Screening for chronic kidney disease in Canadian indigenous peoples is cost-effective
2017; Elsevier BV; Volume: 92; Issue: 1 Linguagem: Inglês
10.1016/j.kint.2017.02.022
ISSN1523-1755
AutoresThomas W. Ferguson, Navdeep Tangri, Zhi Tan, Matthew T. James, Barry Lavallee, Caroline Chartrand, Lorraine McLeod, Allison Dart, Claudio Rigatto, Paul Komenda,
Tópico(s)Healthcare cost, quality, practices
ResumoCanadian indigenous (First Nations) have rates of kidney failure that are 2- to 4-fold higher than the non-indigenous general Canadian population. As such, a strategy of targeted screening and treatment for CKD may be cost-effective in this population. Our objective was to assess the cost utility of screening and subsequent treatment for CKD in rural Canadian indigenous adults by both estimated glomerular filtration rate and the urine albumin-to-creatinine ratio. A decision analytic Markov model was constructed comparing the screening and treatment strategy to usual care. Primary outcomes were presented as incremental cost-effectiveness ratios (ICERs) presented as a cost per quality-adjusted life-year (QALY). Screening for CKD was associated with an ICER of $23,700/QALY in comparison to usual care. Restricting the model to screening in communities accessed only by air travel (CKD prevalence 34.4%), this ratio fell to $7,790/QALY. In road accessible communities (CKD prevalence 17.6%) the ICER was $52,480/QALY. The model was robust to changes in influential variables when tested in univariate sensitivity analyses. Probabilistic sensitivity analysis found 72% of simulations to be cost-effective at a $50,000/QALY threshold and 93% of simulations to be cost-effective at a $100,000/QALY threshold. Thus, targeted screening and treatment for CKD using point-of-care testing equipment in rural Canadian indigenous populations is cost-effective, particularly in remote air access–only communities with the highest risk of CKD and kidney failure. Evaluation of targeted screening initiatives with cluster randomized controlled trials and integration of screening into routine clinical visits in communities with the highest risk is recommended. Canadian indigenous (First Nations) have rates of kidney failure that are 2- to 4-fold higher than the non-indigenous general Canadian population. As such, a strategy of targeted screening and treatment for CKD may be cost-effective in this population. Our objective was to assess the cost utility of screening and subsequent treatment for CKD in rural Canadian indigenous adults by both estimated glomerular filtration rate and the urine albumin-to-creatinine ratio. A decision analytic Markov model was constructed comparing the screening and treatment strategy to usual care. Primary outcomes were presented as incremental cost-effectiveness ratios (ICERs) presented as a cost per quality-adjusted life-year (QALY). Screening for CKD was associated with an ICER of $23,700/QALY in comparison to usual care. Restricting the model to screening in communities accessed only by air travel (CKD prevalence 34.4%), this ratio fell to $7,790/QALY. In road accessible communities (CKD prevalence 17.6%) the ICER was $52,480/QALY. The model was robust to changes in influential variables when tested in univariate sensitivity analyses. Probabilistic sensitivity analysis found 72% of simulations to be cost-effective at a $50,000/QALY threshold and 93% of simulations to be cost-effective at a $100,000/QALY threshold. Thus, targeted screening and treatment for CKD using point-of-care testing equipment in rural Canadian indigenous populations is cost-effective, particularly in remote air access–only communities with the highest risk of CKD and kidney failure. Evaluation of targeted screening initiatives with cluster randomized controlled trials and integration of screening into routine clinical visits in communities with the highest risk is recommended. Chronic kidney disease (CKD) is a worldwide public health problem with an increasing prevalence.1Levey A.S. Coresh J. Chronic kidney disease.Lancet. 2012; 379: 165-180Abstract Full Text Full Text PDF PubMed Scopus (1293) Google Scholar CKD is a potent, independent risk factor for several adverse health outcomes, including kidney failure, hospitalization, cardiovascular events, and early death.2Dalrymple L.S. Katz R. Kestenbaum B. et al.Chronic kidney disease and the risk of end-stage renal disease versus death.J Gen Intern Med. 2011; 26: 379-385Crossref PubMed Scopus (147) Google Scholar, 3Go A.S. Chertow G.M. Fan D. et al.Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.N Engl J Med. 2004; 351: 1296-1305Crossref PubMed Scopus (8986) Google Scholar Early detection, appropriate risk stratification, and subsequent treatment of CKD may delay or prevent many of its associated complications, but at increased up-front cost.4Black C. Sharma P. Scotland G. et al.Early referral strategies for management of people with markers of renal disease: a systematic review of the evidence of clinical effectiveness, cost-effectiveness and economic analysis.Health Technol Assess. 2010; 14: 1-184Crossref PubMed Scopus (152) Google Scholar With the availability of reliable point-of-care quantitative blood and urine tests, it is possible to screen for CKD and to present results quickly and accurately.5McTaggart M.P. Newall R.G. Hirst J.A. et al.Diagnostic accuracy of point-of-care tests for detecting albuminuria: a systematic review and meta-analysis.Ann Intern Med. 2014; 160: 550-557Crossref PubMed Scopus (22) Google Scholar Mass screening for CKD in the general population is not advised,6Levin A. Hemmelgarn B. Culleton B. et al.Guidelines for the management of chronic kidney disease.CMAJ. 2008; 179: 1154-1162Crossref PubMed Scopus (266) Google Scholar, 7Qaseem A. Hopkins Jr., R.H. Sweet D.E. et al.Screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease: a clinical practice guideline from the American College of Physicians.Ann Intern Med. 2013; 159: 835-847Crossref PubMed Scopus (116) Google Scholar and it offers poor value for money in low-risk populations. In contrast, targeted screening in high-risk groups, such as those with diabetes and/or hypertension, has been shown to be cost-effective.8Komenda P. Ferguson T.W. Macdonald K. et al.Cost-effectiveness of primary screening for CKD: a systematic review.Am J Kidney Dis. 2014; 63: 789-797Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar Furthermore, screening is also a cost-effective strategy in certain high-risk ethnic groups, such as African Americans, where there is an elevated risk of kidney failure and its associated complications.9Hoerger T.J. Wittenborn J.S. Zhuo X. et al.Cost-effectiveness of screening for microalbuminuria among African Americans.J Am Soc Nephrol. 2012; 23: 2035-2041Crossref PubMed Scopus (28) Google Scholar Canadian indigenous peoples (First Nations) have rates of kidney failure that are 2- to 4-fold higher than the nonindigenous general Canadian population.10Zacharias J.M. Young T.K. Riediger N.D. et al.Prevalence, risk factors and awareness of albuminuria on a Canadian First Nation: a community-based screening study.BMC Public Health. 2012; 12: 290Crossref PubMed Scopus (32) Google Scholar These rates are largely attributable to elevated rates of diabetes,11Jacobs P. Blanchard J.F. James R.C. Depew N. Excess costs of diabetes in the Aboriginal population of Manitoba, Canada.Can J Public Health. 2000; 91: 298-301PubMed Google Scholar with over 60% of kidney failure cases attributed to diabetic nephropathy in indigenous peoples compared with 35% in the general population.12Dyck R.F. Mechanisms of renal disease in indigenous populations: influences at work in Canadian indigenous peoples.Nephrology (Carlton). 2001; 6: 3-7Crossref Scopus (39) Google Scholar, 13Canadian Institute for Health Information. CORR report: treatment of end-stage organ failure in Canada, 2003 to 2012. 2014. Available at: https://secure.cihi.ca/free_products/2014_CORR_Annual_Report_EN.pdf. Accessed September 18, 2014.Google Scholar Indigenous communities in rural locations often have reduced access to primary and specialist care and therefore have reduced access to opportunistic screening and treatment for chronic conditions. As a result, patients in these communities often travel long distances or else relocate entirely to receive complex care such as dialysis, adversely impacting their quality of life.14Martens P. Martin B. O'Neil J. MacKinnon M. Diabetes and adverse outcomes in a First Nations population: associations with healthcare access, socioeconomic, and geographical factors.Can J Diabetes. 2007; 31: 223-232Abstract Full Text Full Text PDF Scopus (24) Google Scholar, 15Gao S. Manns B.J. Culleton B.F. et al.Access to health care among status Aboriginal people with chronic kidney disease.CMAJ. 2008; 179: 1007-1012Crossref PubMed Scopus (77) Google Scholar, 16Moist L.M. Bragg-Gresham J.L. Pisoni R.L. et al.Travel time to dialysis as a predictor of health-related quality of life, adherence, and mortality: the Dialysis Outcomes and Practice Patterns Study (DOPPS).Am J Kidney Dis. 2008; 51: 641-650Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar, 17Tonelli M. Molzahn A.E. Wiebe N. et al.for the Alberta Kidney Disease NetworkRelocation of remote dwellers living with hemodialysis: a time trade-off survey.Nephrol Dial Transplant. 