Screening to prevent renal failure in insulin dependent diabetic patients: an economic evaluation

BMJ 1995;311:1595-1599 (16 December)

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Screening to prevent renal failure in insulin dependent diabetic patients: an economic evaluation

Bryce A Kiberd, associate professor of medicine,^a Kailash K Jindal, associate professor of medicine ^a

^a Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada

Correspondence to: Professor Kiberd, 5077 RC Dickson Building, Victoria General Hospital, Halifax, Nova Scotia, Canada B3H 2Y9.

Abstract

Objective: To examine the conditions necessary to make screeningfor microalbuminuria in patients with insulin dependent diabetesmellitus cost effective.
Design: This economic evaluation compared two strategies designedto prevent the development of end stage renal disease in patientswith insulin dependent diabetes with disease for five years.Strategy A, screening for microalbuminuria as currently recommended,was compared with strategy B, a protocol in which patients werescreened for hypertension and macroproteinuria.
Intervention: Patients identified in both strategies were treatedwith an angiotensin converting enzyme inhibitor.
Setting: Computer simulation.
Main outcome measures: Strategy costs and quality adjusted lifeyears (QALYs).
Results: The model predicted that strategy A would produce anadditional 0.00967 QALYs at a present value cost of $261.53(1990 US$) per patient (or an incremental cost/QALY of $27041.69)over strategy B. The incremental cost/QALY for strategy A overB was sensitive to several variables. If the positive predictivevalue of screening for microalbuminuria (impact of false labeland unnecessary treatment) is <0.72, the effect of treatmentto delay progression from microalbuminuria to macroproteinuriais <1.6 years, the cumulative incidence of diabetic nephropathyfalls to <20%, or >64% of patients demonstrate hypertensionat the onset of microalbuminuria, then the incremental costs/QALYwill exceed $75000.
Conclusions: Whether microalbuminuria surveillance in this populationis cost effective requires more information. Being aware ofthe costs, recommendation pitfalls, and gaps in our knowledgeshould help focus our efforts to provide cost effective careto this population.

Key messages

Key messages
Treatment with angiotensin converting enzyme inhibitors at the start of microalbuminuria must delay progression to macroproteinuria by on average 1.6 years to be cost effective
The positive predictive value of the test is important; physicians must also avoid inappropriate testing
Twice yearly testing for microalbuminuria after the start of treatment with angiotensin converting enzyme inhibitors is probably not cost effective

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