An economic evaluation of early versus late referral of patients with progressive renal insufficiency

Patients with progressive renal insufficiency (PRI) who start renal replacement therapy (RRT) within 4 months of seeing a nephrologist (late referral) have increased morbidity, mortality, and health care costs. We performed an economic evaluation of early versus late referral of patients with PRI to a multidisciplinary clinic. A decision analysis was performed from the perspective of the health care provider, using a Markov model to simulate progression of PRI and survival of patients on RRT. Our simulated patient cohort comprised 1,000 patients with PRI and estimated creatinine clearance of 20 mL/min. The study time horizon was 5 years. Clinical and cost data were taken from published Canadian and U.S. data, where available. Where published data were lacking, we used data from our prospectively maintained database. The study intervention was attendance at a PRI clinic where patients receive treatment to slow the rate of renal progression, receive treatment of complications of PRI, and are prepared for RRT. Endpoints were total cost of patient care, patient life-years, patient life-years free of RRT, and hospital admission days. Early referral resulted in cost savings and improved patient survival along with more life-years free of RRT and fewer hospital inpatient days. Cost-effectiveness was unaffected by univariate sensitivity analyses. Cost-effectiveness decreased as rates of renal function loss for patients referred early versus late approximated each other. In conclusion, early referral of patients with PRI to a multidisciplinary clinic appears cost-effective.