c.  Kidney Diseases Related to Hypersensitivity Phenomena, Hypothetical
  Frogrem at Intermediate REW Expenditure Level, Based on the Current
State of the Art

1.  Introduction

  This program has four components:

1) Education and administration;

2) Research;

3) Training; snd

4) Facilities.

The estimated total cost for this program is $26,670,000. HEW'S

share is estimated at $20,000,000. Figure 6 graphically iresents the

costs for this portion.  A discussion of the various program components

follows.


2.  Education and Administration

Under an intermediate, postgraduate physician

HEW will contribute $2,5oO,ooO, and an additional

support.  An additional $l,OOO,OOO will be needed

education program,
$500,000 for administrative

from other sources*

There are no immediate benefits expected from this new educational effort,

although long-term benefits will be significant; therefore, the smue
mortality reduction figure of 610 (see Section B.2.) is used.

3. Research

  With an intermediate level of financial support, clinical research
funds can be increased to $~,OOO,OOO ($4,500,000 from HEW). This
represents twelve large scale studies at $500,000 each, rather than

eight as described abave in Section B.3.

  To provide more rapid developments, an increase from fifteen to

twenty laboratory research centers in conjunction with an increase in

the amount of financial support for each of the twenty centers, will be


costs ($1,000,000)

150

100

Education and

PROGRAM

Education and
Administration
  (4.0)     I

*I Training
(1.0)
     TOTAL

Fig. 6.  Kidney Diseases Related to Hypersensitivity Phenomena
    Hypothetical Program Costs at Intermediate HEW Expenditure
    Level, Based on the Current State of the Art.

126a


supported by an intermediate health progrsm.  Total cost would then be.

$3,OOO,OOO of which HEW would contribute $2,25O,oOo.
Individual research grant funds would be increased from $1,5OO,OOO

to $2,000,000 per year, representing an increase in number from 60 to

70 per year at an average smount of $28,500 each. HEWS contribution

would be $1,5OO,OOO.

  All research efforts would total $ll,OOO,OOO with $8,25O,ooO coming

from HEW; the remainder coming from other sources.

4.  Training

  Training for research would be extended to include 20 immunology

research laboratory centers, which will provide for the training of two

fellows per center at a cost of $50,000 per center. Total expenditures
are estimated to be $l,OOO,OOO per year ($75O,OOO from HEW).

5. Facilities

It is estimated'that the yearly cost of expansion for the research

program and the updating of equipment will require approximately
$10,670,000 ($~,OOO,OOO from HEW).

A benefit-cost summary associated with this progrsm is found in

Table VI.


Table VI

KIDNEY DISEASES RFUQEDTO HYFEZSEXKWPIVI~ PHENOMENA, HYPOTHETICAL PROGFlAM AT INTERMEDIATE
         HEWMF'ENDITUlW LEVEL, BASED ONTHEiUJRRENT STATE OFTHEART

.                       I                                   ,

                      ,        Short-Term Benefits       Long-Term Benefits
                      I,
                            Reduction             Reduction In
   Expenditures               Per Year In          End-Stage Uremia

Program

I.   Education and administration


II.  Research

III. Training


IV.  Facilities


                      TOTAL

(Sl:ZO)

3,000

8,250

750

8,000

Total
($1,000)

4,000

11,000

1,000

10,670

26,670

Mortality

610

Prevalence Morbid Days  Per Year Cumulative


D.  Kidney Diseases Related to Hypersensitivity Phenomena, Hypothetical
  Progrsm at Accelerated REW Expenditure Level, Based on the Current
   State of the Art

1.  Introduction

This program has four components:

1) Education and administration;

2) Research;

3) Training; and

4) Facilities.

The estimated total cost for this progrsm is $31,830,000. HEW's

share is estimated to be $23,875,000. Figure 7 shows the costs for this

program and below follows a discussion of the various program components.

2.  Education and Administration

No changes in the educational and sdministrative efforts sre sntici-

pated under this accelerated program.  m3w tin provide $2,5oo,oqo for

educational support and an additional $500,000 for administrative support.

Approximately $1,OOO,OOCl will be assessed to institutions other than HEW.

No immediate benefits ere expected, and the mortality reduction figure of

610 (see Section B.2.) is used sgain.

3. Research

  With ample support, clinical research funds could be increased to
$8,ooo,ooo ($6,ooo,ooo from m).  This would represent 16 large scale

studies rather than eight as envisioned under the current HEW budget

level.

