Screening for chronic kidney disease in Canadian indigenous peoples is cost-effective

Abstract

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.

Preventing CKD in Developed Countries

“…Early detection, appropriate risk stratification, and subsequent treatment of CKD may delay or prevent many associated complications and decrease overall health care costs. 109,110 Screening the general population for early CKD is not cost-effective, and therefore is unwarranted. 6 Selective screening should be directed toward high-risk groups, specifically older persons and those with hypertension and diabetes, as well as some ethnic groups such as African Americans, and indigenous populations of Canada, the United States, and Australia.…”

“…6 Selective screening should be directed toward high-risk groups, specifically older persons and those with hypertension and diabetes, as well as some ethnic groups such as African Americans, and indigenous populations of Canada, the United States, and Australia. 109,111,112 Targeted screening of high-risk individuals, such as those with diabetes or hypertension or both, is cost-effective. 113,114 For instance, the costeffectiveness of a screening program for proteinuria among US adults with hypertension and diabetes has been clearly demonstrated; angiotensin-converting enzyme inhibitor/angiotensin-receptor blockers have been shown to reduce mortality and slow the progression of kidney disease among at-risk individuals identified through this screening program.…”

Access to CKD Care in Rural Communities of India: a qualitative study exploring the barriers and potential facilitators

“…Targeted programs like the Kidney Early Evaluation Program (KEEP)-a targeted community screening program for CKD in individuals with high risk of CKD has shown to improve awareness of CKD, and in-turn health-seeking behavior of the population [43]. Screening for CKD has been shown to be cost effective in diabetes in HIC [17,19,44]. While similar evidence is needed from LMIC, given the high prevalence of CKD and associated premature mortality and the unaffordability of dialysis, CKD screening is likely to offer even more economic returns on the investment.…”

“…There is strong evidence that the development of CVD and progression to ESKD can be prevented by prompt detection of CKD, and early institution of nonpharmacologic [9,10] and pharmacologic therapies [11][12][13][14][15][16][17]. Since patients with early CKD are often asymptomatic, screening for CKD may improve awareness and health-seeking behavior [18].…”

Access to CKD Care in Rural Communities of India: A Qualitative Study Exploring the Barriers and Potential Facilitators

“…(8) There is strong evidence that the development of CVD and progression to ESKD can be prevented by prompt detection of CKD, and early institution of non-pharmacologic (9, 10) and pharmacologic therapies. (11)(12)(13)(14)(15)(16)(17) Since patients with early CKD are often asymptomatic, screening for CKD may improve awareness and health-seeking behavior. (18) Screening and treatment of CKD (albuminuria and eGFR) have been shown to be cost effective in patients with diabetes.…”