Cost-effectiveness of multidisciplinary care in mild to moderate chronic kidney disease in the United States: A modeling study.
Cost-effectiveness of multidisciplinary care in mild to moderate chronic kidney disease in the United States: A modeling study.
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DOI：
10.1371/journal.pmed.1002532
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发表时间：
2018-03
期刊：
影响因子：
15.8
通讯作者：
Goldhaber-Fiebert JD
中科院分区：
文献类型：
--
作者：
Lin E;Chertow GM;Yan B;Malcolm E;Goldhaber-Fiebert JD
在美国，多学科护理（MDC）计划已被提出作为减轻慢性肾脏病（CKD）相关费用和发病率的一种方法。我们评估了在美国45至84岁的CKD 3期和4期医疗保险受益人中，与常规CKD护理相比，理论上基于医疗保险的MDC计划治疗CKD的成本效益。该计划使用了肾脏科医生、高级从业者、教育工作者、营养师和社会工作者。根据医疗保险索赔和已发表的文献，我们开发了一种新的确定性CKD进展的马尔可夫模型，并将其校准为死亡率和进展为终末期肾病的长期风险。然后，我们使用该模型来预测应计贴现成本和患者剩余生命期的质量调整生命年（QHMS）。我们估计了MDC的增量成本-效果比（ICER），或每获得一个QALY的干预成本。MDC比常规护理增加了0.23（95% CI：0.08，0.42）QALY，每获得一个QALY花费51，285美元（每获得一个QALY的阈值为150，000美元，净货币收益为23，100美元; 95% CI：6，252美元，44，323美元）。在分析的所有亚群中，ICER范围为42，663美元至72，432美元/QALY。尿白蛋白排泄量较高的患者中，MDC通常更具成本效益。虽然ICER在年轻患者中较高，但MDC可以使年轻患者的健康状况比老年患者更好。当我们将MDC的有效性降低到基础病例的25%或将成本增加5倍时，MDC仍然具有成本效益。在95%的概率敏感性分析中，该计划的成本低于70，000美元/QALY，在99%的分析中，成本低于87，500美元/QALY。我们研究的局限性包括其理论性质和不太适用于进展为ESRD的低风险人群。我们没有研究MDC对住院（心血管或其他）的潜在影响。我们的模型估计，医疗保险资助的MDC计划可以减少对透析的需求，延长预期寿命，并满足中老年轻度至中度CKD患者的传统成本效益阈值。尤金林和colleageus使用一种建模方法，研究了美国轻度至中度慢性肾脏疾病多学科护理的成本效益。慢性肾脏疾病是美国发病率和死亡率的主要原因。多学科护理当不同专业的医疗保健提供者合作治疗单一疾病时，已成功降低慢性肾脏病患者的死亡率和终末期肾脏病的发生率。了解多学科护理对慢性肾脏疾病的经济影响可以帮助政策制定者决定这样的计划是否以具有成本效益的方式改善健康结果。我们开发了一种新的马尔可夫模型，该模型准确地模拟了慢性肾脏疾病向终末期肾脏疾病的进展，并解释了慢性肾脏疾病患者的异质性。多学科护理在大多数慢性肾脏病患者中具有成本效益，在蛋白尿水平较高的患者中更具成本效益。多学科护理在模型中仍然具有成本效益，即使它比基本情况估计的效率低得多或成本高得多。多学科护理可以以合理的性价比改善慢性肾脏病患者的健康。政策制定者可以考虑实施试点多学科护理计划，以正式测试其有效性和成本效益。
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. Using a modeling approach, Eugene Lin and colleageus examine the cost-effectiveness of multi-disciplinary care in mild to moderate chronic kidney disease in the US. Chronic kidney disease is a major cause of morbidity and mortality in the US. Multidisciplinary care—when healthcare providers of different expertise collaborate to treat a single disease—has successfully reduced mortality and the incidence of end-stage renal disease in patients with chronic kidney disease. Understanding the economic impact of multidisciplinary care in chronic kidney disease could help policy makers decide whether such a program improves health outcomes in a cost-effective way. We developed a novel Markov model that accurately simulates the progression of chronic kidney disease to end-stage renal disease and accounts for heterogeneity in patients with chronic kidney disease. Multidisciplinary care was cost-effective in most patients with chronic kidney disease and was more cost-effective in patients with higher levels of albuminuria. Multidisciplinary care remained cost-effective in the model even if it was substantially less effective or more costly than base case estimates. Multidisciplinary care could improve the health of patients with chronic kidney disease at reasonable value for money. Policy makers could consider implementing pilot multidisciplinary care programs to formally test their effectiveness and cost-effectiveness.
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