Daboratory research would remain at the level anticipated for an

intermediate program at a total cost of $3,000,000 ($2,25O,OOO from


zests ($1,000,000)

150

100

                         Education and
                           Administration

Education and              (410)
Administration                         V
(3;O)                        Research
     V                      (13.5)
  Research
  (10.1)                       A-Training (1.0)
       +-Training (.8)
Facilities                     Facilities

  (10.0)                    (13.3)

HEW

PROCRAM

TOTAL

Fig. 7.  Kidney Diseases Related to Hypersensitivity Phenomena,
    Hypothetical Program Costs at Accelerated HEW Expenditure
     Level, Based on the Current State of the Art.

128a


The number of individual research grants would be increased from

60 to 80 at an average cost of about $31,000 each and a total cost of

approximately $2,5OO,OOO per year ($1,870,000 would be HEW's responsi-

bility).

Total efforts aimed at research would smount t0 $13,500,000

($10,125,000 to come from HEW).

4. Trainina;

Expenditures on research training will remain at $l,OOO,OOO ($750,000
from HEW), the same level as anticipated for the intermediate program,

5. Facilities

With ample support fm HEW, it is expected that $13,330,@00 will

be expended on facilities with $10,000,000 expected to come frm HEW

and $3,330,000 from other sourcesm

A benefit-cost sumnary associated with this program Is found in

Table VII.


Table VII

KIDNEY DISEASES RELATED TO HYPERSENSITIVITY PHENOMENA, HYPOTHETICAL PROGRAM
      AT ACCELERATED HEW EXPENDITURE LEVEL, BASED ON THE CURRENT STATE OF THE ART

           Program



I.   Education and administration


II.  Research

III. Training


IV.   Research


                      TOTAL

                      Short-Term Benefits      Long-Term Benefits


                           Reduction              Reduction In
  Expenditures               Per Year In          End-Stage Uremia
(SlyEJ)     Total
      ($1,000)  Mortality Prevalence Morbid Days Per Year Cumulative


3,000     4,000

10,125    13,500


   750     1,000

10,000    13,330

23,875    31,830      610 - - e m


E.  Kidney Diseases Related to Hypersensitivity Phenomena, Hypothetical
Program for Fiscal Year 1975, at Accelerated HEW Expenditure bevel,
  Based on Expected Advanced State of the Art in 1975

1.  Introduction

  This program has five components:

  1) Prevention of acute glomerulonephritis;
2) Early detection of disease (manifested by proteinuria), treatment

    of diseases associated with hypersensitivity phenomena, and

    supportive education and administration;

3) Research;

4) Training; and

5) Facilities.

The estimated total cost for this program is $334,420,000 of which

HEW will expend $~,320,000.  Figure 8 illustrates costs associated

with the various program components.

  Advances in the state of the art which are anticipated by 1975,

have been broken down into three separate categories. They are:

1) Acute glomerulonephritis-- in T,<hich primary preventive measures

will be available (e.g., a vaccine and/or effective treatment

of streptococcal infections).

2) Chronic glomexxlonephritis-- which is heralded by patients with

  proteinuria and in which secondary preventive measures may be

  available; and

3) Other diseases --such as chronic sclerosing nephritis, the
collagen diseases (e.g., lupus erythematosus, scleroderma, etc.)
in which secondary preventive measures may be available, and's
miscellaneous group of renal diseases (e.g., smyloidosis).


costs ($1,000,000)

334.4

      ,


1 50









1 00









77.3









50

I
   Vaccine
  (40.0)

Diagnosis and
Treatment
(13.0)

Research

HEW

PROCRAM

Diagnosis and

Treatment

Research
(16.6)

4 I rainitig (2.5)

Facilities
(13.3)

TOTAL

Fig. 8.  Kidney Diseases Related to Hypersensitivity Phenomena,
    Hypothetical Program Costs for Fiscal Year 1975, at
    Accelerated HEW Expenditure Level, Based on Expected
      Advanced State of the `jrt in 1975.

130a


  No detailed analysis for the class of Other Diseases, namely
collagen disorders and the miscellaneous group of renal diseases, has

been undertaken.

2.  Prevention of Acute Glomerulonephritis

  Two possible advances in the next 10 years sre analyzed in this

report.  These are:
1) The development of a vaccine to prevent Group A beta-hemolytic
   streptococcal infections (especially Type 12); and/or
2) The development of an efficient means for the early detection

  of beta-hemolytic streptococcal infections and the prevention

  of subsequent glcxuerulonephritis through effective therapy.

a. Develolplent of a Vaccine to Prevent Streptococcal Infection
(1) Relevant Population and Program Component Costs
                       65/
    The assumption is made that 200,000,000- persons would

be vaccinated in 1975 at a cost of $1.00 per individual. Total
cost for this vaccination program is estimated at $200,000,000
($40,000,000 to come from HEW).

