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

• Published in: PLoS medicine Vol. 15; no. 3; p. e1002532
• Main Authors: Lin, Eugene, Chertow, Glenn M, Yan, Brandon, Malcolm, Elizabeth, Goldhaber-Fiebert, Jeremy D
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 27.03.2018; Public Library of Science (PLoS)
• Subjects: Aged; Aged, 80 and over; Analysis; Biology and Life Sciences; Care and treatment; Chronic kidney failure; Clinical medicine; Computer Simulation; Cost analysis; Cost-Benefit Analysis; Developing countries; Dialysis; Disease Progression; Economic aspects; End-stage renal disease; Excretion; Female; Geriatrics; Government programs; Humans; Kidney diseases; Kidneys; LDCs; Life span; Male; Markov Chains; Medicare; Medicine; Medicine and Health Sciences; Middle Aged; Morbidity; Mortality; Nephrology; Occupational health; Older people; Patient Acuity; Patient Care Management - economics; Patient Care Management - methods; Patient Care Team - economics; Patient Care Team - organization & administration; Primary care; Program Development - methods; Renal Insufficiency, Chronic - diagnosis; Renal Insufficiency, Chronic - economics; Renal Insufficiency, Chronic - therapy; Renal replacement therapy; Researchers; Social Sciences; Socioeconomic factors; Studies; Subpopulations; Supervision; Systematic review; United States; Urine; Workers; United States; Palo Alto California; United States > US; California
• ISSN: 1549-1676; 1549-1277; 1549-1676
• DOI: 10.1371/journal.pmed.1002532

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. 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). 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.