Cost-Effectiveness of Team-Based Coaching With Surveillance for Prevention of Acute Kidney Injuries

Abstract

Importance: More than 10% of US patients undergoing endovascular procedures experience contrast-associated acute kidney injuries (AKIs), resulting in increased costs and health deficits. Prevention protocols reduce AKIs, but uptake and adherence vary greatly, and the cost-effectiveness of these interventions is unknown.

Objective: To analyze the cost-effectiveness of 4 implementation interventions for AKI prevention in patients undergoing cardiac catheterizations.

Design, setting, and participants: This economic evaluation used a Markov decision model with 3-year horizon was constructed to simulate quality-adjusted life years (QALYs) and costs after AKI prevention protocol implementation for patients undergoing cardiac catheterization. Data from the IMPROVE AKI trial, a cluster-randomized trial conducted across 20 US Department of Veterans Affairs medical centers from 2019 to 2021, were used for probabilities, with economic and utility data derived from literature. Patients aged 18 years or older, who underwent cardiac coronary angiography for diagnostic or treatment of pathology were included. Patients with a history of dialysis (hemodialysis or peritoneal dialysis) were excluded. Data were analyzed from January to June 2024.

Exposure: Interventions compared were assistance, assistance with surveillance, collaborative, and collaborative with surveillance.

Main outcomes and measures: QALYs and cost in dollars discounted at 3% per year and incremental cost-effectiveness ratio (ICER) using willingness-to-pay threshold of $100 000 per QALY. One-way and probabilistic sensitivity analyses were performed.

Results: Among 122 803 patients, 13 047 experienced AKIs (10.6%). Patient characteristics were balanced across 4 groups with an overall median (IQR) age of 70 (65-74) years, 119 119 males (97%), 25 789 Black patients (21%), 88 418 White patients (72%), and 8596 for all other racial and ethnic groups (7%). AKI incidences were 13.3% (95% CI, 11.0%-15.6%) in assistance, 11.4% (95% CI, 9.5%-13.3%) in assistance with surveillance, 12.7% (95% CI, 11.1%-14.4%) in collaborative, and 7.9% (95% CI, 6.4%-9.5%) in collaborative with surveillance. Intervention costs per patient were $12.74 (IQR, $9.56-$15.93) for collaborative with surveillance, $3.97 (IQR, $2.98-$4.96) for collaborative, $3.36 for assistance with surveillance, and $2.69 for assistance. Drivers for total cost of interventions were costs of AKI and subsequent permanent kidney disease. ICERs revealed collaborative with surveillance as economically dominant. Compared with assistance, collaborative with surveillance saved $742.75 while improving cost-effectiveness by 0.02 QALYs per person. Results were robust to sensitivity analyses.

Conclusions and relevance: In this economic evaluation of implementation strategies for AKI prevention, virtual learning collaborative with automated surveillance reporting was the economically preferred intervention and was estimated to decrease AKI likelihood, permanent kidney disease, and their associated costs after undergoing cardiac catheterization. These results may be generalizable to other endovascular procedures and practice-changing protocols or checklists implementation efforts.

Figure 1.. Schematic Representation of Markov State Diagram After Cardiac Catheterization

Circles indicate various states and arrows indicate transitions between various states. CKD indicates chronic kidney disease; ESRD, end stage renal disease.

Figure 2.. Tornado Diagram Comparing Collaborative With Surveillance vs Assistance

C indicates cost in $; EV, expected value; NMB, Net Monetary Benefit; U, utilities in QALY. The input key can be found in eAppendix in Supplement 1.

Figure 3.. Cost Effectiveness Acceptability Curve Derived Using Probabilistic Sensitivity Analysis

QALY indicates quality-adjusted life years.