  (2) Short-Term Benefits

Short-term benefits are estimated as the following:

1) From an estimated base of 650- deaths resulting from
                 w

  acute glomerulonephritis which would have occurred

  without a vaccination program, a 959 reduction in

  mortatity, i.e., 620 avoided deaths, is anticipated.
2) There will be a 95$ reduction in the number of cases
of acute glomerulonephritis (i.e., 52,250) from an

  estimated base line of 55,000 cases.


             67/
3) Assuming &I morbid days- per case of acute glomerulo-

nephritis, a base line of 2,200,OOC morbid days is

calculated using 55,000 cases as a reference.  Morbid

days will be reduced by 95$, or 2,09o,OCO, with this

program.

(3) Long-Term Benefits

  (a) Annual Long-Term Benefits
    It is estimated that without a vaccine 5s (2,750) of

the 55,000 individuals with acute glomerulonephritis

eventually would have developed end-stage uremia.  Assuming

that each new patient with acute glomerulonephritis which

progresses to the chronic stsge will have a normal age-

life span, then the yesrly death rate from hypersensitivity
diseases will be reduced by 2,610. The vaccine will

reduce the number of cases of acute glomerulonephritis by

95% be., 2,610 of 2,750).

(b) Cumulative Long-Term Benefits

  Assuming that without a vaccine approximately
   681
100,~ of the population eventually would have developed

end-stage uremia due to acute glomerulonephritis, approx-
imately 95,000 (95s of 100,000) persons will have avoided

death resulting from end-stsge uremia.

b.  Alternate Detection and Treatment Program

  An alternative possibility is the development of an effective

means to detect and to provide adequate treatment for immunologic


133 '

reactions in the kidney resulting from streptococcal infections.

Two possibilities are presented below:

  1) Early detection of streptococcal infection and immediate

    therapy with penicillin may prevent the serious sequelae

     resulting frcxn acute glomerulonephritis; or it may succeed

    in interrupting an epidemic of acute streptococcal infections,

    thereby reducing the possible incidence of glcxnerulonephritis;

      and

2) Advances in imrmnosuppresslve therapy could prevent cases

  of acute glanerulonephritis which arise from nephritogenic

  strains of streptococci.

  This progrsm would be directed toward a population in which en

epidemic of nephritogenic beta-hemolytic streptococcal infection is

in progress.  Therefore, a program of close epidemiologic&l. surveil-

lance of the population susceptible to streptococcal infections, and

the rapid institution of immediate treatment procedures would be

undertaken.

  A 2C$ reduction in mortality would be expected lowering the

number of mortalities due to the acute disease process by 130 per
ye&/ A reduction in prevalence rates by 30$ would decrease the

number of cases by 16,500 per year from a base line of 55,000; the

number of morbid days would be decreased by 30$, or 660,000 days

per year, from a base line of 2,200, cxloP/  The total effect on the

2,750 individuals who would have developed end-stage uremia each

would be a reduction by 36, i.e., 830 cases, with this progr SIG'

Cumulative long-term benefits would be 30,000 avoided cases of


134

  end-stage uremia (30$ of the estimated 100,000 who would have
developed kidney failure eventually)@  These alternative benefits

  have not been included in the summation of the program analysis.

3.  Proteinuria

  A second approach in preventing renal hypersensitivity disease would
be an attempt at the early detection of persistent proteinuria. It is
assumed that this phenomenon represents an early stage of renal disease
in which the filtering apparatus of the nephron is malfunctioning, giving

some indication of impending chronic nephritis.  The major objective of

the program is to develop an effective means for the early detection of
persistent proteinuria, to identify those cases in which proteinuria
signifies renal disease, and to devise adequate therapy which will

interrupt the disease process, thereby preventing progression to a

state of renal failure.  It will be assumed that under this advanced

state of the art, a means of therapy has been developed which is
effective in 5C$ of those cases treated.

  a. Relevant Population and Program Component Cost

   Assuming that 150,000,000 people can be screened each year via

  periodic physical examinations, multiphasic screening programs, etc.,
                                   73/
2$ (3,000,OOO of these) will have a positive test for proteinurisr
   Of 3,000,OOO patients with a positive test, approximately 20$,
600,000, will be expected to have confirmed proteinuria as shown by

  more refined and more expensive tests.  The confirmatory test costs

  $1.00; therefore, the total cost is $3,000,000 since each individual
                               74/

with a positive screening test must have a confirmatory test-r


  Of the 600,000 confirmed positive patients having proteinuria,
it is anticipated that additional studies will establish 20$ (120,000)
as having persistent proteinuri&'  The estimated cost for these
additional studies is $5.00 per test for a total cost of $3,000,000
($5.00 x @Wm.

