Home-Based Albuminuria Screening Cost-Effective for Preventing Kidney, Cardiovascular Events

Xavier G.L.V. Pouwels, PhD

Credit: University of Twente

Findings from a recent study are calling attention to the potential benefits of home-based albuminuria testing for predicting and preventing progressive chronic kidney disease (CKD) and cardiovascular disease, highlighting its cost-effectiveness for improving health outcomes in the general population compared to usual care.¹

The analysis was based on data from a real-world implementation study used to develop an individual-level health-state transition model for simulating the impact and potential benefits of home-based albuminuria screening on cardiovascular and renal outcomes as well as costs in Dutch individuals 45-80 years of age.¹

A sign of kidney disease signaling excess protein in one’s urine, albuminuria is also associated with diabetes, hypertension, heart disease, and heart failure. Routine protein screening is sometimes recommended for people deemed to be at high risk of kidney damage, although albuminuria’s lack of visible symptoms in its early stages has led some to propose the need for general-population screening to support the implementation of timely treatment and preventive interventions. The cost-effectiveness of albuminuria population screening is not well understood, especially in the context of home-based general screening compared to usual care.²

“Recently, clinical trials have shown that adding sodium glucose co-transporter 2 (SGLT2) inhibitors further reduces albuminuria and also improves kidney and cardiovascular outcomes. These drugs have, therefore, been added to the standard treatment for CKD,” wrote Xavier G.L.V. Pouwels, PhD, assistant professor of health technology and services research at the University of Twente in the Netherlands, and colleagues.¹ “Screening for albuminuria may be useful to identify individuals who could benefit from these treatments.”

To evaluate the cost-effectiveness of home-based general population screening for increased albuminuria, investigators developed an individual-level simulation model to compare home-based screening with a urine collection device to usual care in individuals 45–80 years of age. The model was based on the randomized Towards HOMe-based Albuminuria Screening (THOMAS) study, which evaluated the effectiveness of 2 home-based albuminuria screening strategies in 15,074 Dutch individuals aged 45–80.¹

The present cost-effectiveness study reports only the THOMAS results obtained using a urine collection device and omits those from participants who measured their albumin-to-creatinine ratio using an app-based dipstick method.¹

Cost-effectiveness was assessed from the Dutch healthcare perspective with a lifetime horizon. The costs of the screening process and benefits of preventing CKD progression, including dialysis and kidney transplantation, and cardiovascular disease events, including non-fatal myocardial infarction, non-fatal stroke, and fatal cardiovascular disease event, were reflected.¹

A synthetic cohort of 100,000 individuals was generated based on data from the 124 THOMAS study participants to populate the model, ensuring the characteristics of the simulated cohort aligned with the original study participants. Probabilities of participating in different screening steps and positive results were based on the THOMAS study data. The model inputs were derived from the study findings and expert opinions to simulate the cost-effectiveness of home-based albuminuria screening.¹

Model outcomes were the number of CKD and cardiovascular disease-related events, total costs, quality-adjusted life years, and the incremental cost-effectiveness ratio per quality-adjusted life year gained by screening versus usual care.¹

Results showed the absolute difference between screening versus usual care in lifetime probability of dialysis was 0.2%, kidney transplantation was 0.05%, non-fatal myocardial infarction was 0.6%, non-fatal stroke was 0.6%, and fatal cardiovascular events were 0.2%. Investigators noted this led to relative decreases in lifetime incidence of these events of 10.7%, 11.1%, 5.1%, 4.1%, and 1.6%, respectively, compared to usual care.¹

Further analysis revealed the incremental cost of screening was €1607 and the quality-adjusted life years associated with screening were 0.17, leading to a corresponding incremental cost-effectiveness ratio per quality-adjusted life year of €9225.¹

The probability of screening being cost-effective for the Dutch willingness-to-pay threshold for preventive population screening of €20,000 per quality-adjusted life year was 95.0%.¹

Of note, implementing screening in a subgroup of 45–64-year-olds reduced the incremental cost-effectiveness ratio to €7946 per quality-adjusted life year, whereas implementing screening in a subgroup of 65–80-year-olds increased the incremental cost-effectiveness ratio to €10,310 per quality-adjusted life year.¹

A scenario analysis assuming treatment optimization in all individuals with newly diagnosed risk factors or known risk factors not within the target range reduced the incremental cost-effectiveness ratio to €7083 per quality-adjusted life year, resulting in incremental cost and quality-adjusted life year gains of €2145 and 0.30, respectively.¹

“Home-based screening for increased albuminuria to prevent cardiovascular disease and CKD events is likely cost-effective. More health benefits can be obtained by screening younger individuals and better optimization of care in individuals identified with newly diagnosed or known risk factors outside target range,” investigators concluded.¹

References:

1. ^{Pouwels XGLV, van Mil D, Kieneker LM, et al. Cost-effectiveness of home-based screening of the general population for albuminuria to prevent progression of cardiovascular and kidney disease. The Lancet. https://doi.org/10.1016/j.eclinm.2023.102414}
2. ^{Johns Hopkins Medicine. Proteinuria. Conditions and Diseases.Accessed February 6, 2024. https://www.hopkinsmedicine.org/health/conditions-and-diseases/proteinuria}