Inside CKD: Cost-Effectiveness of Multinational Screening for CKD

Abstract

Introduction: Early detection of chronic kidney disease (CKD) could slow its progression; however, most patients in earlier stages remain undiagnosed. Our study objective was to assess the cost-effectiveness of multinational CKD screening strategies from the payer perspective across general and higher-risk populations.

Methods: Using the published Inside CKD microsimulation, we projected virtual closed populations to assess CKD screening strategies in 31 countries or regions over a lifetime horizon. We considered people aged ≥ 65 or ≥ 45 years in the general population and in high-risk subgroups (type 2 diabetes [T2D], hypertension, or cardiovascular disease [CVD]). Simulated populations could receive 2 serum creatinine (SCr) tests assessing estimated glomerular filtration rate (eGFR), "2 eGFR only", or an additional urinary albumin-to-creatinine ratio test (UACR), "2 eGFR and 1 UACR", versus current practice. Eligible patients received renin-angiotensin system inhibitors (RASi).

Results: Screening the general population aged ≥ 45 years for CKD was cost-effective versus current practice in all countries or regions using the "2 eGFR and 1 UACR" strategy, and cost-effective in all but 1 country using the 2 eGFR only strategy. The 2 eGFR and 1 UACR strategy showed consistently higher cost-effectiveness. Screening general populations aged ≥ 45 years increased projected CKD diagnosis rates per 100,000 persons eligible for screening from 459 by current practice to 7475 patients using 2 eGFR only, or 14,392 using 2 eGFR and 1 UACR. Similar trends in cost-effectiveness and diagnosis rates were observed in persons aged ≥ 65 years.

Conclusion: CKD screening may be cost-effective in general populations worldwide, including in populations aged ≥ 45 years. Our analysis corroborates global guideline recommendations for simultaneous eGFR and UACR testing if considered in the context of local factors.

Keywords: chronic kidney disease; cost-effectiveness analysis; microsimulation; serum creatinine; urine albumin-to-creatinine ratio.

Graphical abstract

Figure 1

Incremental change in kidney replacement therapy (KRT) prevalence by modality in the general population per 100,000 people by screening strategy (unweighted average across considered 31 countries or regions). The simulated cohort comprised only people without a CKD diagnosis who are eligible for screening and not all patients are assumed to undergo screening. Negative values indicate an incremental decrease in the number of individuals initiating KRT resulting from a screening strategy compared to current practice. CKD, chronic kidney disease; eGFR: estimated glomerular filtration rate; KRT, kidney replacement therapies; UACR: urine albumin-to-creatinine ratio.

Figure 2

Incremental per-patient accrual of LYs and QALYs in the general population after screening for CKD. Solid lines represent the mean value across 31 countries or regions, the shaded regions pertain to the range of values observed in the base case analyses across countries. LY, life years; QALY, quality-adjusted life year.

Figure 3

Cost-effectiveness of screening, in general population and high-risk subgroups, across 31 countries or regions, expressed as (a) pairwise ICERs as a function of WTP threshold versus current practice, (b) incremental net monetary benefit between the pairwise analyses. Green color indicates an incremental cost-effective ratio that is below the WTP threshold meaning that the strategy would be considered cost-effective according to the study criteria, with bordered squares indicating analyses that were not considered cost-effective. The net monetary benefit characterizes the relative value of cost-effective screening interventions and suits evaluation of pairwise analyses. Green color indicates that the net monetary benefit of the “2 eGFR and 1 UACR” is at least double the “2 eGFR only” strategy, yellow color indicates that they are comparable, and red indicates that “2 eGFR only” strategies are better value. CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; HTN, hypertension; ICER, incremental cost-effectiveness ratio; T2D, type 2 diabetes; WTP, willingness-to-pay threshold; UACR, urine albumin-to-creatinine ratio; UAE, United Arab Emirates; UK: United Kingdom; USA: United States of America.

Figure 4

Evolution of the cost effectiveness of screening over time for the “2 eGFR only” (red) and “2 eGFR and 1 UACR” (blue) strategies in the general population across 31 countries or regions. Solid lines indicate the mean value across countries or regions; the grey shaded area indicates the range of estimates across the 31 countries or regions; the grey dotted line indicates the WTP threshold, with cost-effective estimates falling below the line. Screening occurs in the index year, with outcomes assessed in subsequent years. eGFR, estimated glomerular filtration rate; ICER, incremental cost-effectiveness ratio; UACR, urine albumin to creatinine ratio; WTP, willingness-to-pay threshold.