2015; 30: 1767-1773https://doi.org/10.1093/ndt/gfv112Crossref PubMed Scopus (9) Google Scholar To date, the cost-effectiveness of mass screening for CKD in Canadian First Nations or other high-risk indigenous populations has not been assessed. Therefore, the objective of this study was to assess the cost utility of one-off, point-of-care screening and treatment for CKD using both estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (ACR), in a rural adult Canadian indigenous population. We hypothesized that, due to a higher prevalence of albuminuria, increased rates of progression to kidney failure,18Zacharias J. Komenda P. Olson J. et al.Home hemodialysis in the remote Canadian north: treatment in Manitoba fly-in communities.Semin Dial. 2011; 24: 653-657Crossref PubMed Scopus (13) Google Scholar, 19Samuel S.M. Palacios-Derflingher L. Tonelli M. et al.for the Alberta Kidney Disease NetworkAssociation between First Nations ethnicity and progression to kidney failure by presence and severity of albuminuria.CMAJ. 2014; 186: E86-E94Crossref PubMed Scopus (45) Google Scholar and increased costs of providing renal replacement therapy in remote communities,20Ferguson T.W. Zacharias J. Walker S.R. et al.An economic assessment model of rural and remote satellite hemodialysis units.PLoS One. 2015; 10: e0135587Google Scholar screening- and risk-based treatment for CKD in Canadian indigenous peoples would be cost-effective. The life expectancy remaining at age 45 years was 28.96 years in the usual care arm and 29.04 years in the screening arm; at age 65 years, life expectancy was 13.43 years in the screening arm and 13.42 years in the usual care arm (Supplementary Tables S1 and S2). This latter metric represents an approximately 8-year lower life expectancy in this indigenous population than in the general Manitoba population,21Statistics Canada. Life tables, Canada, provinces and territories, 2009 to 2011. 2011. Available at: http://www.statcan.gc.ca/pub/84-537-x/84-537-x2013005-eng.htm. Accessed April 22, 2015.Google Scholar a finding consistent with the life expectancy gap previously described in Manitoba’s indigenous population.22Martens P.J. Sanderson D. Jebamani L.S. Mortality comparisons of First Nations to all other Manitobans: a provincial population-based look at health inequalities by region and gender.Can J Public Health. 2005; 96: S33-S38PubMed Google Scholar Screening for CKD in rural and remote Canadian indigenous peoples was associated with an incremental cost-effectiveness ratio (ICER) of $23,700 per quality-adjusted life-year (QALY). In the usual care scenario, total costs were $12,790 and effectiveness was 12.9869 QALYs, whereas screening was associated with a cost of $13,400 and effectiveness of 13.0124 QALYs (Table 1).Table 1Results of cost-effectiveness simulation and scenario analysesPopulationIncremental cost ($C)Incremental QALYsCost/QALY (ICER)Baseline model All FINISHED communities6050.025523,700 Air access communities2920.03757790 Road access communities8060.015452,480Threshold for relative risk reduction afforded by treatment extended to patients with moderately increased albuminuria (urine ACR ≥ 3 mg/mmol) All FINISHED communities–260.0643Screening dominant Air access–6200.0873Screening dominant Road access4300.04359800Scenario analysis of increased home modality uptake Increase by 25%1080.02554240 Increase by 50%–3890.0255Screening dominant Increase by 100%–13850.0255Screening dominantACR, albumin-to-creatinine ratio; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life-year. Open table in a new tab ACR, albumin-to-creatinine ratio; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life-year. The results of our one-way sensitivity analyses are illustrated in Figure 1 and Table 2. Primary model drivers were the baseline prevalence of any kidney damage, treatment effectiveness with respect to reduction of disease progression, the incremental costs of CKD management, treatment adherence, and the cost of dialysis. However, the model was found to be robust to univariate changes across plausible ranges of these variables. Probabilistic sensitivity analysis