Presentation (CTI)

OBJECTIVES: Payers investing in CKD screening face a targeting problem: with 25.1 million undiagnosed adults at actionable Stages 2-3b, where should screening dollars maximize fiscal return? This study decomposes the prevention counterfactual by stage, quantifies stage-shift savings across four uptake scenarios, and identifies Stage 2 as the dominant investment signal — not because per-patient savings are highest, but because population mass creates the greatest aggregate opportunity.
METHODS: Stage-specific inpatient costs from Golestaneh et al. (Am J Manag Care. 2017;23[10 Suppl]:S163-S172) are applied using a 35/65 commercial-to-Medicare payer mix. Cost inputs include 30-day readmission costs rising from ~10% at no-CKD to over 23% at ESRD, amplifying the stage-shift differential. Per-patient savings: Savings(k→k−1) = Weighted Cost(k) − Weighted Cost(k−1), yielding $5,599/patient (Stage 3a→2) and $8,459/patient (Stage 3b→3a). Undiagnosed counts from NHANES 2017-2020 × ACS 2023 (N = 99.1M adults 55+) versus USRDS 2024 diagnosed counts. Four scenarios (40%-100%) at $40/person generate annual net savings, 10-year cumulative, and QALYs gained.
RESULTS: Stage 2 carries the largest undiagnosed burden: 14.9 million adults (20% diagnosis rate) incurring $88.8 billion annually. Stage 3a→2 generates the largest stage-shift savings: $5,599/patient × 8.0 million Stage 3a undiagnosed = $44.7 billion. Stage 3b→3a yields $18.2 billion ($8,459/patient × 2.2M). At 60% uptake, net savings are $38.9 billion (21:1 ROI); 10-year cumulative savings reach $389 billion (~897,000 QALYs). At 40%, savings are $25.9 billion. Full-detection savings reach $64.9 billion. The paradox: the lowest-cost stage holds the largest undetected population, making Stage 2 the highest-leverage screening target.
CONCLUSIONS: Stage 2 is the optimal CKD screening target — not the most severely ill patients, but the largest undetected population at the earliest actionable stage. This stage-decomposition reframes CKD prevention as a payer investment decision with calculable stage-specific ROI, applicable to European multi-payer contexts where screening requires explicit cost-per-stage justification for HTA and coverage policy.