Clinical Question: Is annual proteinuria screening in adults cost-effective?

Setting: Not applicable

Study Design: Cost-effectiveness analysis

Synopsis: In the majority of patients who develop end-stage renal disease, the condition goes undetected until prevention is ineffective. Having low levels of protein in the urine can be an early marker of increased risk of progressive kidney disease, but it is unclear whether screening all adults for proteinuria is indicated. Screening patients who have diabetes for proteinuria with an annual dipstick test already has been shown to be cost-effective. To assess the value of population-based dipstick screening for the early detection of urine protein in all adults, the authors performed a cost-effectiveness analysis using a Markov decision model to compare a strategy of screening with no screening beginning at 50 years of age.

The patients who were identified with proteinuria began treatment with an angiotensin-converting enzyme inhibitor or an angiotensin-II receptor blocker. The authors carefully analyzed the literature to obtain estimates of event probabilities (e.g., estimated compliance rates, natural disease progression, potential harms from unnecessary interventions, treatment benefits), and direct and indirect costs. Sensitivity analyses were performed for age, frequency of screening, and disease risk factors. Outcomes were based on cost per quality-adjusted life-year (QALY), which is a commonly used parameter to compare various screening tests and interventions.

The cost-effectiveness of annually screening patients younger than 60 years who do not have hypertension or diabetes was unfavorable ($282,818 per QALY; gain of 0.0022 QALYs per person, or less than one quality-adjusted life-day per person). Annual screening of low-risk patients 60 years and older was more cost-effective ($53,372 per QALY). In patients with hypertension, annual screening was highly cost-effective ($18,621 per QALY; a gain of 0.03 QALYs per person). A lower frequency of screening low-risk patients every 10 years beginning at 60 years of age also was cost-effective ($6,195 per QALY).

Bottom Line: Annual screening of adults to detect proteinuria and prevent end-stage renal disease is not cost-effective unless directed only at high-risk groups (i.e., patients with diabetes and hypertension). Screening every 10 years beginning at 60 years of age, however, is highly cost-effective. (Level of Evidence: 1b)