Economic Benefits of Intervention
An abundance of literature is available on the economics of ESRD. In the industrial world, treatment is usually readily available and is covered by government or private health insurance. Previous restrictions—for example, treatment being limited to certain age groups—have been removed (Chugh and Jha 1995). Dialysis treatment accounts for 0.7 to 1.8 percent of health care budgets in European countries, even though dialysis patients account for only 0.02 to 0.05 percent of the population (Schiepatti, Perico, and Remuzzi 2003).
The most cost-effective option is prevention. Population screening is not particularly cost-effective, given the low incidence of ESRD—namely, 100 to 200 per million population worldwide (Kher 2002)—and given that testing is not highly accurate. According to Kiberd and Jindal (1998), screening costs around US$20 per test, but the positive predictive value for a single test is only 0.3. Even repeat testing does not improve predictive value dramatically. Screening strategies have, therefore, focused on specific populations at higher risk of ESRD than the general population. Whereas only 2 to 5 percent of more than 1 billion hypertensive patients will ultimately develop nephropathy, approximately 30 percent of type 1 and type 2 diabetic patients will develop overt nephropathy (Satko and Freedman 2001). The conclusion is that treating all diabetics in developed countries with ACE inhibitors is a cost-saving strategy. The modest outlay for ACE inhibitors, which amounts to US$320 per year in the United States and is likely to come down as more ACE inhibitor treatments come off patent, offsets the much larger future costs of dialysis and transplant (Golan, Birkmeyer, and Welch 1999; Kiberd and Jindal 1998).
We undertook a crude cost-effectiveness calculation for treating diabetics in developing countries with ACE inhibitors in those cases in which no treatment of ESRD is undertaken. If we use Clark and others' (2000) assumptions, 82 percent of diabetic patients not using ACE inhibitors would survive for 11 years from the onset of macroproteinuria to ESRD, whereas 72 percent of those using ACE inhibitors would survive for 18 years from the onset of macroproteinuria to ESRD (the annualized death rate for both groups is 1.8 percent). If we make the gross assumption that all patients with ESRD in poor developing countries die, this assumption suggests that, at a discount rate of 3 percent and an annual cost for ACE inhibitors of US$320, the cost per quality-adjusted life year (QALY) saved would be about US$1,100 for treating diabetic patients with macroproteinuria. Because of the lack of data, these calculations apply survival rates in developed countries to developing countries; thus, the rates are likely too high. Using survival rates in developing countries would probably increase the cost per QALY saved, but treatment with ACE inhibitors is nevertheless likely to be an attractive investment (table 36.3).
Satko and Freedman (2001) suggest that screening first- and second-degree relatives of ESRD patients may be cost-effective. They cite one study that found 38 percent of first-degree relatives of African-American patients with hypertensive ESRD had some form of renal disease (Bergman and others 1996). Satko and Freedman also cite a study by Freedman, Soucie and McClellan (1997) revealing that in 4,365 incident ESRD patients in the southeastern United States, 14 percent of white patients and 23 percent of black patients had first- or second-degree relatives with ESRD (the rates would probably have been higher if subclinical nephropathy had been included). Satko and Freedman (2001) recommend annual screening for blood pressure, urinalysis, measurement of serum creatinine and blood urea nitrogen concentration, and testing for diabetes mellitus, when appropriate, for first- and second-degree relatives of ESRD patients. They did not calculate any formal cost-effectiveness results (table 36.3).
Kidney transplants are the most cost-effective intervention for ESRD. Transplant costs in developed countries have declined steadily from about US$60,000 in 1970 to about US$10,000 currently (Winkelmayer and others 2002). In addition to facing transplant costs, patients face ongoing costs for immunosuppressive drugs, which start at about US$3,000 per year initially but can decline thereafter to US$300 per year (Kher 2002). Kidney transplants are cheaper in India than in the United States, ranging from US$1,500 in government hospitals to as much as US$7,000 in private hospitals. Such costs, combined with a higher quality of life than obtained with dialysis, make renal transplantation the most cost-effective option (table 36.3). However, the availability of kidneys is a major limiting factor. Developed countries tend to have well-organized organ retrieval programs, and cadaveric donor transplants are more common than they are in developing countries. Japan, with its extremely low transplant rates, is an exception, perhaps because of difficulties in obtaining permission for organ donation.
Developing countries have limited access to cadaveric donor programs but better living donor programs. Unrelated living donors are more common than in developed countries because poverty increases the willingness of donors to offer kidneys in exchange for payment. The Philippines recently restricted donations to "emotionally related" donors, but that limitation does not prevent abuses, such as men marrying women of the appropriate blood type in the hope of obtaining a kidney. Developing countries face particular transplantation problems, such as patients' inability to continue paying for immunosuppressive drugs and the transmission of hepatitis B and C, malaria, and TB through organ transplant (Kher 2002).
Long-term hemodialysis was introduced in 1960 and is the most costly treatment option at approximately US$60,000 per year at a center and US$40,000 at home in developed countries. It is most cost-effective if used as an interim measure before kidney transplant. Peritoneal dialysis—for example, continuous ambulatory peritoneal dialysis—was developed in the late 1970s and is less expensive—approximately US$20,000 per year (Winkelmayer and others 2002). Most economies continue to rely on hemodialysis for dialysis patients, except for those mandating that continuous ambulatory peritoneal dialysis be the first choice—that is, Hong Kong (China), Mexico, New Zealand, and the United Kingdom. Switching to continuous ambulatory peritoneal dialysis has the potential of reducing costs for developing countries, especially if they manufacture the consumables domestically rather than importing them. Nevertheless, dialysis remains costly and is not a viable long-term solution in places where health budgets are limited.
More than 120 countries have dialysis programs (Moeller, Gioberge, and Brown 2002). The following data from India highlight the stark economics of dialysis (Kher 2002). Government hospitals will provide hemodialysis only for acute renal failure or pretransplant stabilization (Li and Chow 2001), and with an incidence of 100 per million population, approximately 100,000 patients develop ESRD each year. Of the 10,000 who consult a nephrologist, RRT is initiated for 9,000. Of the 8,500 who begin hemodialysis, about 60 percent are lost to follow-up within three months, probably because of the costs involved. Few remain on dialysis after 24 months. Between 17 and 23 percent of those on dialysis for two to three months receive transplants.