demonstrated that at a threshold of $50,000/QALY, approximately 72% of simulations found screening to be cost-effective (12% were dominant and <0.1% of simulations were inferior), and that at a threshold of $100,000/QALY, 93% of simulations found screening to be cost-effective (Figure 2).Table 2One-way sensitivity analysis of influential model parametersVariableIncremental cost ($C)Incremental QALYsCost/QALYBaseline6050.025523,700Initial CKD risk strata prevalence (baseline low = 19.5%, intermediate = 4.5%, high = 1.5%) Initial CKD risk strata prevalence increased 50%6130.038316,000 Initial CKD risk strata prevalence decreased 50%5970.012846,770Discount rate (baseline = 5%) Discount rate decreased to 0%3460.06915000 Discount rate decreased to 3%5340.037014,450Treatment adherence (baseline = 75%) Treatment adherence increased to 100%3300.03409700 Treatment adherence decreased to 50%8800.017051,690Annual risk of CKD progression Risk of progression increased 50%2170.03136940 Risk of progression decreased 50%9620.018851,150ACE-I/ARB treatment effectiveness—progression reduction (baseline = 33% progression reduction) Relative risk reduction increased 50%1160.03143700 Relative risk reduction decreased 50%10810.019954,300ACE-I/ARB treatment effectiveness—mortality reduction (baseline = 23% mortality reduction) Relative risk reduction increased 50%6540.034019,230 Relative risk reduction decreased 50%5580.017631,780Utility value associated with CKD (baseline = 0.85) Utility value increased to 0.906050.027322,200 Utility value decreased to 0.756050.022127,400Utility value associated with dialysis (baseline = 0.72) Utility value increased to 0.856050.024524,670 Utility value decreased to 0.606050.026522,860Expected cost of dialysis (baseline = $92,900) Cost of dialysis increased 50%2440.02559560 Cost of dialysis decreased 50%9660.025537,830Cost of screening (baseline = $589) Cost of screening increased to $1000 per person10160.025539,790 Cost of screening decreased to $200 per person2150.02558450Average incremental CKD treatment costs (baseline for high risk = $2,083, intermediate risk = $399, low risk = $210) Incremental CKD treatment costs increased 50%10320.025540,440 Incremental CKD treatment costs decreased 50%1770.02556950Annual incidental screening rate (baseline = 5%) Incidental screening rate increased to 10%/yr5630.016534,100 Incidental screening rate decreased to 2.5%/yr6540.033119,770Rate of ACE-I/ARB usage in those screened (baseline = 0%) Increased usage to 20% of all those screened7660.020138,190 Increased usage to 40% of all those screened9290.014564,112ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker; CKD, chronic kidney disease; QALY, quality-adjusted life-year. Open table in a new tab Figure 2Probabilistic sensitivity analysis comparing screening strategy versus usual care. The diagonal dashed line represents a $50,000 per quality-adjusted life-year threshold. Points falling below this line represent simulations that were cost-effective (cost at most $50,000 for each additional quality-adjusted life-year). Points situated below the x-axis ( 0 incremental effectiveness) represent simulations in which the screening strategy was found to be dominant (both less costly and more effective).View Large Image Figure ViewerDownload Hi-res image Download (PPT) ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker; CKD, chronic kidney disease; QALY, quality-adjusted life-year. In scenario analyses, extension of the benefits of treatment to those with moderately increased albuminuria (urine ACR ≥ 30 mg/g or 3 mg/mmol from baseline ≥ 300 mg/g or 30 mg/mmol) found screening to be the dominant treatment strategy when considering all communities together and those accessible only by air. When considering road access communities, screening was associated with an ICER of $9,800/QALY. Increase of home modality uptake by 25% produced an ICER of $4,240/QALY across all communities. Increasing uptake by 50% or 100% resulted in screening being the dominant treatment strategy. Results of scenario analyses are presented in Table 1. Due to higher assumed costs of satellite dialysis and treatment-related transportation, increased prevalence of progressive CKD, and higher levels of severely increased albuminuria, the incremental cost of screening in air access–only communities totaled $292 with an incremental effectiveness of 0.0375 QALYs (ICER $7790/QALY). Conversely, road accessible communities had lower assumed satellite dialysis costs, a lower