  For each of these 120,000 individuals a complete diagnostic

work-up including:  urine analysis, amount of total protein excretion,

studies of renal functions such as clearance and concentrating abili-
ties, roentgen studies (to include a flat film of the abdomen,
intravenous pyelogrsms, and possibly retrograde pyelogrsms if
necessary), and in some instances a renal biopsy to be examined

under the electron microscope is necessary to establish a definite

cause of proteinuria.  The estimated cost is $500 per individual
study for a total cost of $60,000,000.
  Total costs for confirming tests amount to $66,000,000, none

of which is expected to cOme from HEW.

  One-third of the 120,000 individuals with confirmed persistent
proteinuria (i.e., 40,000), could potentially develop debilitating
renal diseass' Of this number about 50$ (20,000) are estimated

to have renal disease associated with hypersensitivity phenomena.
It is estimated that a single therapeutic course would cost $100
per patient for a total of $2,000,000.
Total costs for this program component are $98,000,000
($2,000,000 of which is to be borne by HEW).
Support for education and administration is estimated to cost
HEW $3,000,000 with $l,OOO,OOO coming from other sources*


136

4.

b.  Short-Term Benefits

  Short-term benefits for individuals having diagnosed renal

disease with hypersensitive origin followed by some form of

treatment are:

1) A reduction of l$, or approximately 150 deaths, from a
           777
  base line of 14,500-- expected annual deaths in patients

with hypersensitivity diseases of the kidney;

2) A reduction of 56, or 10,000 cases, from a base line of

  20,000 cases diagnosed as hypersensitivity disease of the
kidney;E/ and

3) A reduction of 65$, 520,000 days, from an estimated

800,000 morbid day BTe/

c. Iong-Term Benefits

(1) Annual Long-Term Benefits

       The annual death rate could be reduced by 50$1 based on the

  assumption that new cases are diagnosed each year and that therapy

   is effective in one-half of the individuals.  The therapeutic

  results should improve as cases can be detected earlier; and
                             w
ultimately a decrease of 6,000 from a base line of l2,000-

  cases of fatal end-stage uremia per year could be effected.
(2) Cumulative Long-Term Benefits
                          W
    From an expected base of 450,000 individuals- having

  confirmed persistent proteinuria who would have developed
end-stage uremia eventually, a reduction of 56, or 225,000,

  is anticipated in an accelerated HEW health program.

Total Screening, Diagnosis and Treatment Costs

Total costs for screening, diagnosis, and treatment are estimated

to be $102,000,000 ($13,OOO,OOO from HEW).


337

5. Total Short-Term Benefits

Total short-term benefits resulting from the control of acute

glomerulonephritis using a vaccine and from the detection and control

of proteinuria are as follows:

  1) A reduction in immediate mortality by 'j"j'O per year;

  2) A reduction in the number of cases by 62,250; and

  3) A reduction in the number of morbid days by 2,610,ooo.

6. Total Long-Term Benefits

Total long-term benefits resulting from the control of acute

glomerulonephritis using a vaccine and from the detection and control

of proteinuria are an annual reduction of,8,610 cases of fatal end-stage

uremia and cumulative long-term reduction of 320,OOO.

7.  Research

  Research programs under the advanced state of the art sre anticipated

to increase so that HEW's expected level of effort w-J.11 be $12,450,000;

$4,150,000 will come from other sources.

8. Training

  Funds needed for training will approximate 15s of the amount spent

on research, i.e., $2,493,000, of which $1,870,000 will come from HEW

and $620,000 will come from other sources.

9. Facilities

HEW will expend about $10,000,000 for facilities and an additional

$3,330,000 will come from other sources.

10.  Estimated Benefits Dependent Upon Research

   Benefits dependent on new disease control techniques are;

a) Short-Term Benefits:


338

1) A reduction in immediate mortality by 770 deaths (680
                  82/
based on 1966 U. S. population);-

2) A reduction in the number of cases by 62,250 (54,610

based on 1966 U. S. population); and.

3) A reduction in the number of morbid days by 2,610,OOO

(2,289,470 based on 1966 U. S, population).

b) Long-Term Benefits:

1) An annual reduction of fatal end-stage uremia by 8,610

cases (7,550 based on 1966 U. S. population); and

2) A cumulative reduction of fatal end-stage uremia by

32O,OOO cases (based on 1966 U, S. population).

A benefit-cost summary assokated with this program is found in

Table VIII.


