Hospital-based inpatient resource utilization associated with autosomal dominant polycystic kidney disease in the US

Real World Outcomes Associated with Idarucizumab: Population-Based Retrospective Cohort Study

BACKGROUND

Idarucizumab reverses the anticoagulant effect of dabigatran, but few comparative studies have reported on clinical outcomes with idarucizumab.

OBJECTIVE

Our objective was to determine the effect of idarucizumab on clinical outcomes.

METHODS

We conducted a retrospective cohort study in a nationally representative sample of hospitals in the United States. The study population included adults ≥ 18 years who were hospitalized for dabigatran-associated major bleeding between January 1, 2015 and December 31, 2017. We compared idarucizumab-exposed patients to the unexposed group. Our primary outcome of interest was in-hospital mortality.

RESULTS

We included 266 exposed and 1345 non-exposed participants across 271 hospitals. Among participants with gastrointestinal bleeding, there was no statistically significant difference in the odds of in-hospital mortality [9/153 (5.9%) vs 37/1124 (3.3%); adjusted odds ratio = 1.39, 95% confidence interval 0.51-3.45] between the idarucizumab-exposed and non-exposed groups. Among participants with intracranial bleeding, there was an excess of in-hospital mortality [13/112 (11.6%) vs 6/217 (2.8%)] associated with idarucizumab exposure, but limitations include sparse data and the inability to rule out residual confounding or confounding by disease severity.

CONCLUSIONS

Among a large nationally representative sample of adult patients with dabigatran-associated major bleeding in the United States, we found no difference in in-hospital mortality among patients with gastrointestinal bleeding associated with idarucizumab exposure. An excess risk of in-hospital mortality associated with idarucizumab exposure among participants with intracranial bleeding deserves further exploration.

The societal economic burden of autosomal dominant polycystic kidney disease in the United States

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common inherited kidney diseases characterized by progressive development of renal cysts and numerous extra-renal manifestations, eventually leading to kidney failure. Given its chronic and progressive nature, ADPKD is expected to carry a substantial economic burden over the course of the disease. However, there is a paucity of evidence on the impact of ADPKD from a societal perspective. This study aimed to estimate the direct and indirect costs associated with ADPKD in the United States (US).

METHODS

A prevalence-based approach using data from scientific literature, and governmental and non-governmental organizations was employed to estimate direct healthcare costs (i.e., medical services, prescription drugs), direct non-healthcare costs (i.e., research and advocacy, donors/recipients matching for kidney transplants, transportation to/from dialysis centers), and indirect costs (i.e., patient productivity loss from unemployment, reduced work productivity, and premature mortality, caregivers' productivity loss and healthcare costs). The incremental costs associated with ADPKD were calculated as the difference between costs incurred over a one-year period by individuals with ADPKD and the US population. Sensitivity analyses using different sources and assumptions were performed to assess robustness of estimates and account for variability in published estimates.

RESULTS

The estimated total annual costs attributed to ADPKD in 2018 ranged from $7.3 to $9.6 billion in sensitivity analyses, equivalent to $51,970 to $68,091 per individual with ADPKD. In the base scenario, direct healthcare costs accounted for $5.7 billion (78.6%) of the total $7.3 billion costs, mostly driven by patients requiring renal replacement therapy ($3.2 billion; 43.3%). Indirect costs accounted for $1.4 billion (19.7%), mostly driven by productivity loss due to unemployment ($784 million; 10.7%) and reduced productivity at work ($390 million; 5.3%). Total excess direct non-healthcare costs were estimated at $125 million (1.7%).

CONCLUSIONS

ADPKD carries a considerable economic burden, predominantly attributed to direct healthcare costs, the majority of which are incurred by public and private healthcare payers. Effective and timely interventions to slow down the progression of ADPKD could substantially reduce the economic burden of ADPKD.

Aspirin Compared with Anticoagulation to Prevent Venous Thromboembolism After Knee or Hip Arthroplasty: a Large Retrospective Cohort Study

BACKGROUND

Although guidelines now allow the use of aspirin as an alternative to anticoagulants for venous thromboembolism prophylaxis after knee or hip arthroplasty, there is limited data on contemporary use and outcomes with aspirin.

OBJECTIVE

To describe the use of pharmacologic thromboprophylaxis and to assess venous thromboembolic risk with aspirin compared with anticoagulation after knee or hip arthroplasty.

DESIGN

Retrospective cohort study using data from the US MedAssets database.

