Date Published: March 27, 2018
Publisher: Public Library of Science
Author(s): Eugene Lin, Glenn M. Chertow, Brandon Yan, Elizabeth Malcolm, Jeremy D. Goldhaber-Fiebert, Maarten W. Taal
Abstract: BackgroundMultidisciplinary care (MDC) programs have been proposed as a way to alleviate the cost and morbidity associated with chronic kidney disease (CKD) in the US.Methods and findingsWe assessed the cost-effectiveness of a theoretical Medicare-based MDC program for CKD compared to usual CKD care in Medicare beneficiaries with stage 3 and 4 CKD between 45 and 84 years old in the US. The program used nephrologists, advanced practitioners, educators, dieticians, and social workers. From Medicare claims and published literature, we developed a novel deterministic Markov model for CKD progression and calibrated it to long-term risks of mortality and progression to end-stage renal disease. We then used the model to project accrued discounted costs and quality-adjusted life years (QALYs) over patients’ remaining lifetime. We estimated the incremental cost-effectiveness ratio (ICER) of MDC, or the cost of the intervention per QALY gained. MDC added 0.23 (95% CI: 0.08, 0.42) QALYs over usual care, costing $51,285 per QALY gained (net monetary benefit of $23,100 at a threshold of $150,000 per QALY gained; 95% CI: $6,252, $44,323). In all subpopulations analyzed, ICERs ranged from $42,663 to $72,432 per QALY gained. MDC was generally more cost-effective in patients with higher urine albumin excretion. Although ICERs were higher in younger patients, MDC could yield greater improvements in health in younger than older patients. MDC remained cost-effective when we decreased its effectiveness to 25% of the base case or increased the cost 5-fold. The program costed less than $70,000 per QALY in 95% of probabilistic sensitivity analyses and less than $87,500 per QALY in 99% of analyses. Limitations of our study include its theoretical nature and being less generalizable to populations at low risk for progression to ESRD. We did not study the potential impact of MDC on hospitalization (cardiovascular or other).ConclusionsOur model estimates that a Medicare-funded MDC program could reduce the need for dialysis, prolong life expectancy, and meet conventional cost-effectiveness thresholds in middle-aged to elderly patients with mild to moderate CKD.
Partial Text: Chronic kidney disease (CKD) affects approximately 10% of Medicare beneficiaries in the US but accounts for a disproportionate 20% of expenditures . Patients with end-stage renal disease (ESRD) are more costly, representing 1.6% of Medicare beneficiaries and responsible for 7.2% of costs . At the same time, life expectancy is substantially lower in patients with CKD than in the general population [1–3].
Using data from literature, we developed and calibrated a deterministic Markov model that accurately models disease progression of patients with stage 3 and 4 CKD and accounts for population heterogeneity including age, sex, race, severity of kidney disease, and albuminuria. From this model, we found that a Medicare-funded MDC program in non-dialysis-requiring (eGFR 20 to 59 ml/min/1.73 m2) CKD is cost-effective in middle-aged to elderly patients. Although cost-effective in all subgroups, the program is more cost-effective in patients with more advanced CKD, particularly those with higher levels of albuminuria. Provision of MDC to younger patients was more expensive, but younger patients gained the most in health outcomes, as measured by QALYs. Notably, MDC remained cost-effective even if it was 5 times more expensive or one-quarter as effective as our base case.