Table VIII

KIDNEY DISEASES RELATED TO HYPERSENSITIVITY PHENOMENA, HYPOTHETICAL PROGRAM FOR FISCAL YEAR 1975
  AT ACCELERATED HEW EXPENDITURE LEVEL, BASED ON EXPECTED ADVANCED STATE OF THE ART IN 1975

Program

I.  Attack on acute glomerulonephritis
  streptococcal vaccine

II.  Proteinuria, screening, diagnosis and
   treatment, and supportive education
   and administration:

    1.  Screening

    2.  Confirming test for persistent
     proteinuria
a
:    3.  Confirming test for renal compli-
       cations

   4.  Treatment for renal complications

                   Sub-Total

5.  Education and administration


               Sub-Total

III. Research

IV.  Training

V.   Facilities

TOTAL

Expenditures

(sl::o)

40,000

10,000

10,000

3,000

13,000

12,450

1,870

10,000

77,320   334,420       770   62,250    2,610,OOO   8,610    320,000

Total
($1,000)

200,000

30,000

6,000

60,000

2,000

98,000

4,000

102,000

16,600
2,490

13,330

Short-Term Benefits       Long-Term Benefits

Reduction              Reduction In
Per Year In          End-Stage Uremia

Mortality  Prevalence  lorbid Days  Per Year  Zumulative


IV.  KIDNEY DISEASES RELATED TO HYPERTENSIVE VASCULAR DISEASES

A.  Introduction

This section pertains to programs needed to control renal diseases

associated with hypertension.  It is assumed throughout the discussion that

the amelioration of hypertension will result in a significant reduction in

             jg/
associated renal disease.

In 1966, 71,347 death+' are estimated to have had hypertensive vascu-

lar disease as the underlying cause of death.  Of this group it is estimated
         85/

that about 3Oc were caused at least partially by serious renal sequelae.

In 1966, some 11,430,OOO individuals are estimated t.o have had hyper-

tensive vascular disease ;.associated with these were 181,280,OOO days of

restricted activity, 68,580,OOO days of bed disability, and 11,330,OOO
               861

work-loss days resulted.-

Three programs are considered in this analysis (see Chapter 5, Research

Methodology) and are described in detail below.

B.  Kidney Diseases Related to Hypertensive Vascular Diseases, Hypothetical
Program at Current HEW Expenditure Level, Based on the Current State of
  the Art

1.  Introduction

This program has four components:

1) Diagnosis, treatment, supportive education and administration;

2) Research;

3) Training; and

4) Facilities.

The total estimated cost for this program is $419,440,000 ($40,272,000

specifically for associated renal problems).  HEW would account for

$9,180,000, all of which would be used to control the renal complications


of hypertension.  Figure 9 illustrates the program expenditures for

associated renal problems.  A discussion of the various program

components follows.

2.  Diagnosis, Treatment and Supportive Education and Administration

  Screening, diagnosis and treatment are aimed at individuals 17 years

of age and over who have potentially curable (non-essential) hypertension

or currently non-curable (essential) hypertension.

a.  Relevant Population and Program Component Costs

  This program component provides for the extension of complete

care to individuals with known hypertension.  HEW would provide

financial support for education and administration of this program.

Various studies have shown that between lo-20% of all hyper-
                                  871

tensive patients have potentially curable hypertension.-  It is

estimated that approximately 15%, 1,450,000, of the known total

hypertensive population (9,330,OOO in 1966) have curable (non-essential)

hypertension.  Of this number, it is estimated that about 450,000

are presently receiving adequate treatment.  With this program, an

additional 450,000 would receive adequate treatment over a five-year

period.  This program would provide treatment for 90,000 of these

patients each year.

  Since this is a population of known hypertensives and no screening

test would be necessary, the cost for definite diagnosis and treatment

of a specific type of hypertensive vascular disease would be $1,000

per patient per year.  The total cost is then $90,000,000 per year,
                    881

and an estimated 10% ($9,000,000>- of this amount is to be used to

treat associated renal hypertensive disease.


100

50


40.3









9.2

Dianxiosis and
Treatment (4.0)

PROGRAM

Diagnosis and
Treatment
(33.4)

Research (5.1)

            ,
TOTAL

Training (.5)
CFacilities (1.3)

Fig. 9.  Kidney Diseases Related to Hypertensive Vascular Diseases,
    Hypothetical Program Costs at Current HEW Expenditure Level,
     Based bn the Current State of the Art.

1

40a


No screening test is required for the currently known non-

curable hypertensives.  The treatment cost for each of these
                         B/

individuals is estimated at $200.00 per year.   In addition, it is

anticipated that this program will provide for an increase of 20%
       go/
(1,586,000)-  in the number of patients being adequately treated.

