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A Cost-effectiveness Analysis

L. Ebony Boulware, MD, MPH; Bernard G. Jaar, MD, MPH; Michelle E. Tarver-Carr, MD, PhD; Frederick L. Brancati, MD, MHS; Neil R. Powe, MD, MPH, MBA

JAMA. 2003;290:3101-3114.

Context  Chronic kidney disease is a growing public health problem. Screening for early identification could improve health but could also lead to unnecessary harms and excess costs.

Objective  To assess the value of periodic, population-based dipstick screening for early detection of urine protein in adults with neither hypertension nor diabetes and in adults with hypertension.

Design, Setting, and Population  Cost-effectiveness analysis using a Markov decision analytic model to compare a strategy of annual screening with no screening (usual care) for proteinuria at age 50 years followed by treatment with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II-receptor blocker (ARB).

Main Outcome Measure  Cost per quality-adjusted life-year (QALY).

Results  For persons with neither hypertension nor diabetes, the cost-effectiveness ratio for screening vs no screening (usual care) was unfavorable ($282 818 per QALY; incremental cost of $616 and a gain of 0.0022 QALYs per person). However, screening such persons beginning at age 60 years yielded a more favorable ratio ($53 372 per QALY). For persons with hypertension, the ratio was highly favorable ($18 621 per QALY; incremental cost of $476 and a gain of 0.03 QALYs per person). Cost-effectiveness was mediated by both chronic kidney disease progression and death prevention benefits of ACE inhibitor and ARB therapy. Influential parameters that might make screening for the general population more cost-effective include a greater incidence of proteinuria, age at screening ($53 372 per QALY for persons beginning screening at age 60 years), or lower frequency of screening (every 10 years: $80 700 per QALY at age 50 years; $6195 per QALY at age 60 years; and $5486 per QALY at age 70 years).

Conclusions  Early detection of urine protein to slow progression of chronic kidney disease and decrease mortality is not cost-effective unless selectively directed toward high-risk groups (older persons and persons with hypertension) or conducted at an infrequent interval of 10 years.

Author Affiliations: Department of Medicine, Johns Hopkins University School of Medicine (Drs Boulware, Jaar, Brancati, and Powe), Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health (Drs Boulware, Brancati, and Powe), Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions (Drs Boulware, Jaar, Tarver-Carr, Brancati, and Powe), Baltimore, Md.

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