Cost-effectiveness of screening for chronic kidney disease in the general adult population: a systematic review

Abstract

Introduction Chronic kidney disease (CKD) is a significant public health problem, with rising incidence and prevalence worldwide and is associated with increased morbidity and mortality. Early identification and treatment of CKD can slow its progression and prevent complications, but it is not clear if CKD screening is cost-effective. The aim of this study is to conduct a systematic review of the cost-effectiveness of CKD screening strategies in general adult populations worldwide, and to identify factors, settings and drivers of cost-effectiveness in CKD screening. Methods Studies examining the cost-effectiveness of CKD screening in general adult population were identified by systematic literature search on electronic databases (MEDLINE OVID, Embase, Cochrane Library and Web of Science) for peer-reviewed publications, hand-searched reference lists and grey literature of relevant sites, focusing on the following themes: (i) CKD, (ii) screening and (iii) cost-effectiveness. Studies comprising of health economic evaluations performed for CKD screening strategies, compared against no CKD screening or usual-care strategy in adult individuals, were included. Study characteristics, model assumptions and CKD screening strategies of selected studies were identified. The primary outcome of interest is the incremental cost-effectiveness ratio (ICER) of CKD screening, in cost per quality-adjusted life year (QALY) and life-year gained (LYG), expressed in 2022 US dollars equivalent. Results 21 studies were identified, examining CKD screening in general and targeted populations. The cost-effectiveness of screening for CKD was found to vary widely across different studies, with ICERs ranging from ${\$}$113 to ${\$}$430 595, with a median of ${\$}$26 662 per QALY and from ${\$}$6516 to ${\$}$38 372, with a median of ${\$}$29 112 per LYG. Based on the pre-defined cost-effectiveness threshold of ${\$}$50 000 per QALY, majority of the studies found CKD screening to be cost-effective. CKD screening was especially cost-effective in those with diabetes (${\$}$113 to ${\$}$42 359, with median of ${\$}$27 471 per QALY) and ethnic groups identified to be higher risk of CKD development or progression (${\$}$23 902 per QALY in African American adults and ${\$}$21 285 per QALY in Canadian indigenous adults), as indicated by a lower ICER. Additionally, the cost-effectiveness of CKD screening improved if it was performed in older adults, population with higher CKD risk-scores, setting higher albuminuria detection threshold or when increasing the interval between screening. In contrast, CKD screening was not cost-effective in population without diabetes and hypertension (ICERs range from ${\$}$117 769 to ${\$}$1792 142, with a median of ${\$}$202 761 per QALY). Treatment effectiveness, prevalence of CKD, cost of CKD treatment and discount rate were identified to be the most common influential drivers of the ICERs. Conclusions Screening for CKD is especially cost-effective in patients with diabetes and high-risk ethnic groups, but not in population without diabetes and hypertension. Increasing the age of screening, screening interval, albuminuria detection threshold or selection of population based on CKD risk-scores may increase cost-effectiveness of CKD screening, while treatment effectiveness, prevalence of CKD, cost of CKD treatment and discount rate were influential drivers of the cost-effectiveness.

Albuminuria: An Underappreciated Risk Factor for Cardiovascular Disease

“…Overcoming barriers and increasing screening rates of patients at risk are possible, especially because the ready availability and relative low cost of screening tests renders screening of populations at risk, such as those with diabetes or hypertension, very cost effective. 110 Several institutions, including primary care and secondary care, have employed simple measures such as electronic health record‐based reminders and patient and clinician education to improve albuminuria screening rates. 111 , 112 …”

Cost-effectiveness of screening for chronic kidney disease: existing evidence and knowledge gaps

“…In this issue of Clinical Kidney Journal , Yeo et al. provide an up-to-date systematic review of cost-effectiveness analyses of CKD screening strategies in the general adult population [ 8 ]. Below, we address several issues that are relevant to make CKD screening (cost-) effective.…”

“…In their systematic review, Yeo et al. included 21 studies, of which the majority investigated screening for albuminuria ( n = 13), and fewer studies investigated screening for estimated glomerular filtration rate (eGFR) ( n = 3) or both ( n = 3) [ 8 ]. Traditionally, eGFR is the most commonly used marker to detect CKD.…”

“…In their review, Yeo et al. identified 13 studies examining CKD screening targeted to such high-risk populations [ 8 ]. From those studies, they conclude that CKD screening is especially cost-effective in patients with diabetes at a median incremental cost-effectiveness ratio (ICER) of US$27 471 (range US$113–US$42 359) and in patients with hypertension at a median ICER of US$53 531 (range US$28 351–US$424 191).…”

Testing the waters on home-based albuminuria screening to enhance the detection and management of CKD

“…In the THOMAS study using the UCD method, the number needed to screen to identify one participant with newly diagnosed increased ACR was 58; however, the number of patients screened who received new treatment was <1%. In previous studies, a selective approach to screen only high-risk patients including those with diabetes, hypertension, familial history, or high-risk ethnic groups has been demonstrated to be cost-effective and carries a higher predictive value [ 5 ]. In the THOMAS study 25% had a urine ACR >30 mg/mmol alongside diabetes and hypertension, highlighting that albuminuria in the general population is often a complication rather than cause of other co-morbidities.…”