Therefore, total treatment costs for these individuals would be

$317,200,000.             911
       Approximately 64b of this amount, $19,032,000 would

be used for the treatment of associated renal disease.

  Total cost for the above program is $407,200,000 ($28,032,000

of which is for associated renal problems).  These costs are not to

be borne by HEW.

  The supportive education and administration component involves

the postgraduate education of physicians as well as the community

on kidney malfunction as it is related to hypertensive disease.
Technical support as well as some financial support is also included.

It is estimated that $4,000,000 is the minimum amount needed under

the 1966 HEW funding level to activate this program component.

Approximately $1,330,000 will be generated by institutions and sources

other than HEW.

  Total cost for this program component is $419,440,000

($40,272,000 used for associated renal disease).  Total HEW expendi-

ture for program component 2.a. is $4,000,000, all of which is

employed for treatment of kidney disease.

b.  Short-Term Benefits

  The following are estimated short-term benefits:

  (1) Known Potentially Curable (non-essential) Hypertensive
       Patients:


t42

921

1) Of a total population of 90,000- having non-essential

hypertension, a 60% reduction in the immediate mortality

rate is expected (i.e., 340 of the estimated 570 normally
                       931

occurring deaths will be prevented).- Approximately 50%

(170) of these prevented deaths would have resulted from
                   94/

associated renal dysfunction.-

2) A similar 60% decrease in the number of cases in the

same population is expected (i.e., 54,000 out of 90,000).

About 50% of this reduced number would be associated with
                  951

renal hypertensive changes.-

3) It is estimated that each patient with hypertensive

vascular disease suffers an average of 16 morbid days per
   961
year;-  the total for all affected patients in this

population would be 1,440,OOO morbid days (90,000 x 16).

Implementation of this program would effectively decrease

the number of morbid days by 864,000, or 60% (50% of

this number, 432,000 would involve patients with
                  971

associated renal problems).-

(2) Known Currently Non-Curable (essential) Hypertensive
   Patients:

1) It is estimated that a 15% decrease of 7,490 in mortality
                      981

from a total of 49,940 deaths- will result (27%, or

2,020, of which will have renal complications); and

2) It is estimated that a 20% reduction in the number of
                         j!J

morbid days from a base line of 25,376,OOO    will

result in 5,075,200 additional healthy days (27%, or

1,370,300 associated renal problems).


There is no change in prevalence rate or number of new

cases.

(3) Total for Known Hypertensive Patients:

   Total short-term benefits for the surveyed high-risk groups

are the prevention of 7,830 deaths (2,190 having associated

renal problems), a reduction of 54,000 cases (27,000 with

associated renal problems), and a reduced number of morbid days

by 5,939,200 (1,802,230 resulting from associated renal disease).

C.  Long-Term Benefits

  (1) Annual Long-Term Benefits

It is anticipated that the number of patients in end-stage

renal failure resulting from non-essential hypertension will be

reduced by 2,940 each year (a 60% reduction rate from an esti-
             lOO/

mated base of 4,900)-  At the same time, it is estimated that
             101/
                      -
there would be 13,880    patients suffering from essential

hypertension who would have developed end-stage uremia each year.

This number is

implementation

   The total

expected to be reduced by 104, or 1,390, by the

of this program.

annual long-term benefits will amount to a

reduction in the number of patients developing end-stage uremia

by 4,330.

(2) Cumulative Long-Term Benefits

It is felt that 7% or 98,000, m/ of all potentially curable

known hypertensives (1,400,OOO) would eventually develop chronic


renal failure.  With this program a reduction of this number by


60% (i.e., 58,800) is expected.  An additional 3.5%, or 277,550,

of the presently non-curable known hypertensives (7,930,OOO)

would eventually have developed fatal end-stage uremia.

Development of this program is designed to reduce thisfigure

            103/
by lo%, or 27,760.-

Therefore, total cumulative long-term benefits amount to

     a prevention of 86,560 cases of fatal end-stage uremia.

3.  Research

  This research program will consist of a number of problem-focussed

clinical and laboratory research studies as well as of individual grants

for wholly independent study in the pertinent areas.

The clinical research programs would be carried out in 20 separate

study groups, and laboratory research programs would also be carried out

in 20 separate study groups. 1041 Fifteen of these study groups would be

combined in the same geographic location, leaving 5 groups to accomplish

basic laboratory research independently and 5 groups to accomplish clinical

research independently.

  The laboratory research would be funded with approximately $40,000
      1051
per group, - for a total of $800,000.  The clinical research would be
                      106/

funded with approximately $50,000     per grow, or approximately

$1,000,000.  Since 15 of these groups will be concerned with both
L laboratory and clinical research, the level of support to these centers

would be $90,000 each.

