203 DISCUSSION Our study showed that the GoYK intervention would yield substantial costsavings across the life course of CKD patients, as well as a substantial reduction in deaths and in the need for dialysis in the first years. GoYK is likely to yield costsavings due to its simple and inexpensive implementation and maintenance, along with its expected impact on the reduction of CKD progression. The biggest impact of GoYK on costs and the number of deaths stems from the reduction in the transition to ESRD, where renal replacement therapies are required. Given that these therapies are extremely expensive and burdening, even small decreases in the number of patients that need them would result in large gains in costs and quality of life. Moreover, since the mortality rate of ESRD is considerably higher than that of other CKD stages, a reduction in ESRD would also mean a reduction in total deaths. Our findings corroborate the results of previous studies on CKD, which showed that the effectiveness of treatments and educational programs in reducing the progression to ESRD is an important factor in making an intervention cost-saving[44,45]. Our results may still be an underestimation of the cost-saving of GoYK, given that most of the tools and skills covered by the intervention are not specific to CKD, potentially covering other diseases and leading to even greater gains. One relevant example is cardiovascular disease, a burdening and expensive condition that is closely linked to CKD[16,35]. GoYK remained cost-effective in all the sensitivity analyses performed, demonstrating the robustness of our results. Almost all sensitivity analyses led to cost-saving results, and the ones that were not cost-saving were still costeffective, remaining below the Dutch cost-effectiveness threshold of €80,000, recommended for diseases with a high burden like CKD[41,42]. However, it is worth mentioning that GoYK might reach a higher number of patients than used in our analysis, which would translate into a proportionally lower intervention cost per patient. We explored this possibility in an additional analysis, revealing that even if GoYK had no effect on ESRD development, extending it to a minimum of 1,250 patients would result in an ICER below €20,000 per QALY. This is the lowest threshold recommended by the Dutch guidelines, normally applied to diseases with a burden much inferior to CKD.
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