Multidisciplinary Care: Cost-effective for Chronic Kidney Disease Patients

Highlights:

Medicare-funded multidisciplinary care (MDC) programs in the US are likely to be cost-effective in patients with mild to moderate chronic kidney disease (CKD).
Medical care for patients under MDC added 0.23 quality-adjusted life years (QALYs - the total lifetime costs and outcomes) than compared to conventional care.
Further research, is therefore required to evaluate the optimal and most cost-effective composition of MDC depending on patients’ risk factors and for different stages of CKD.

Medicare-funded multidisciplinary care programs in the US are likely to be cost-effective in patients with mild to moderate chronic kidney disease (CKD), found a new study from Stanford University, California. This study was published in PLOS Medicine.

In the United States, the expenditures associated with chronic kidney disease (CKD) is more (20%) than the number of Medicare beneficiaries the disease affects (10%). CKD patients with end-stage renal disease (ESRD) in particular cost more; they represent 1.6% of Medicare beneficiaries but are responsible for 7.2% of costs. At the same time, life expectancy is substantially lower in patients with CKD than in the general population. Multidisciplinary care (MDC) has been proposed as a way to mitigate the high costs and mortality associated with CKD.

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‘Mild to moderate chronic kidney disease patients can benefit economically if they enroll in a multidisciplinary care program than in conventional care.’

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What is Multidisciplinary Care (MDC)?

Multidisciplinary care is a system when health care providers of different expertise collaborate to treat a single disease. MDC has been shown to reduce mortality and the incidence of end-stage renal disease in patients with CKD, but the cost-effectiveness of such programs remains unclear. MDC has had successful outcomes in other health conditions like heart failure intensive care, and cancer.

However, little was known about the cost-effectiveness of MDC in a US CKD population. The model had to take into account heterogeneity in CKD and the subgroups that benefit the most from MDC; this may help providers more efficiently treat vulnerable patients with CKD.

In the new study, researchers are developing a novel CKD progression model that incorporates disease heterogeneity and mortality risk. Then they performed a cost-effective analysis of a Medicare-based multidisciplinary care program, for US populations of differing CKD severity. They hypothesized that MDC is more profitable in patients with more severe CKD. The program included inputs from nephrologists, advanced practitioners, educators, dietitians, and social workers, for patients with stage 3 and 4 CKD.

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Why was the study conducted?

The main aim of the study was to understand the cost-effectiveness of multidisciplinary care in chronic kidney disease in the United States (US). Since CKD is a major cause of morbidity and mortality in the US, a study like this can help policymakers decide whether MDC cost-effectively improves health outcomes.

A novel Markov model of CKD progression was used to assess the impact of a programme of MDC in mild to moderate CKD (estimated glomerular filtration rate [eGFR]. The model intended to assess the effectiveness of MDC in slowing progression of CKD and reducing mortality. Data was compiled from Medicare claims and published literature.

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Results of the study

The study estimates that MDC meets conventional cost-effectiveness thresholds in middle-aged to elderly patients with mild to moderate CKD.
Predicted benefit measured as quality-adjusted life years or QALYs gained adds 0.23 QALYs over usual care, with a cost of $51,285 per QALY gained. This takes into account the accepted cost-effectiveness thresholds for high-income countries.
MDC was estimated to be more cost-effective in patients with higher urine albumin excretion.
The study showed that MDC remained cost-effective at a limit of US$150,000 per QALY gained, even when effectiveness was reduced to 25% or cost was increased 5-fold.

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Limitations of the study

Other additional components that could have been added include inputs from a pharmacist, a physiotherapist, an occupational therapist, or a psychologist
Since the optimal composition of MDC will likely vary with the stage and severity of CKD as well as the target for improvement, the optimal and cost-effective composition of MDC has to be evaluated for different stages of CKD
The proposed program may not apply to populations at low risk for progression to end-stage renal disease hence MDC packages have to be developed so that they best suit the patients’ risk profile

However, overall, the findings support the use of medicare-funded multidisciplinary care programs for patients with mild to moderate CKD.

The authors Richard Fluck and Maarten Taal from Royal Derby Hospital, UK say "Much remains to be done to identify the optimal package of care for different patient subgroups, but we agree with the authors that the data provide sufficient evidence to support initiation of pilot MDC programmes as well as further research to identify optimal models for implementation."

Chronic Kidney Disease (CKD)

CKD is characterized by gradual loss of kidney function over months or years. It often has no symptoms and is diagnosed by a blood test. Progression of kidney disease to kidney failure can be prevented by early detection.

Reference

Fluck RJ, Taal MW “What is the value of multidisciplinary care for chronic kidney disease?” PLoS Med 15(3) (2018) : e1002533. https://doi.org/10.1371/journal.pmed.1002533

Source-Medindia