  The remaining area of research would consist of approximately 50

individual grants, at $40,000 each, for a total grant cost of $2,000,000.

  The total amount for research equals $1,800,000 for laboratory and

clinical research and $2,000,000 for individual grants yielding a total


of $3,800,000 supported by HEW.  An additional $1,270,000 is expected

to be generated by other sources.

  The clinical studies mentioned above will consist of long-term stud

of the natural history and treatment of hypertensive vascular disease,

especially as it relates to renal disease.  Both the laboratory and

clinical studies will result in additional benefits to disease areas

other than renal disease such as hypertensive heart disease, arterio-

sclerosis, etc.  The basic research programs would be directed towards

the discovery of'the etiology of hypertension, the identification of

facets and factors in the disease process which affect renal function,

and the development of novel treatment methods.

4.  Training

  The training of physicians and allied personnel would cost HEW

approximately $380,000.  An additional $130,000 would be obtained from

other sources.


5.   Facilities

  The expenditures for facilities is estimated at $l,OOO,OOO with an

additional $330,000 to come from other agencies.

les

A benefit-cost summary associated with this program is found in Table

IX.


Table IX

KIDNEY DISEASES RELATED TO HYPERTENSIVE VASCULAR DISEASES, HYPOTHETICAL PROGRAM
       AT CURRENT HEW EXPENDITURE LEVEL, BASED ON THE CURRENT STATE OF THE ART

Short-Term Benefits

Long-Term Benefits

Reduction
Per Year In

Reduction In
End-Stage Uremia

Per Year

Zumulative

Expenditures

Total
($1,000)

Mortality

Prevalence

!iorbid Days

Program

5,959,200
(1,802,230;

I.A. Diagnosis and treatment of individuals
  17 years of age and over with known
  curable (non-essential) hypertension
  and non-curable hypertension
B. Supportive education and administra-
    tion

Sub-Total

II.  Research


III. Training

IV.  Facilities

TOTAL

`;;;$;$I
   3
5,330
(5,330)

4,000
(4,000)

4,000
(4,000)

412,530
(33,362)

3,800
(3,800)

  380
(380)
1,000
(1,000)

(

(4,330)

9,180
(9,180)

54,000
(27,000)

419,440    7,830
(40,272)  (2,190p

(86,560)

u  Figures in parenthesis refer to statistics attributable to renal complications.


146.

C.

Kidney Diseases Related to Hypertensive Vascular Diseases, Hypothetical
Program at Intermediate HEW Expenditure Level, Based on the Current
State of the Art

1.  Introduction

  This program has four components:
1) Screening, diagnosis, treatment, and supportive education and

administration;

2) Research;

3) Training; and

4) Facilities.

The estimated total cost for this program is $496,150,000 ($6,936,000

will be used for associated renal problems).  HEW will account for

$22,098,000 ($21,207,000 for associated renal complications). Figure

10 illustrates the total program expenditures by components. A discus-

sion of the various program components follows.

2.  Screening, Diagnosis, Treatment, and Supportive Education and
   Administration

This program is designed to cover a six-year period in order to

attain maximum effectiveness under an intermediate budget constraint.

In the intermediate program level, an additional risk group must be


considered.  This group is comprised of individuals who have not been

examined by a physician during the preceding year.  In this population,

there are an estimated 43,500,OOO persons 17 years of age and over in

     1071                        1081
the U. S.,   2,100,OOO with undiagnosed hypertension.    Over a 6 year
period, 50% (21,750,OOO) of these individuals could realistically be

screened.  This means that each year 3,792,OOO persons would be

subjected to a screening test. 1091 If only 50% of the total population at

risk is randomly screened, then it can be assumed that 50% of the

individuals with hypertension will be detected, i.e., 1,050,OOO.   Since


costs ($1,000,000)

150

100

70.0




50









21.:








I

Diagnosis and
Treatment (43.4)

!-

p!zsJTraining (.5)
         HEW
                      PROGRAM

Research (6.2)

6Training (.7)

Facilities (10.7

TOTAL

Fig. 10.  Kidney Diseases Related to Hypertensive Vascular Diseases, Hypothetical

Program Costs at Intermediate HEW Expenditure Level, Based on the
Current State of the Art.

146a


the program covers a 6 year period, 175,000 individuals will have a

positive screening test for hypertension each year.  The cost per test

is $1.25, thus, the total cost for a general screening test is

$4,740,000 ($1.25 x 3,792,OOO). $240,000 of this amount can be

attributed to renal involvement.  HEW will support 20% of the total

or $948,000 ($57,000 of which is attributed to renal disease).

