Cost-effectiveness of multidisciplinary care in mild to moderate chronic kidney disease in the United States: A modeling study

Abstract

Background: Multidisciplinary 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 findings: We 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).

Conclusions: Our 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.

Fig 1. Markov model for simulating chronic kidney disease (CKD) progression.

We modeled progression of CKD using levels of estimated glomerular filtration rate (eGFR). For simplicity, we modeled each level of eGFR in increments of 5 ml/min/1.73 m². Each cycle, patients have a probability of staying at the same eGFR level or dropping to the next eGFR. Between eGFRs of 5 and 15 ml/min/1.73 m², patients also have the possibility of progressing to end-stage renal disease (ESRD). We modeled ESRD as a single health state. Death can occur at any point.

Fig 2. Varying the cost of multidisciplinary care (MDC).

In sensitivity analyses, we varied the cost of MDC. We depict the incremental cost-effectiveness ratios (ICERs) for the entire population (A) and stratified by estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (UACR) (B–D). Our base case assumed that MDC increased the use of chronic kidney disease–specific medications (Meds) and laboratory tests (Labs) in 25% of the population. In subsequent analyses, we assumed that MDC increased the use of these medications and laboratory tests in 0%, 10%, 50%, and 100% of the population. We also increased the cost of the entire program 2-fold and 5-fold. In all analyses, we found that MDC remained cost-effective, but the upper end of the 95% confidence intervals exceeded the willingness to pay threshold of $150,000 per QALY in the most expensive cases. The program was more expensive (higher ICERs) in patients with UACR of 1 mg/g when compared to patients with UACR of 300 or 1,000 mg/g.

Fig 3. Cost-effectiveness acceptability curves for multidisciplinary care (MDC).

We estimated the probability that the MDC program was cost-effective in different populations and with all sensitivity analyses. We show the acceptability curves for the overall population (A) and stratified by estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (UACR) (B–D). In all populations, greater than 95% of probability sensitivity analyses costed less than $90,000 per QALY, and greater than 99% of analyses costed less than $150,000 per QALY. In general, MDC was less likely to be cost-effective in populations with no albuminuria (UACR 1 mg/g) and higher eGFR (59 ml/min/1.73 m²). We also assessed the probability when varying effectiveness (E) and cost (F). When MDC was 50% as effective as the base case, it was cost-effective with 98% probability at a willingness to pay (WTP) threshold of $150,000 per QALY. This probability dropped with other effectiveness scenarios. For most cost scenarios, MDC was cost-effective with 95% probability at a WTP of $150,000, though this probability dropped to 89% when MDC cost 5 times the base case.