prevalence of high-risk CKD, and lower levels of severely increased albuminuria, with a resulting incremental cost of $806 and incremental effectiveness of 0.0154 QALYs from the screening strategy (ICER $52,480/QALY) (Table 1). In this study, we found that screening and treatment for CKD in comparison to usual care in Canadian rural indigenous is highly cost-effective (ICER $23,700/QALY). Moreover, in the most remote communities accessible only by air travel, screening was found to be even more cost-efficient (ICER $7,790/QALY). The primary model drivers of cost-effectiveness included treatment effectiveness, baseline CKD prevalence, adherence to prescribed treatment, and the incremental cost of managing CKD on case finding. Nonetheless, these drivers, when varied over a plausible range, consistently produced an ICER below or near $50,000/QALY. Together, these findings suggest that large-scale CKD screening initiatives in this high-risk population are economically justifiable. To our knowledge, this is the first formal cost-effectiveness analysis examining the economic and health impact of a mass screening strategy for CKD in indigenous peoples. Several other studies have explored the question of mass versus opportunistic screening for CKD in a variety of different populations. In general, these studies have found that mass screening of an unselected community population is not cost-effective, whereas targeted screening in certain groups with high prevalence of CKD and high risk of progression to kidney failure (e.g., patients with diabetes and/or hypertension or African Americans8Komenda P. Ferguson T.W. Macdonald K. et al.Cost-effectiveness of primary screening for CKD: a systematic review.Am J Kidney Dis. 2014; 63: 789-797Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, 9Hoerger T.J. Wittenborn J.S. Zhuo X. et al.Cost-effectiveness of screening for microalbuminuria among African Americans.J Am Soc Nephrol. 2012; 23: 2035-2041Crossref PubMed Scopus (28) Google Scholar) would be cost-effective. Our study confirms these previous findings and extends them to a Canadian indigenous population. Rates of progression to end-stage renal disease and prevalence of albuminuria were major drivers of cost-effectiveness across all studies.8Komenda P. Ferguson T.W. Macdonald K. et al.Cost-effectiveness of primary screening for CKD: a systematic review.Am J Kidney Dis. 2014; 63: 789-797Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar Screening was thus most cost-effective in those populations with highest prevalence of albuminuria and propensity to kidney failure. Canadian indigenous groups appear to meet these criteria. The First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) study23Komenda P. Lavallee B. Ferguson T.W. et al.The prevalence of CKD in rural Canadian indigenous peoples: results from the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) screen, triage, and treat program.Am J Kidney Dis. 2016; 68: 582-590Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar found that indigenous communities had a prevalence of kidney disease (defined as urine ACR ≥ 30 mg/g [3 mg/mmol] or GFR < 60 ml/min per 1.73 m2) that was twice as high as for the Canadian general population (25.5% vs. 12.5%).24Arora P. Vasa P. Brenner D. et al.Prevalence estimates of chronic kidney disease in Canada: results of a nationally representative survey.CMAJ. 2013; 185: E417-E423Crossref PubMed Scopus (229) Google Scholar Administrative data confirms a high incidence and young age of onset of kidney failure in these indigenous communities, consistent with rapid progression of kidney disease.25Komenda P. Yu N. Leung S. et al.Secular trends in end-stage renal disease requiring dialysis in Manitoba, Canada: a population-based study.CMAJ Open. 2015; 3: E8-E14Crossref PubMed Google Scholar The reasons for the high incidence of CKD and rate of progression to kidney failure in Canadian indigenous communities have been previously explored. The causes appear to be multifactorial. There is a consistently documented high prevalence of diabetes and hypertension among residents of rural indigenous communities.26Young T.K. Reading J. Elias B. O'Neil J.D. Type 2 diabetes mellitus in Canada's first nations: status of an epidemic in progress.CMAJ. 2000; 163: 561-566PubMed Google Scholar, 27Fransoo R, Martens P, Prior H, et al. The 2013 RHA Indicators Atlas 2013. 