#5431 THE VALUE OF MANAGING DIABETIC KIDNEY DISEASE: CONTRASTING FINDINGS FROM THE INDIVIDUAL PATIENT AND POPULATION LEVEL PERSPECTIVES
Authors: Mcewan Phil , Evans Marc 
Published: June 2023

Abstract

Background and Aims
The management of diabetic kidney disease (DKD) is associated with considerable resource utilisation. Within the context of the broader healthcare system, understanding the health economic implications of adopting strategies to ameliorate the progression of DKD is imperative for fully informed decision-making. The objective of this study was to estimate the UK whole healthcare system economic value, from the individual patient and population perspectives, associated with modifying the progression of DKD through attenuating the decline in eGFR by values consistent with those observed in recent randomised clinical outcome trials.

Method
Since type 2 diabetes (T2D) is the commonest single cause of chronic kidney disease (CKD), we developed a deterministic model utilising published estimates of disease progression stratified by stages: stage 1/2, stage 3a, stage 3b and stage 4/5. Patient characteristics and mean annual decline in eGFR were aligned to the placebo arm of DECLARE-TIMI 58 (-2.44 ml/min/1.732). We explored scenarios where a sustained attenuation in the rate of eGFR decline by 1 and 2ml/min/1.732 per year was realised. T2D specific and all-cause mortality were captured using UKPDS risk equations. CKD stage specific costs and changes in health utility were drawn from NICE guidelines (NG203). Per-patient and population level costs (indexed to 2022) and quality adjusted life years (QALYs) were estimated, and both discounted at 3.5%.

Results
We estimated there were 3.2M, 0.6M, 0.2M and 0.04M DKD patients in stages 1/2, 3a, 3b and 4/5 respectively. Declining kidney function was associated with increasing per-patient lifetime costs and decreasing QALYs: stage 1/2 £36,714, 8.1 QALYs; stage 3a £90,666, 6.5 QALYs; stage 3b £126,931, 5.2 QALYs; stage 4/5 £168,604, 3.7 QALYs. A sustained attenuation in the rate of eGFR decline by 1 and 2ml/min/1.732 per year had the greatest impact in those in stage 3b: with cost savings of £23,690 and £47,463 and gains in QALYs of 0.68 and 1.46 for 1 and 2ml/min/1.732 respectively. At the population level, however, total lifetime cost for DKD was greatest in those in stage 1/2 £30.3Bn; followed by stage 3a, £19.2Bn; stage 3b £9.5Bn; stage 4/5 £146M. A sustained attenuation in eGFR resulted in the largest cost savings in those in stage 1/2: £16.9 Bn and £22.3Bn for 1 and 2ml/min/1.732 respectively, and the greatest gains in QALYs of 0.8M and 1.1M for 1 and 2ml/min/1.732 respectively. In contrast, population level stage 4 cost savings and QALY gains were modest at £70.7M and £281.6M and 0.02M and 0.4M for 1 and 2ml/min/1.732 respectively.

Conclusion
The notion of value in healthcare is influenced by stakeholder perspective. From the clinician's and patient's perspective the greatest value in attenuating the progression of DKD is in those with more advanced disease. However, from the health care provider perspective, at the population level, modest cost-savings and QALY gains are realised in such patients. By contrast, those at an earlier disease stage deliver much greater population level return on investment consequent upon larger numbers of such individuals. This study illustrates that attenuating DKD progression provides value at both the individual and public health levels, irrespective of disease stage.