The Chronic Kidney Disease Care Model: Quantifying Management Strategies for Improving Patient Outcomes in the USA

Abstract

While chronic kidney disease (CKD) afflicts an estimated 14% of US adults, the majority remain unaware of the ailment until later stages. CKD progression can lead to reduced quality of life, cardiovascular disease (CVD), and end-stage renal disease (ESRD). Consensus guidelines highlight novel interventions for the early recognition and management of CKD. Here, we describe the rationale and structure of a policy model for CKD that provides contemporary estimates of long-term effectiveness and cost-effectiveness of medical interventions. The utility of the model is illustrated by assessing potential management strategies for CKD. A state transition model was developed to follow over their lifetime a hypothetical cohort of insured US adults with CKD. CKD progression was tracked through Kidney Disease: Improving Global Outcomes (KDIGO) categories. Patients entering the cohort could transition to ESRD, CVD, heart failure (HF), or death from other causes. Those with a nonfatal first event were followed until death. The probability of a first event was determined by cohort characteristics, including estimated glomerular filtration rate (eGFR). Survival following a first nonfatal event was modeled parametrically. Costs were estimated using linked electronic health record-linked claims that included data from more than 100 million US adults. A health sector perspective was adopted. Relevant parameters for CKD progression, treatment efficacy, and utilities were derived from peer-reviewed studies. Under usual care, over a full patient lifetime, the model predicts that just 15% of patients will experience a death unrelated to CKD as their first event and that this will happen after an average of 12 years. With fully optimized treatment, and with no delay to treatment initiation, the percentage of patients dying of causes unrelated to CKD increases to 20%, and the time before that event increases to 14 years. Guideline-optimized treatment and eliminating treatment delay was estimated to result in an improvement of 0.68 QALYs over the patient lifetime at a cost of US $47,800. The CKD Care Model provides a flexible, transparent tool for projecting the impact of eGFR decline on clinical outcomes and evaluating management strategies for CKD. Illustrative analyses suggest that guideline-optimized treatment can improve patient outcomes at additional costs that appear favorable by conventional value-for-money standards.