2016. Available at: http://mchp-appserv.cpe.umanitoba.ca/reference/RHA_2013_web_version.pdf. Accessed May 5, 2016.Google Scholar Beyond this, nearly one-third of those screened in the FINISHED study were found to have kidney disease without evidence of concurrent diabetes or hypertension.23Komenda P. Lavallee B. Ferguson T.W. et al.The prevalence of CKD in rural Canadian indigenous peoples: results from the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) screen, triage, and treat program.Am J Kidney Dis. 2016; 68: 582-590Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Thus a substantial portion of potentially treatable kidney disease could be missed if screening in these communities were limited to those with diabetes and hypertension. Our findings have implications for clinical care and research. Our study confirms that mass screening of high-prevalence, high-progression risk communities is likely to be cost-effective. This finding is generalizable to other at-risk indigenous populations. For example, a high prevalence of CKD and kidney failure has been observed in the United States among the Navajo, Zuni, and Pima Indians,28Stidley C.A. Shah V.O. Scavini M. et al.The Zuni kidney project: a collaborative approach to an epidemic of kidney disease.J Am Soc Nephrol. 2003; 14: S139-s143Crossref PubMed Google Scholar, 29Shah V.O. Scavini M. Stidley C.A. et al.Epidemic of diabetic and nondiabetic renal disease among the Zuni Indians: the Zuni Kidney Project.J Am Soc Nephrol. 2003; 14: 1320-1329Crossref PubMed Scopus (35) Google Scholar, 30Hoy W. Jim S. Warrington W. et al.Urinary findings and renal function in adult Navajo Indians and associations with type 2 diabetes.Am J Kidney Dis. 1996; 28: 339-349Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 31Nelson R.G. Bennett P.H. Beck G.J. et al.for the Diabetic Renal Disease Study GroupDevelopment and progression of renal disease in Pima Indians with non-insulin-dependent diabetes mellitus.N Engl J Med. 1996; 335: 1636-1642Crossref PubMed Scopus (403) Google Scholar and in Australia and New Zealand among the Pacific Islanders, Maori, and Aboriginal and Torres Strait Islanders.32McDonald S.P. Russ G.R. Current incidence, treatment patterns and outcome of end-stage renal disease among indigenous groups in Australia and New Zealand.Nephrology (Carlton). 2003; 8: 42-48Crossref PubMed Scopus (82) Google Scholar, 33Hoy W.E. Hughson M.D. Singh G.R. et al.Reduced nephron number and glomerulomegaly in Australian Aborigines: a group at high risk for renal disease and hypertension.Kidney Int. 2006; 70: 104-110Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar, 34Hoy W.E. Mathews J.D. McCredie D.A. et al.The multidimensional nature of renal disease: rates and associations of albuminuria in an Australian Aboriginal community.Kidney Int. 1998; 54: 1296-1304Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar Ideally, the cost-effectiveness of such an intervention would be confirmed in a cluster randomized controlled trial. Such a trial appears well justified by our findings. However, as a trial of this magnitude will take years to perform and would be costly, and as the human cost of inaction appears substantial, consideration could be given to implementing mass screening in communities with the highest risk. Integrating additional potential benefits of screening and treatment in the existing model framework may improve the cost-effectiveness of a screening intervention. Previous studies have considered the impact of albuminuria screening on the reduction of cardiovascular events and found screening to be cost-effective even in the general population.35Boersma C. Gansevoort R.T. Pechlivanoglou P. et al.Prevention of Renal and Vascular End Stage Disease Study GroupScreen-and-treat strategies for albuminuria to prevent cardiovascular and renal disease: cost-effectiveness of nationwide and targeted interventions based on analysis of cohort data from the Netherlands.Clin Ther. 2010; 32: 1103-1121Abstract Full Text PDF PubMed Scopus (37) Google Scholar, 36Kondo M. Yamagata K. Hoshi S.L. et al.Cost-effectiveness of chronic kidney disease mass screening test in Japan.Clin Exp Nephrol. 2012; 16: 279-291Crossref PubMed Scopus (42) Google Scholar Some potential benefits include the reduction of cardiovascular events in patients with diabetes using blood pressure–lowering pharmacotherapy,37Wright Jr., J.T. Williamson J.D. Whelton P.K. et al.for the SPRINT Research GroupA randomized trial of intensive versus standard blood-pressure control.N Engl J Med. 2015; 373: 2103-2116Crossref PubMed Scopus (3909) Google Scholar and the potential for increased uptake of statin prescriptions in newly identified CKD cases.38Tonelli M. Isles C. Curhan G.C. et al.Effect of pravastatin on cardiovascular events in people with chronic kidney disease.Circulation. 