PATIENTS

Adults with a principal discharge diagnosis of knee or hip arthroplasty between January 1, 2013, and December 31, 2014.

MAIN MEASURES

We identified charges for medications used for thromboprophylaxis within 7 days after the index surgery from billing records. The primary outcome was postoperative venous thromboembolism identified by International Classification of Diseases, 9th edition codes, from the index hospitalization, rehospitalization within 30 days, or during an outpatient visit within 90 days postoperatively. We compared postoperative thromboembolic risk in patients receiving aspirin-only and those receiving anticoagulants using propensity score-adjusted multivariable logistic regression models.

KEY RESULTS

We identified 74,234 patients with knee arthroplasty and 36,192 with hip arthroplasty who received pharmacologic thromboprophylaxis. Aspirin-only was used in 27.9% of all patients, while 24.2% and 24.1% received warfarin or enoxaparin as prophylactic monotherapy, respectively. Postoperative venous thromboembolism occurred in 495 (0.67%) patients undergoing knee arthroplasty and 145 (0.40%) undergoing hip arthroplasty. Aspirin-only was not related to increased odds of postoperative venous thromboembolism compared with anticoagulants in multivariable adjusted analyses (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.56-0.87, and OR 0.93; 95% CI, 0.62-1.38 for knee or hip arthroplasty, respectively).

CONCLUSIONS

More than a fourth of all patients received aspirin as the sole antithrombotic agent after knee or hip arthroplasty. Postoperative thromboprophylaxis with aspirin-only was not associated with a higher risk of postoperative venous thromboembolism compared with anticoagulants after hip or knee arthroplasty.

Recent advances in management of autosomal-dominant polycystic kidney disease

PURPOSE

Promising developments in the search for effective pharmacotherapies for autosomal-dominant polycystic kidney disease (ADPKD) are reviewed.

SUMMARY

The formation and development of cysts characteristic of ADPKD result in inexorable renal and extrarenal manifestations that give rise to more rapid disease progression and more widespread complications than are seen with other forms of chronic kidney disease. To date, no agent has gained Food and Drug Administration marketing approval for use in patients with ADPKD, complicating efforts to meet the medical needs of this population. Although definitive ultrasonographic diagnostic strategies are available, molecular screening approaches lack sufficient evidence and patient outcomes data to support broad clinical application. Recently completed and ongoing clinical trials point to a number of encouraging platforms for evidence-based ADPKD management. Tolvaptan therapy significantly improved cyst burden and slowed disease progression among patients with early-stage ADPKD in a large-scale trial, while somatostatin therapies may also be useful in halting disease progression and managing comorbid polycystic liver disease. Stem cell research and nanomedicine might represent novel approaches to gaining comprehensive insights on ADPKD and, ultimately, to targeting the disease's origins, thereby making restoration of kidney function possible.

CONCLUSION

A number of pharmacotherapy approaches to ADPKD management show promise but are unlikely to be curative, fueling interest among researchers in finding new applications for nanomedicine and stem cell technologies that can slow ADPKD progression and better control complications of the disease.

Analysis of Nationwide Data to Determine the Incidence and Diagnosed Prevalence of Autosomal Dominant Polycystic Kidney Disease in the USA: 2013-2015

BACKGROUND

This study addresses an important gap, as it is the first US nationwide, epidemiologic study of ADPKD incidence and prevalence.

SUMMARY

This 3-year, observational study utilized data from Truven Health MarketScan® administrative claims, as well as cross-sectional data from the National Ambulatory Medical Care Survey (NAMCS). We estimated the annual incidence and diagnosed prevalence using population-based data on over 170 million de-identified patients to provide the most current epidemiologic estimates available. The ADPKD-diagnosed prevalence was 4.3 per 10,000 in the NAMCS, which closely corresponded with age-adjusted rates from patients with either commercial insurance or employer-sponsored Medicare supplemental insurance. The annual incidence was 0.62 per 10,000. Both nationwide data sets indicate that approximately 140,000 patients are currently diagnosed in the USA. We also found significant differences by gender and age. Females are nearly twice as likely as males to be diagnosed in early adulthood, while the incidence in males was highest in those aged 65 years or older. ADPKD appears more likely to be diagnosed in men after disease progression or the development of chronic kidney disease.