   In addition to the cost of screening, expenses for treatment and

confirming diagnosis will be incurred.

  Approximately 15%, 26,500, of the 175,000 diagnosed hypertensives

are assumed to have curable hypertension.  At a cost of $1,000 per year,

total treatment and confirming diagnosis costs will be $26,250,000

($2,625,000 for associated renal complications).

  Approximately 85% (148,750) of the 175,000 have non-curable hyper-


tension.  At an estimated treatment cost of $200 per individual per

year, total costs will be $29,750,000 ($1,785,000 for associated renal

complications).  Treatment costs will be borne by sources other than


HEW.

  Total costs for this part of the program are $467,940,000

($32,726,000 for associated renal complications). HEW's share of the

total is $948,000 ($57,000 for associated renal complications).

  The supportive educational and administrative funds needed to

implement the screening, diagnosis and treatment for these hypertensive

patients is estimated to be $8,000,000 from HEW with an expected additional

$2,670,000 from other sources.  These funds are to be used for the

postgraduate education of physicians and allied medical personnel, as

well as for technical and administrative support by HEW.


The total cost for this program component is estimated to be

$478,610,000 ($43,396,000 for associated renal complications). HEW's

share is $8,948,000 ($8,057,000 for associated renal complications).

a.  Short-Term Benefits:

The following are estimated short-term benefits.

(1) Newly Detected Potentially Curable (non-essential)
   Hypertensives:

1) Of the total population of 26,250 having the disease,

140 deaths would have occurred without this program;

a reduction of 80 (60%) is anticipated (50% of which

reflect those deaths avoided in cases having asso-

ciated renal problems). 1101

2)  A 60% reduction in prevalence is also expected,

accounting for 15,750 (50% or 7,880 with associated
        1111

  renal problems).                112j
3) From a base line of 42O;OOO morbid days- a 60%

  reduction is expected, i.e., 252,000 days (126,000

in patients with associated renal problems).

(2) Newly Detected Currently Non-Curable (essential)
   Hypertensives

Short-term benefits associated with the currently non-

curable hypertensives, 17 years of age and over, are as follows:

1) An estimated 15% decrease of 160 in immediate mor-
                        1131

tality from a base line of 1,070 deaths    which would

have occurred without this program (27% of the avoided

deaths, or 40,  are attributed to cases with asso-

ciated renal problems).


2) There is no change in prevalence rate.

3) An estimated 20% reduction, 476,000, in the number
                              1141

of morbid days from a base line of 2,380,OOO

(128,520 as a result of associated renal problems).

(3) All Hypertensives

Total short-term benefits for the surveyed high-risk

groups are

1) A reduction of 8,070 deaths (2,270 with associated

renal problems);

2) A reduction in prevalence of 69,750 (34,880 with

associated renal problems); and

3) A reduction in morbid days of 6,193,72,0 (2,056,820 in

patients with associated renal problems).

b.  Long-Term Benefits

The following are estimated long-term benefits:       .

(1) Annual Long-Term Benefits

It is estimated that of a total of 550 deaths which would

have occurred in the newly detected non-essential hypertensives

annually, 60%, or 330 per year, would be prevented by this
    1151
program.

In the population with newly diagnosed essential hypertension,

a 10% reduction of 156 in the number of cases of fatal end-
                             u/

stage uremia is expected from a base line of 1,560.

Total (annual) long-term benefits for all groups surveyed

equal 4,820 prevented cases of fatal end-stage uremia each

year.


(2) Cumulative Long-Term Benefits

It is anticipated that this program will result in a

60% reduction in the number of cumulative cases of fatal

end-stage uremia in patients with newly detected non-essential

hypertension.  This would be a reduction of 6,720 from a

base line of 11,025.

1181

It is also expected that 3,120 (10% of the total 31,240)-

potential cases of fatal end-stage uremia will be prevented in

patients with essential hypertension.

Total cumulative long-term benefits for all the surveyed

high-risk groups, including those discussed above in Section

B.2.c., amount to a reduction of 96,300 cases of fatal end-

stage uremia.

3.   Research

  The research program would be expanded in the following manner:

clinical research will be expanded to include 25 separate groups at a

cost of $50,000 per group for a total of $1,250,000.

Laboratory research projects will also be expanded to include 25

separate study groups at a cost of $40,000 per group for a total of

$1,000,000.

The number of individual grants will be increased from 50 to 60

at a cost of approximately $40,000 each for a total of $2,400,000.

Total support for research efforts from HEW would amount to

$4,650,000.  An additional $1,550,000 would be generated by other

sources.

4.  Training

  The training of physicians and allied personnel will cost HEW