Cost–Effectiveness of Angiotensin-converting Enzyme Inhibitors in Nondiabetic Advanced Renal Disease

Charles Christian Adarkwah; Afschin Gandjour

Expert Rev Pharmacoeconomics Outcomes Res. 2011;11(2):215-223.

Expert Commentary

For patients with nondiabetic proteinuric advanced renal disease covered by the SHI, treatment with an ACE inhibitor is highly cost effective. It is still unclear whether a societal perspective leads to larger or smaller savings than an SHI perspective. On the one hand, ACE inhibitor treatment avoids productivity loss due to renal failure and copayments for the treatment of renal failure. On the other hand, drug copayments lead to additional costs. Moreover, the transferability of the conclusion of this study to other countries is limited given differences in costs, clinical management (e.g., treatment of ESRD) and epidemiology.

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Cite this: Cost–Effectiveness of Angiotensin-converting Enzyme Inhibitors in Nondiabetic Advanced Renal Disease - Medscape - Apr 01, 2011.

Table 1. Baseline characteristics of patients with chronic kidney disease.
Characteristics	Hou et al. ^†		Ihle et al. ^‡
Characteristics	ACE inhibitor (n = 112)	Placebo (n = 112)	ACE inhibitor (n = 36)	Placebo (n = 34)
Age (years)	44	45	41	48
Male subjects, n (%)	56 (50)	55 (49)	23 (64)	13 (38)
Blood pressure (mmHg): – Systolic – Diastolic	153 87	152 85	147 87	154 88
Renal function: – Serum creatinine (mg/dl) – GFR (ml/min/1.73 m²) – Urine protein excretion (g/day)	4.0 26.3 1.6	3.9 25.8 1.7	5.2 14.6 2.3	4.4 15.8 1.9

ACE: Angiotensin-converting enzyme; GFR: Glomerular filtration rate.
^† Data from [1].
^‡ Data from [14].

Table 2. Data used to determine the cost–effectiveness of angiotensin-converting enzyme inhibitor treatment.
Variable	Base-case estimate	Range tested in sensitivity analysis^†	Ref.
*Annual transition probabilities*
Advanced renal insufficiency to ESRD without ACE inhibitor	0.14	0.08–0.19	[1,14]
Advanced renal insufficiency to death	Age and gender dependent	0.003–0.54	[105]
ESRD to death	0.13	No range tested	[2]
*Effectiveness of ACE inhibitor*
Relative risk of advanced renal insufficiency to ESRD	0.61	0.39–0.95	[1,14]
*Utilities (health states)*
General population (age dependent)	0.83–0.94	No range tested	[22]
Disutility of CKD	0.056	-0.045–0.156	[21]
Disutility of ACE inhibitor treatment	1.00	0.95–1.00	[23]
ESRD	0.62	0.39–0.84	[24]
*Annual costs (€)*
Per-patient cost of CKD compared with non-CKD population	Age dependent	No range tested	[28–30,103,104]
ACE inhibitor (20 mg benazepril daily; 5 mg enalapril daily in the SA)	130.58	53.47–130.58	[102]
Creatinine and potassium screening	1	No range tested	[26,105]
ESRD – Transplantation – Dialysis	45,366 19,958 54,077	32,872–57,879 17,962–21,953 38,387–71,167	[2,3,27,31,101,106]
SMR of CKD	3.41	2.84–4.11	[20]
Discount rate	0.03	0.00–0.10	[15]

^†Based on 95% confidence intervals of the mean except for ESRD (estimate).
ACE: Angiotensin-converting enzyme; CKD: Chronic kidney disease; ESRD: End-stage renal disease; SA: Sensitivity analysis; SMR: Standardized mortality ratio.

Table 3. Results of the base-case analysis based on mean estimates of input variables.
Strategy	Costs (€)	Undiscounted LYs	Discounted QALYs	ICER (€/QALY)
No ACE inhibitor treatment	205,200	11.63	6.77	Dominated
ACE inhibitor treatment	172,676	13.20	8.26	Dominant

ACE: Angiotensin-converting enzyme; ICER: Incremental cost–effectiveness ratio; LY: Life year; QALY: Quality-adjusted life year.

Table 4. Univariate sensitivity analyses from a statutory health insurance perspective^†.
	Incremental costs (€)	Incremental QALYs	Incremental cost– effectiveness ratio
*Base case*
	-32,524	1.49	Dominance
*Annual transition probabilities from advanced renal insufficiency to ESRD*
Without ACE inhibitor
Lower bound	-33,589	1.44	Dominance
Higher bound	-27,154	1.37	Dominance
*Effectiveness of ACE inhibitor*
Relative risk of advanced renal insufficiency to ESRD
Lower bound	-63,736	2.80	Dominance
Higher bound	-2511	0.15	Dominance
*Utilities (health states)*
Chronic kidney disease
Lower bound	-32,524	1.43	Dominance
Higher bound	-32,524	1.54	Dominance
ESRD
Lower bound	-32,524	1.65	Dominance
Higher bound	-32,524	1.33	Dominance
Disutility of ACE inhibitor treatment
Lower bound	-32,524	1.18	Dominance
Higher bound	-32,524	1.49	Dominance
*Costs*
ACE inhibitor
Lower bound	-33,001	1.49	Dominance
Higher bound	-32,524	1.49	Dominance
ESRD
Lower bound	-21,596	1.49	Dominance
Higher bound	-43,469	1.49	Dominance
SMR
Lower bound	-32,364	1.56	Dominance
Higher bound	-32,704	1.41	Dominance
*Discount rate of costs and effects*
0%	-37,860	2.33	Dominance
5%	-29,444	1.14	Dominance
7%	-26,716	0.90	Dominance
10%	-23,207	0.66	Dominance

^†Effects of varying base-case estimates on the incremental cost–effectiveness ratio of treating all patients with advanced renal insufficiency with an ACE inhibitor versus no ACE inhibitor treatment (reference strategy). 'Lower bound' and 'higher bound' refer to the limits of the 95% confidence interval or estimate thereof.
ACE: Angiotensin-converting enzyme; ESRD: End-stage renal disease; QALY: Quality-adjusted life year; SMR: Standardized mortality ratio.

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