KEY MESSAGES

Our results revealed striking age and gender differences in the incidence of ADPKD. Young women are diagnosed with ADPKD at nearly twice the rate of young men, perhaps due to the use of ultrasound in women during child-bearing years. This points to a need for increased recognition of ADPKD, with an emphasis on younger men in particular. ADPKD has been inaccurately perceived as a common condition based on misinterpretation of early epidemiologic data (1957) confirmed by our data and recent European data. ADPKD affects approximately 140,000 patients in the USA and meets the criterion for a rare disease. Our results indicate a need for further study of gender and ADPKD diagnosis, progression, management, and outcomes.

Global costs attributed to chronic kidney disease: a systematic review

SUMMARY The aim of this study is to discuss the global costs attributed to chronic kidney disease (CKD) and its impact on healthcare systems of developing countries, such as Brazil. This is a systematic review based on data from PubMed/Medline, using the key words “costs” and “chronic kidney disease”, in January 2017. The search was also done in other databases, such as Scielo and Google Scholar, aiming to identify regional studies related to this subject, published in journal not indexed in PubMed. Only papers published from 2012 on were included. Studies on CKD costs and treatment modalities were prioritized. The search resulted in 392 articles, from which 291 were excluded because they were related to other aspects of CKD. From the 101 remaining articles, we have excluded the reviews, comments and study protocols. A total of 37 articles were included, all focusing on global costs related to CKD. Despite methods and analysis were diverse, the results of these studies were unanimous in alerting for the impact (financial and social) of CKD on health systems (public and private) and also on family and society. To massively invest in prevention and measures to slow CKD progression into its end-stages and, then, avoid the requirement for dialysis and transplant, can represent a huge, and not yet calculated, economy for patients and health systems all over the world.

Incremental health care resource utilization and expenditures associated with autosomal-dominant polycystic kidney disease

Purpose

Incremental health care resource utilization and expenditures associated with autosomal dominant polycystic kidney disease (ADPKD) were estimated.

Methods

Study data were from a large administrative claims database. Individuals aged 18 years or older enrolled in tracked health plans for 12 months from April 1, 2011 through March 31, 2012, and with an International Classification of Disease, Ninth Revision, Clinical Modification diagnosis code for "polycystic kidney, autosomal dominant" (753.13) or for "polycystic kidney, unspecified type" (753.12) were identified as having ADPKD, and linked one-to-one with individuals without ADPKD based on age and gender. Zero-inflated negative binomial models estimated incremental health care resource utilization and expenditures, adjusting for risk factors.

Results

A total of 3,844 individuals with ADPKD who satisfied selection criteria were linked one-to-one with 3,844 individuals without ADPKD. Multivariate, regression models adjusting for risk factors revealed incremental mean (standard error) resource use associated with ADPKD of 0.68 (0.090) hospital days, equal to 68 additional hospital days per 100 ADPKD patients, and 6.9 (0.28) outpatient visits, equal to 690 additional visits per 100 ADPKD patients. Mean (standard error) incremental total expenditures associated with ADPKD were US$8,639 ($470). Mean incremental expenditures were largest for outpatient expenditures at US$4,918 ($198), followed by mean incremental hospital expenditures of US$2,603 ($263), and mean incremental medication expenditures of US$1,589 ($77). Based on sub-group analysis, mean incremental total expenditures were US$2,944 ($417) among ADPKD patients without end-stage renal disease and US$38,962 ($6,181) for those with end-stage renal disease.

Conclusion

ADPKD was associated with considerable incremental health care resource utilization and expenditures. Significant illness burden was found even before patients reached end-stage renal disease.

Real-world costs of autosomal dominant polycystic kidney disease in the Nordics

Background

There is limited real-world data on the economic burden of patients with autosomal dominant polycystic kidney disease (ADPKD). The objective of this study was to estimate the annual direct and indirect costs of patients with ADPKD by severity of the disease: chronic kidney disease (CKD) stages 1–3; CKD stages 4–5; transplant recipients; and maintenance dialysis patients.

Methods

A retrospective study of ADPKD patients was undertaken April–December 2014 in Denmark, Finland, Norway and Sweden. Data on medical resource utilisation were extracted from medical charts and patients were asked to complete a self-administered questionnaire.

Results

A total of 266 patients were contacted, 243 (91%) of whom provided consent to participate in the study. Results showed that the economic burden of ADPKD was substantial at all levels of the disease. Lost wages due to reduced productivity were large in absolute terms across all disease strata. Mean total annual costs were highest in dialysis patients, driven by maintenance dialysis care, while the use of immunosuppressants was the main cost component for transplant care. Costs were twice as high in patients with CKD stages 4–5 compared to CKD stages 1–3.

