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• W22383667 abstract "Purpose: An epidemic of renal disease in Australian Aborigines poses serious health and health-care funding problems. The Tiwi, an Australian Aboriginal tribe (population 1,800) living on two islands off the Northern Territory (NT) coast, until recently had the highest age-adjusted incidence of end-stage renal disease (ESRD) in the world: sixty times that of the non-Aboriginal NT population. They also had one of the highest cardiovascular disease mortality rates in Australia. A community-wide screening program in the early 1990's found a high prevalence of risk factors for renal and cardiovascular disease that included hypertension. Type II diabetes and albuminuria. This thesis evaluates the effectiveness and cost-effectiveness of a systematic treatment program that focuses on intensive blood pressure control, targeted at people at risk, or with early renal disease. Methods: The cost-effectiveness analysis required measurement of the effects and incremental costs of a treatment program in three remote communities from a health funder's perspective. Effectiveness was defined as the number of people avoiding the need for dialysis. This was estimated by two methods: an intention-to-treat qsurvivalq analysis of a historical controlled trial model of the treatment program period compared to the period preceding the program, and an epidemiological prediction of new dialysis starts for the Tiwi tribe (population incidence). In addition to the need for dialysis, three process measures - the urinary albumin creatinine ratio (ACR), glomerular filtration rate (GFR), and blood pressure in the patients' first two years in the program - were analyzed and compared to the findings of systematic reviews of randomised trials. Records of treatment program encounters from 1995 to 1998 were used to estimate resource utilization. Costs were determined using both allocation (qtop-downq) and usage-based (qbottom-upq) approaches. The boundaries of cost-effectiveness and cost-savings were calculated in a sensitivity analysis. Results: Between November 1995 and October 1998, 228 persons were followed for 506 person years. There were 3,370 consultations which, at three clinic days per week, averaged 7.6 visits per clinic-day. Dialysis starts avoided in the first three years were calculated from the hazard ratio (HR) in the survival model as six dialysis starts avoided (unadjusted) (HR, 0.25; 95% confidence interval, 0.05 - 1.2), and increased to twelve dialysis starts avoided when adjusted for age and ACR (HR, 0.14; 95% confidence interval, 0.003 - 0.77). The second method, the epidemiological prediction model, also estimated six dialysis starts avoided (unadjusted, p = 0.20), and increased to eighteen dialysis starts avoided when adjusted for a progressive epidemic (p l 0.001). The evaluation of process measures found the mean arterial pressure lowered by 9 mmHg (a 10 percent reduction, p l 0.0001) for the entire group, and 16 mmHg (a 14 percent reduction, p l 0.0001) for those with hypertension at baseline (g 140/90 mmHg). Measures of renal function, which were declining previously, stabilized. The program was estimated to cost $1,210 per person per year. This was comprised of nurse costs of $341, Aboriginal health worker costs of $188, physician costs of $142, perindopril costs of $299, laboratory test costs of $187, and travel costs of $53. The lifetime cost per person for ESRD treatment and comorbidity of $309,280 was based on a median ERSD treatment survival of 3.3 years for NT Aborigines, or $669,500 based on a 7.5 year median survival for Tiwi. Cost-savings estimates ranged from $884,000 to $4 million (3.3 year median ESRD treatment survival), and $3.3 to $11.4 million (7.25 year median ESRD treatment survival). Discussion: In the treatment period from 1996 to 1998 the rates of ESRD fell for the Tiwi, while the epidemic continued to grow for non-Tiwi Aborigines of the NT Top-End, arguing against a temporal trend. The improvements in the three process measures concurred with improvements reported in the systematic reviews. The strengths and weaknesses of the analytical methods are described in detail. These findings show that the treatment program, using simple protocols and effective therapy, provides significant benefit and, for most plausible values, is dominant in a cost-effectiveness analysis. Key words: Clinical epidemiology, health technology assessment, indigenous health, Tiwi, survival analysis, antihypertensive therapy, end-stage renal disease." @default.
• W22383667 created "2016-06-24" @default.
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• W22383667 date "2003-01-01" @default.
• W22383667 modified "2023-09-27" @default.
• W22383667 title "Preventing renal failure in Australian Aborigines : an effective and cost analysis of a screening and treatment program" @default.
• W22383667 hasPublicationYear "2003" @default.
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