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

<div><p>Background</p><p>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.</p><p>Methods and findings</p><p>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$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$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).</p><p>Conclusions</p><p>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.</p></div

Cost-effectiveness of MDC by race.

<p>Cost-effectiveness of MDC by race.</p

Sensitivity analyses: Varying the effectiveness and cost of MDC.

<p>Sensitivity analyses: Varying the effectiveness and cost of MDC.</p

Cost-effectiveness when varying the effectiveness of MDC—whole population.

<p>Cost-effectiveness when varying the effectiveness of MDC—whole population.</p

Hazard ratios of multidisciplinary care by race.

<p>Hazard ratios of multidisciplinary care by race.</p

Hazard ratios of multidisciplinary care by severity of kidney disease.

<p>Hazard ratios of multidisciplinary care by severity of kidney disease.</p

Hazard ratios of multidisciplinary care by sex.

<p>Hazard ratios of multidisciplinary care by sex.</p

Varying the cost of multidisciplinary care (MDC).

<p>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.</p

Medications and laboratory tests increased by MDC in the base case.

<p>Medications and laboratory tests increased by MDC in the base case.</p

Cost-effectiveness of MDC by age.

<p>Cost-effectiveness of MDC by age.</p