health consequences of RAS treatment will further reduce the cost of care in preventing deterioration of kidney function offsetting the initial rising costs of purchasing RAS drugs. Optimization of RAS drugs would therefore be considered an affordable and rational strategy to reduce the overall healthcare costs in the long term, and provide cost-effective treatment to the population.