Trivedi Hariprasad S, Pang Michael M H, Campbell Anne, Saab Paulette
Harry S. Truman Memorial Veterans' Hospital, Columbia, MO 65201, USA.
Am J Kidney Dis. 2002 Apr;39(4):721-9. doi: 10.1053/ajkd.2002.31990.
Because of the predicted increase in end-stage renal disease (ESRD) incidence (projected increase from 1998 to 2010; 86,825 to 172,667), prevalence (projected increase from 1998 to 2010; 326,217 to 661,330), and cost (total cost based on 1998 ratio of Medicare versus non-Medicare cost; $16.74 billion in 1998 to $39.35 billion in 2010), a cohesive national effort is needed to develop strategies to slow the progression of chronic renal failure (CRF). The question arises to how much reduction in the progression of CRF would lead to a meaningful decrease in the prevalence and cost of ESRD. There are no objective data that show the economic impact of slowing the progression of CRF. We developed a mathematical model to assess the economic impact of decreasing the progression of CRF by 10%, 20%, and 30%. US Renal Data System (USRDS) projections were used to model the rate of increase in ESRD incidence and prevalence. Glomerular filtration rate (GFR) at the initiation of ESRD therapy and cost per patient-year were based on USRDS data. The average decline in GFR in subjects with CRF was estimated to be 7.56 mL/min/y. All dollar savings reflect 1998 costs, discounted for the future at 3% per annum. We also determined how much slowing of the progression of CRF is important from patients' perspectives by means of a written questionnaire (which inquired about willingness to go on a restricted diet, take six extra medications per day, and make six extra office visits per year) and calculation of the pre-ESRD time gained for different degrees of reduction in the progression of CRF. If the rate of decline in GFR decreased by 10%, 20%, and 30% after December 31, 1999, in all patients with GFRs of 60 mL/min or less, cumulative direct healthcare savings through 2010 would equal approximately $18.56, $39.02, and $60.61 billion, respectively. For a 10%, 20%, and 30% decrease in the rate of decline in GFR in all patients with a GFR of 30 mL/min or less, estimated cumulative savings through 2010 equal $9.06, $19.98, and $33.37 billion, respectively. Responses to the questionnaire showed that approximately 79% of subjects with CRF (n = 113) perceived a few weeks' dialysis-free period significant (P < or = 0.0001), a period corresponding to a 10% reduction in the rate of decline in GFR. Our data suggest that the cumulative economic impact of slowing the progression of CRF, even by as little as 10%, would be staggering. They provide strong support for the development and implementation of intensive reno-protective efforts beginning at the early stages of chronic renal disease and continued throughout its course.
由于预计终末期肾病（ESRD）的发病率（预计从1998年的86,825例增至2010年的172,667例）、患病率（预计从1998年的326,217例增至2010年的661,330例）以及成本（基于1998年医疗保险与非医疗保险成本的比例计算的总成本；1998年为167.4亿美元，2010年为393.5亿美元）均会上升，因此需要全国上下齐心协力制定策略，以减缓慢性肾衰竭（CRF）的进展。问题在于CRF进展减缓到何种程度才会使ESRD的患病率和成本显著下降。目前尚无客观数据表明减缓CRF进展所产生的经济影响。我们建立了一个数学模型，以评估将CRF进展减缓10%、20%和30%所产生的经济影响。美国肾脏数据系统（USRDS）的预测数据被用于模拟ESRD发病率和患病率的增长速度。ESRD治疗起始时的肾小球滤过率（GFR）以及患者每年的成本均基于USRDS数据。据估计，CRF患者的GFR平均每年下降7.56 mL/min。所有节省的费用均反映1998年的成本，并按每年3%的比率进行了未来贴现。我们还通过一份书面调查问卷（询问患者是否愿意接受饮食限制、每天多服用六种药物以及每年多进行六次门诊就诊）以及计算不同程度减缓CRF进展所获得的ESRD前时间，从患者的角度确定减缓CRF进展到何种程度才具有重要意义。如果在1999年12月31日之后，所有GFR为60 mL/min或更低的患者的GFR下降率分别降低10%、20%和30%，那么到2010年累计直接医疗费用节省分别约为185.6亿美元、390.2亿美元和606.1亿美元。对于所有GFR为30 mL/min或更低的患者，若GFR下降率分别降低10%、20%和30%，预计到2010年累计节省分别为90.6亿美元、199.8亿美元和333.7亿美元。调查问卷的结果显示，约79%的CRF患者（n = 113）认为几周的无透析期意义重大（P≤0.0001），这一时期相当于GFR下降率降低10%。我们的数据表明，即使将CRF进展减缓低至10%，其累计经济影响也将是惊人的。这些数据为在慢性肾病早期阶段就开展并贯穿整个病程的强化肾脏保护措施的制定和实施提供了有力支持。
