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Boulware LE, Jaar BG, Tarver-Carr ME, Brancati FL, Powe NR. Screening for Proteinuria in US Adults: A Cost-effectiveness Analysis. JAMA. 2003;290(23):3101–3114. doi:10.1001/jama.290.23.3101
Author Affiliations: Department of Medicine, Johns Hopkins University School of Medicine (Drs Boulware, Jaar, Brancati, and Powe), Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health (Drs Boulware, Brancati, and Powe), Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions (Drs Boulware, Jaar, Tarver-Carr, Brancati, and Powe), Baltimore, Md.
Context Chronic kidney disease is a growing public health problem. Screening
for early identification could improve health but could also lead to unnecessary
harms and excess costs.
Objective To assess the value of periodic, population-based dipstick screening
for early detection of urine protein in adults with neither hypertension nor
diabetes and in adults with hypertension.
Design, Setting, and Population Cost-effectiveness analysis using a Markov decision analytic model to
compare a strategy of annual screening with no screening (usual care) for
proteinuria at age 50 years followed by treatment with an angiotensin-converting
enzyme (ACE) inhibitor or an angiotensin II-receptor blocker (ARB).
Main Outcome Measure Cost per quality-adjusted life-year (QALY).
Results For persons with neither hypertension nor diabetes, the cost-effectiveness
ratio for screening vs no screening (usual care) was unfavorable ($282 818
per QALY; incremental cost of $616 and a gain of 0.0022 QALYs per person).
However, screening such persons beginning at age 60 years yielded a more favorable
ratio ($53 372 per QALY). For persons with hypertension, the ratio was
highly favorable ($18 621 per QALY; incremental cost of $476 and a gain
of 0.03 QALYs per person). Cost-effectiveness was mediated by both chronic
kidney disease progression and death prevention benefits of ACE inhibitor
and ARB therapy. Influential parameters that might make screening for the
general population more cost-effective include a greater incidence of proteinuria,
age at screening ($53 372 per QALY for persons beginning screening at
age 60 years), or lower frequency of screening (every 10 years: $80 700
per QALY at age 50 years; $6195 per QALY at age 60 years; and $5486 per QALY
at age 70 years).
Conclusions Early detection of urine protein to slow progression of chronic kidney
disease and decrease mortality is not cost-effective unless selectively directed
toward high-risk groups (older persons and persons with hypertension) or conducted
at an infrequent interval of 10 years.
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