2004; 110: 1557-1563Crossref PubMed Scopus (348) Google Scholar, 39Baigent C. Landray M.J. Reith C. et al.The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial.Lancet. 2011; 377: 2181-2192Abstract Full Text Full Text PDF PubMed Scopus (1886) Google Scholar In addition, prescription of new therapies such as sodium-glucose cotransporter 2 inhibitors can provide benefit in patients with type 2 diabetes and high cardiovascular risk.40Fitchett D. Zinman B. Wanner C. et al.Heart failure outcomes with empagliflozin in patients with type 2 diabetes at high cardiovascular risk: results of the EMPA-REG OUTCOME trial.Eur Heart J. 2016; 37: 1526-1534Crossref PubMed Scopus (729) Google Scholar Multiple factors would influence the efficacy of these treatments in a decision analysis model, including prevailing rates of usage of each pharmacotherapy, the underlying prevalence of untreated diabetes in screened communities, and ancillary effects of a screening program such as community education, increased awareness, and lifestyle interventions. Overall effectiveness of a screen and treat initiative could therefore be better measured with a cluster randomized trial that can better capture multiple concurrent effects and their influence on patient outcomes. Nonetheless, the model framework incorporating only the effects of angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin-receptor blocker (ARB) prescriptions in patients with severely increased albuminuria demonstrates a high likelihood that screening for CKD in this population would be cost-effective. Our analysis has many strengths. We stratified risk of progression using both eGFR and quantitative urine ACR, whereas many previous analyses have evaluated the cost utility of screening for CKD based on urine ACR or eGFR screening alone.8Komenda P. Ferguson T.W. Macdonald K. et al.Cost-effectiveness of primary screening for CKD: a systematic review.Am J Kidney Dis. 2014; 63: 789-797Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar This classification of progression risk aligns with current CKD evaluation and management guidelines, and there has been a demonstrated relationship between the dual staging system by both eGFR and urine ACR and adverse outcomes, including kidney failure, progressive CKD, cardiovascular events, and increased mortality.41Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work GroupKDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.Kidney Int Suppl. 2013; 3: 1-150Abstract Full Text Full Text PDF Scopus (1579) Google Scholar Additionally, we used demographic, progression, and cost data derived directly from a real-world screening program in indigenous communities. Our study has conservatively assumed that early detection of CKD and treatment with ACE-Is or ARBs would only benefit patients with severely increased albuminuria. There were also some limitations to our analysis. The source data from FINISHED used a single measurement of urine ACR to classify persistent albuminuria, whereas an ideal classification of CKD would be made with elevated urine ACR sustained over a 3-month period.41Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work GroupKDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.Kidney Int Suppl. 2013; 3: 1-150Abstract Full Text Full Text PDF Scopus (1579) Google Scholar In addition, the self-selected nature of the FINISHED cohort may underestimate the prevalence of CKD if the healthiest individuals self-select for presentation or overestimate the prevalence if those with risk factors, such as hypertension or diabetes, self-select for presentation. Our findings suggest that targeted screening and treatment for CKD using point-of-care testing equipment in rural Canadian indigenous populations is cost-effective, particularly in remote air access–only communities that had the highest risk of CKD and kidney failure. These findings are relevant to other high-risk indigenous groups with a similar burden of CKD and progression risk to kidney failure. Evaluation of targeted screening initiatives with cluster randomized controlled trials, as well as integration of screening into routine clinical visits in high-risk communities is recommended.
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