Annual proteinuria screening not cost-effective

Journal of Family Practice, April, 2004

Boulware LE, Jaar BG, Tarver-Carr ME, Brancati FL, Powe NR. Screening for proteinuria in US adults. A cost-effective analysis. JAMA 2003; 290:3101-3114.

* CLINICAL QUESTION

Is annual proteinuria screening in adults cost-effective?

* BOTTOM LINE

Annual screening of adults to detect proteinuria and prevent end-stage renal disease (ESRD) is not cost-effective unless directed only at high-risk groups (that is, those patients with diabetes and hypertension). Screening every 10 years beginning at the age 60 years, however, is highly cost-effective. (LOE=1b)

* STUDY DESIGN

Cost-effectiveness analysis

* SETTING

Not applicable

* SYNOPSIS

The majority of patients who develop ESRD go undetected until prevention is ineffective. The presence of low levels of urine protein can be an early marker of increased risk of progressive kidney disease, but it is unclear whether the screening of all adults for proteinuria is indicated. Screening diabetic patients for proteinuria with an annual dipstick has already been shown to be cost-effective.

To assess the value of population-based dipstick screening for early detection of urine protein in all adults, the researchers performed a cost-effectiveness analysis using a Markov decision model to compare a strategy of screening with no screening beginning at age 50 years. Patients identified with proteinuria began treatment with either an angiotensin-converting enzyme inhibitor or an angiotensin II-receptor blocker.

The researchers did a careful analysis of the literature to obtain estimates of event probabilities (including estimated compliance rates, natural disease progression, potential harms from unnecessary interventions, and treatment benefits) and costs, including both direct and indirect costs. Sensitivity analyses were performed for age, frequency of screening, and disease risk factors. Outcomes were based on cost per quality-adjusted life-year (QALY), which is a commonly used parameter to compare various screening tests and interventions.

The cost-effectiveness of annual screening of patients aged younger than 60 years with neither hypertension nor diabetes was unfavorable ($282,818 per QALY; gain of 0.0022 QALYs per person). Annual screening of low-risk patients aged 60 years and older was more cost-effective ($53,372 per QALY). For patients with hypertension, annual screening was highly cost-effective ($18,621 per QALY; gain of 0.03 QALYs per person). A lower frequency of screening low-risk patients every 10 years beginning at age 60 was also cost-effective ($6,195 per QALY).