Cost‐utility analysis of comprehensive periodontal management for chronic kidney disease progression in Chinese adults with periodontitis in China: A seven‐state Markov cohort study
Yadong Wang, Jukun SongAbstract
Background
Observational evidence suggests that periodontitis is associated with the progression of chronic kidney disease (CKD) in Chinese adults, and that periodontal care may be associated with a lower risk of end‐stage renal disease (ESRD). Because this evidence is observational rather than causal, whether comprehensive periodontal management is a cost‐effective use of resources in CKD remains uncertain and has not been formally evaluated within the Chinese healthcare system.
Methods
We developed a seven‐state Markov cohort model (CKD stages G1–G5/ESRD + Death) for a Chinese adult cohort aged 50 years at entry. Three strategies were compared: usual care (UC), scaling and root planing plus periodontal maintenance (SRP), and comprehensive intensive management (CIM). Clinical parameters were derived from verified published sources. Costs (CNY 2024) and health utility values (EQ‐5D‐5L, Chinese tariff) were extracted from peer‐reviewed literature. Model outcomes included discounted lifetime costs and quality‐adjusted life years (QALYs) over a 40‐year horizon with a 3.5% annual discount rate. The willingness‐to‐pay (WTP) threshold was CNY 90,000/QALY (approximately 1× Chinese GDP per capita, 2024). Sensitivity analyses included one‐way deterministic sensitivity analysis (DSA), probabilistic sensitivity analysis (PSA; n = 10,000 Monte Carlo simulations), expected value of perfect information (EVPI), budget impact analysis (BIA), and a break‐even time‐horizon analysis. In addition, the CKD transition probabilities were re‐derived from published longitudinal cohort data (C‐STRIDE; a 10‐year Taiwanese integrated kidney‐care cohort) and cross‐checked against an externally validated Asian multi‐state Markov model; multi‐factor scenario, threshold and value‐of‐information analyses were added; and the comprehensive‐management strategy was decomposed against the EFP S3‐level guideline, including a conservative scaling‐and‐root‐planing‐only floor.
Results
In the early CKD subgroup (G1–G2 dominant), SRP and CIM produced incremental cost‐utility ratios (ICURs) of CNY 217,600/QALY and CNY 109,700/QALY, respectively, both exceeding the WTP threshold (not cost‐effective). In the advanced CKD subgroup (G3–G4 dominant), both SRP and CIM were dominant strategies (lower lifetime costs and higher QALYs vs UC), driven by substantial cost savings from avoided dialysis (SRP: −CNY 21,100; CIM: −CNY 40,300 per patient over 40 years). The probability of cost‐effectiveness at WTP = CNY 90,000/QALY was 27%–32% (early CKD) versus ≥ 97% (advanced CKD). For advanced CKD, the break‐even time horizon was 5 years. The EVPI was CNY 1190/patient for early CKD, indicating that further research is economically justified. Under the literature‐anchored parameters, the advanced‐CKD result remained robustly dominant across scenarios, probabilistic (probability of cost‐effectiveness ≈ 99.9%) and conservative scaling‐only analyses, whereas the early‐CKD result was sensitive to the contested assumptions (probability of cost‐effectiveness ≈ 50%) and is therefore reported as exploratory.
Conclusions
Under a set of exploratory assumptions—and conditional on the observational (non‐causal) association between periodontal scaling and reduced ESRD risk—comprehensive periodontal management may be economically attractive in patients with advanced CKD (G3–G4), where the result was robust to literature‐anchored transition probabilities and to scenario, probabilistic and conservative scaling‐only analyses. In early CKD, the cost‐effectiveness is uncertain (probability of cost‐effectiveness ≈ 50%). These exploratory scenario analyses identify early CKD as a high‐value target for a future randomized controlled trial rather than a basis for immediate policy mandates.
Plain Language Summary
Gum disease (periodontitis) and kidney disease (chronic kidney disease, CKD) are both very common in China and are linked: people with severe gum disease progress to kidney failure faster. This study used a computer model to ask whether treating gum disease is worth the cost for the Chinese health system. We compared three approaches—no extra gum care, standard deep cleaning, and intensive gum treatment—in patients with different stages of CKD. For patients with moderate‐to‐advanced CKD (stages G3–G4), intensive gum treatment saved money and improved health at the same time, mainly because it delayed the need for dialysis, which costs around CNY 95,000 per year. The savings paid for the treatment within 5 years. For patients with early CKD (stages G1–G2), gum treatment was not cost‐effective under cautious assumptions, but became cost‐effective when realistic upper‐end estimates were used. The uncertainty around the early‐CKD result is large enough to justify a clinical trial in China. These exploratory findings suggest that comprehensive periodontal care may be economically attractive in advanced CKD and warrant confirmation in a prospective study before any change to China's national health‐insurance (NHSA) policy; because the underlying evidence is observational, they do not by themselves establish that periodontal treatment slows kidney disease progression.