Cost-Effectiveness and Estimated Health Benefits of Treating Patients with Vitamin D in Pre-Dialysis

Sophie Snyder; Christopher S. Hollenbeak; Kamyar Kalantar-Zadeh; Matthew Gitlin; Akhtar Ashfaq

doi:10.1515/fhep-2019-0020

Abstract

Background

The optimal timing of treatment with vitamin D therapy for patients with chronic kidney disease (CKD), vitamin D insufficiency, and secondary hyperparathyroidism (SHPT) is a pressing question in nephrology with economic and patient outcome implications.

Objective

The objective of this study was to estimate the cost-effectiveness of earlier vitamin D treatment in CKD patients not on dialysis with vitamin D insufficiency and SHPT.

Design

A cost-effectiveness analysis based on a Markov model of CKD progression was developed from the Medicare perspective. The model follows a hypothetical cohort of 1000 Stage 3 or 4 CKD patients over a 5-year time horizon. The intervention was vitamin D therapy initiated in CKD stages 3 or 4 through CKD stage 5/end-stage renal disease (ESRD) versus initiation in CKD stage 5/ESRD only. The outcomes of interest were cardiovascular (CV) events averted, fractures averted, time in CKD stage 5/ESRD, mortality, quality-adjusted life years (QALYs), and costs associated with clinical events and CKD stage.

Results

Vitamin D treatment in CKD stages 3 and 4 was a dominant strategy when compared to waiting to treat until CKD stage 5/ESRD. Total cost savings associated with treatment during CKD stages 3 and 4, compared to waiting until CKD stage 5/ESRD, was estimated to be $19.9 million. The model estimated that early treatment results in 159 averted CV events, 5 averted fractures, 269 fewer patient-years in CKD stage 5, 41 fewer deaths, and 191 additional QALYs.

Conclusions

Initiating vitamin D therapy in CKD stages 3 or 4 appears to be cost-effective, largely driven by the annual costs of care by CKD stage, CV event costs, and risks of hypercalcemia. Further research demonstrating causal relationships between vitamin D therapy and patient outcomes is needed to inform decision making regarding vitamin D therapy timing.

Keywords: 25-hydroxyvitamin D; cardiovascular disease; chronic kidney disease (CKD); cost-effectiveness; disease progression; economic analysis; end-stage renal disease (ESRD); fracture; health care costs; parathyroid hormone (PTH); pre-dialysis care; secondary hyperparathyroidism (SHPT)

Conflict of Interest Statement: Sophie Snyder is an employee of BluePath Solutions. Matthew Gitlin is the Managing Director of BluePath Solutions. Akhtar Ashfaq is an employee of OPKO Health, Inc. Christopher S. Hollenbeak and Kamyar Kalantar-Zadeh have no conflicts of interest to declare. OPKO Health, Inc. funded the model development upon which this manuscript was based, as well as manuscript development. Aside from the contributions of the OPKO-employed authors, the funder had no role in study design; the collection, analysis, and interpretation of data; or in the writing of the report. The manuscript was provided to OPKO Health, Inc. for review prior to submission.
Authors’ Contributions
AA, CH, KKZ, MG, and SS designed research; AA, MG, and SS conducted research; MG and SS analyzed data; SS wrote the paper; AA and SS had primary responsibility for final content, CH and KKZ provided supervision and mentorship. All authors read and approved the final manuscript.
Sources of Support: OPKO Health, Inc. funded the development of the model and manuscript.

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