MODELING THE COST-EFFECTIVENESS OF MULTI-DISCIPLINARY CARE IN CHRONIC KIDNEY DISEASE

Purpose:

   End-stage renal disease (ESRD) accounts for 5.6% of total Medicare expenditures, though patients on dialysis make up 1.6% of its beneficiaries. Multi-disciplinary care (MDC) has been proposed as a way to mitigate the morbidity and costs accompanying the transition from chronic kidney disease (CKD) to ESRD. In this study, we assessed the cost-effectiveness of MDC in patients with CKD.

Methods:

   We developed a probabilistic Markov model, simulating the progression of CKD to ESRD. Unlike previous models of CKD progression, ours incorporated patient heterogeneity, which allowed CKD progression to change with known risk factors (age, CKD stage, and level of albuminuria). For different subpopulations of CKD, we calibrated progression probabilities to previously published data on mortality and likelihood of developing ESRD. Calibration involved minimizing the sum of squared differences between modeled and empirically observed outcomes and yielded CKD progression and mortality probabilities conditional on each subgroup’s risk factors. We evaluated the cost-effectiveness of MDC relative to usual care from the Medicare payer perspective and discounted costs and QALYs at 3% annually. Using data from a recent systematic review, we assumed that MDC decreased mortality rates by 15% and progression rates to ESRD by 55%. We assumed that a typical MDC program had four nurse practitioner visits a year, estimating its cost using Medicare’s fee schedule. We obtained ESRD mortality rates and costs from the United States Renal Data System (USRDS). In sensitivity analysis, we varied the efficiency of MDC and the clinical characteristics of the starting CKD population.

Results:

   MDC cost $24,613 per QALY gained compared to usual care. We found that MDC remained below $35,000 per QALY gained over a wide range of severities of CKD (from stage 3 to 5), ages (25 to 75 years), and levels of albuminuria (100 mg/g to 1000 mg/g). The cost-effectiveness results were also robust to changes in the efficiency of MDC. A relatively ineffective MDC program that decreased mortality and progression rates by only 2% still cost $84,916 per QALY gained.

Conclusions:

   Even if deployed inefficiently, MDC programs would likely be cost-effective in CKD patients in the United States. Taking into account the heterogeneity of CKD patients is important in modeling CKD progression and may help to efficiently target interventions aimed at slowing progression to ESRD.