In the United States, the expenditures associated
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.
What is Multidisciplinary
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.
‘Mild to moderate chronic kidney disease patients can benefit economically if they enroll in a multidisciplinary care program than in conventional care.’
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.
Why was the study
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.
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.
Limitations of the
- Other additional components that could have been added include
inputs from a pharmacist, a physiotherapist, an occupational therapist, or
- 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
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