Population-Wide CKD Screening Cost-Effective When Started At Age 55 Years, Study Finds

Joshua Salomon, PhD

Credit: Stanford University

Initiation of population-wide screening for chronic kidney disease (CKD) followed by treatment with conventional CKD therapy combined with sodium-glucose cotransporter-2 (SGLT2) inhibitors would be cost-effective for US adults when initiated at 55 years of age, according to findings from a recent study.¹

Results showed screening every 5 years combined with SGLT2 inhibitors from 55-75 years of age would cost $128,400 per quality-adjusted life year (QALY) gained. While initiation of screening at 35 or 45 years of age produced larger population health benefits, these strategies incurred additional costs totaling> $200,000 per QALY gained.¹

In the absence of effective CKD treatment options at the time, in 2012, the US Preventive Services Task Force found insufficient evidence to show screening and early detection of CKD improved clinical outcomes.² However, the recent emergence of SGLT2 inhibitors as a practice-changing therapy for CKD has prompted clinical guideline organizations to update standard of care recommendations for CKD to include these medications.¹

“Demonstration of substantial benefits from SGLT2 inhibitors in reducing kidney disease progression and mortality in patients with CKD has reopened the question of whether screening for CKD is effective and provides good value,” Joshua Salomon, PhD, a professor of health policy and senior fellow at the Freeman Spogli Institute for International Studies at Stanford University, and colleagues wrote.¹

In a previous study, investigators evaluated the potential benefits and costs of population-wide screening for CKD combined with the provision of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers plus SGLT2 inhibitors, determining screening has the potential to produce large population health benefits and was cost-effective among US adults aged 35 years or older. However, the analysis did not evaluate the optimal timing of screening initiation, a limitation they sought to address in the current study.³

For separate cohorts of patients aged 35, 45, 55, 65, or 75 years, investigators considered intervention strategies that start screening immediately or defer screening to start at older ages. Strategies were additionally distinguished based on screening frequency.¹

In the study, screening for CKD consisted of testing for albuminuria using the urine albumin-creatinine ratio (UACR) test and subsequent testing for serum creatinine to calculate estimated glomerular filtration rate (eGFR) accounting for sex and age.¹

Investigators used a previously published decision-analytic Markov cohort model that simulated progression of CKD among US adults from ≥ 35 years of age and was calibrated to population-level data from the National Health and Nutrition Examination Survey. The effectiveness of SGLT2 inhibitors was derived from the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) trial. Additionally, investigators obtained mortality, quality-of-life weights, and cost estimates from published cohort studies, randomized clinical trials, and US Centers for Medicare & Medicaid Services data.¹

Outcomes included cumulative incidence of kidney failure requiring kidney replacement therapy; averted cases of kidney failure requiring kidney replacement therapy; lifetime health care sector costs; life expectancy; QALYs; and incremental cost-effectiveness ratios (ICERs).¹

Results showed population-wide screening for albuminuria followed by treatment with conventional CKD therapy and SGLT2 inhibitors reduced the burden of kidney failure requiring kidney replacement therapy across all age groups compared with status quo case finding with conventional CKD therapy alone. Specifically, for individuals 35 years of age, starting screening at age 55 years and continuing every 5 years through age 75 years, combined with SGLT2 inhibitors, decreased the cumulative incidence of kidney failure requiring kidney replacement therapy from 2.4% to 1.9%.¹

Additionally, screening for CKD with conventional CKD therapy plus SGLT2 inhibitors yielded gains in life expectancy and QALYs compared with the status quo across all age groups, with larger benefits observed if screening every 5 years was initiated immediately. Under status quo, for those aged 35 years, discounted life years and QALYs were 23.8 (95% UI, 23.7-23.9) and 19.1 (95% UI, 17.8-20.1), respectively. Starting screening every 5 years at age 55 years increased life years and QALYs by 0.13 (95% UI, 0.05-0.20) and 0.09 (95% UI, 0.04-0.14), respectively.¹

Of note, screen-and-treat interventions with SGLT2 inhibitors increased health care costs. When screening began at age 55 years, average health care costs compared with the status quo increased by $8300, from $241,100 to $249,300 (95% UI, $189,800-$310,700), a notably smaller increment than beginning at age 35 years ($11,900). Although initiation of screening every 5 years at age 35 or 45 years yielded greater gains in population-wide health benefits, investigators noted these strategies cost more than $200,000 per additional QALY gained.¹

Investigators acknowledged multiple limitations to these findings, including the lack of available data on the long-term effectiveness of SGLT2 inhibitors; the fact that the model did not explicitly simulate the prevalence and incidence of key comorbidities; the inability to consider all clinical implementation barriers potentially reducing cost-effectiveness; the use of a single cost-effectiveness analysis; and the inability to conduct the analysis from a societal perspective.¹

“This cost-effectiveness study found that initiation of population-wide screening for CKD followed by treatment with conventional CKD therapy combined with SGLT2 inhibitors at age 55 years was cost-effective for US adults,” investigators concluded.¹ “Initiation at younger ages may have greater population health benefits but incurred additional costs.”

References

1. ^{Cusick MM, Tisdale RL, Chertow GM, et al. Populationwide Screening for Chronic Kidney Disease: A Cost-Effectiveness Analysis. JAMA Health Forum. 2024;5(11):e243892. doi:10.1001/jamahealthforum.2024.3892}
2. ^{Moyer VA, U.S. Preventive Services Task Force. Screening for chronic kidney disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. doi:10.7326/0003-4819-157-8-201210160-00533}
3. ^{Cusick MM, Tisdale RL, Chertow GM, et al. Population-wide screening for chronic kidney disease: a cost-effectiveness analysis. Ann Intern Med. 2023;176(6):788-797. doi:10.7326/M22-3228}