Conclusions

Costs associated with ADPKD are significant and the progression of the disease is associated with an increased frequency and intensity of medical resource utilisation. Interventions that can slow the progression of the disease have the potential to lead to substantial reductions in costs for the treatment of ADPKD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2513-8) contains supplementary material, which is available to authorized users.

Cost-effectiveness of angiotensin-converting enzyme inhibitors versus angiotensin II receptor blockers as first-line treatment in autosomal dominant polycystic kidney disease

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is a rare kidney disorder impacting ∼1:2,500 individuals among the general US population. Hypertension is a significant predictor of ADPKD progression, and a risk factor for development of cardiovascular disease (CVD), the most common cause for mortality among ADPKD patients. Angiotensin-converting enzymes inhibitors (ACE-I) are widely used as first-line treatment in ADPKD for the management of hypertension. However, their cost-effectiveness relative to other hypertensive medications, such as angiotensin II receptor blockers (ARB), has never been assessed.

OBJECTIVE

To determine if ARB are more cost-effective than ACE-Is as first-line treatment in ADPKD.

METHODS

A Markov-state decision model was constructed for estimation of cost and outcome benefits in hypertensive ADPKD patients. Transition probabilities were extrapolated from a retrospective cohort study comparing chronic kidney disease (CKD) stage transitions in ADPKD patients. Annual pharmaceutical costs per average daily dose per CKD stage were extracted from a US healthcare claims database. Median total healthcare costs per CKD stage or transplant were extracted from the published literature. The time horizon was set to 30 years, with 1-year duration to cycle shift. A cost-effectiveness analysis was conducted to estimate the incremental cost-effectiveness ratio (ICER) of ACE-I vs ARB per additional year of prevented transplant and/or death. A one-way probabilistic sensitivity analysis was conducted, with 10% variation in probabilities and cost.

RESULTS

Total annual healthcare costs accrued after 30 years among ADPKD patients taking ACE-Is was estimated to be $3,505,028.41, compared to ARB at $3,644,327.65. Life expectancy was increased by 1.39 years among patients taking ACE-I. Approximate 10-year survival in patients taking ACE-Is was 47% compared to ARB at 34%.

CONCLUSIONS

ACE-I dominated ARB and displayed greater cost-effectiveness due to lower cost and increased capacity to prolong years of life without transplant or death among hypertensive ADPKD patients. This model strengthens the value of ACE-I over ARB as first-line treatment for hypertension management in ADPKD patients.

Healthcare resource consumption and cost of care among patients with polycystic kidney disease in Italy

Objective

The aim of this study was to assess healthcare resource consumption and its associated costs among patients with polycystic kidney disease (PKD) in a real-world setting.

Methods

An observational retrospective cohort analysis was conducted using data from the administrative databases of four Italian local health units. Data for patients who were diagnosed with PKD during the inclusion period (January 1, 2010 to December 31, 2012) were extracted. The date on which a patient’s first PKD hospitalization occurred during the inclusion period was defined as the index date (ID), and the ID was defined as the date of the first dialysis treatment recorded during the inclusion period for patients undergoing dialysis. Data regarding the clinical characteristics of patients included in the study during the 12 months prior to the ID (pre-ID; characterization period) were collected. All patients were then followed up for the 12 months following the ID (post-ID; follow-up period). Healthcare consumption and its associated costs were analyzed during the follow-up period. All costs are reported in euros (€).

Results

A total of 1,123 patients with PKD were included in this study, 61.9% of whom were male; the mean age of the patients was 57.7±24.5 years. At diagnosis, 11.2% and 1.1% of patients were affected by the dominant and recessive forms of PKD, respectively. Approximately 8% of the included patients were undergoing dialysis at ID (baseline). The incidence of dialysis was fourfold greater among patients with autosomal-dominant PKD (ADPKD) than among the total cohort (33.3% compared with an overall 8.3%). During the follow-up period, the average annual rates of healthcare resource consumption were greater among dialyzed than non-dialyzed patients. The average healthcare expenditures were €45,059.62 and €3,913.89 (p<0.001) per year for dialyzed and non-dialyzed PDK patients, respectively. Our findings suggest that in the real-world Italian context, consumption of healthcare among patients with PKD has increased at dialysis initiation due to the cost of outpatient specialist healthcare services as well as other costs. Research on the prevention of PKD-related complications and disease progression may help to facilitate a decrease in the costs associated with this condition.