Pharmacoeconomics in nephrology: considerations on cost-effectiveness of screening for albuminuria

In this issue, Palmer et al. [1] demonstrate that screening for nephropathy in hypertensive type 2 diabetic patients and subsequent treatment with renoprotective antihypertensive agents may result in excellent value for money from the US health care perspective. Estimated costs and effects were combined in a cost-utility analysis, to express the incremental costs per quality-adjusted life year (QALY) for add-on treatment of the angiotensin receptor blocker (ARB) irbesartan after detection of nephropathy through screening, compared with conventional antihypertensive treatment only, in the absence of screening. Nephropathy was defined as microalbuminuria or nephropathy; i.e. urine albumin excretion (UAE) >20μg/min (corresponding to a UAE expressed per 24 h > 30 mg/24 h, with >300 mg/24 h generally defining nephropathy). Such screening and subsequent ARB treatment—add on to conventional antihypertensive therapy—was estimated to result in favourable clinical outcomes with only marginally increasing overall costs. Furthermore, estimated incremental cost-effectiveness was well below a willingness to pay (WTP) threshold of US$50 000 per QALY for the USA [2]. Despite the fact that such an absolute quantitative threshold for costs per QALY has to be interpreted with caution by decision-makers in health care systems, the exact cost-per-QALY ratio found by the authors at US$20 011 per QALY gained and an estimated 77% probability of being below this US$50 000 threshold certainly suggest a favourable pharmacoeconomic profile [1,3]. Palmer et al. used a Markov model to simulate the progression from a healthy state to end-stage renal diseases (ESRDs) and second-order Monte Carlo simulation—both ‘state-of-theart’ mathematical techniques in pharmacoeconomics—to account for multiple parameter uncertainty and to derive results as listed above [3,4]. In this editorial, we discuss the