Welton Nicky J, McAleenan Alexandra, Thom Howard Hz, Davies Philippa, Hollingworth Will, Higgins Julian Pt, Okoli George, Sterne Jonathan Ac, Feder Gene, Eaton Diane, Hingorani Aroon, Fawsitt Christopher, Lobban Trudie, Bryden Peter, Richards Alison, Sofat Reecha
School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK.
AntiCoagulation Europe, Bromley, UK.
Health Technol Assess. 2017 May;21(29):1-236. doi: 10.3310/hta21290.
Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of thromboembolic events. Anticoagulation therapy to prevent AF-related stroke has been shown to be cost-effective. A national screening programme for AF may prevent AF-related events, but would involve a substantial investment of NHS resources.
To conduct a systematic review of the diagnostic test accuracy (DTA) of screening tests for AF, update a systematic review of comparative studies evaluating screening strategies for AF, develop an economic model to compare the cost-effectiveness of different screening strategies and review observational studies of AF screening to provide inputs to the model.
Systematic review, meta-analysis and cost-effectiveness analysis.
Primary care.
Adults.
Screening strategies, defined by screening test, age at initial and final screens, screening interval and format of screening {systematic opportunistic screening [individuals offered screening if they consult with their general practitioner (GP)] or systematic population screening (when all eligible individuals are invited to screening)}.
Sensitivity, specificity and diagnostic odds ratios; the odds ratio of detecting new AF cases compared with no screening; and the mean incremental net benefit compared with no screening.
Two reviewers screened the search results, extracted data and assessed the risk of bias. A DTA meta-analysis was perfomed, and a decision tree and Markov model was used to evaluate the cost-effectiveness of the screening strategies.
Diagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age.
A national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations.
Many inputs for the economic model relied on a single trial [the Screening for Atrial Fibrillation in the Elderly (SAFE) study] and DTA results were based on a few studies at high risk of bias/of low applicability.
Comparative studies measuring long-term outcomes of screening strategies and DTA studies for new, emerging technologies and to replicate the results for photoplethysmography and GP interpretation of 12-lead electrocardiography in a screening population.
This study is registered as PROSPERO CRD42014013739.
The National Institute for Health Research Health Technology Assessment programme.
心房颤动（AF）是一种常见的心律失常，会增加血栓栓塞事件的风险。已证明抗凝治疗预防与AF相关的中风具有成本效益。一项全国性的AF筛查计划可能会预防与AF相关的事件，但将涉及英国国家医疗服务体系（NHS）资源的大量投入。
对AF筛查试验的诊断试验准确性（DTA）进行系统评价，更新对评估AF筛查策略的比较研究的系统评价，建立一个经济模型以比较不同筛查策略的成本效益，并回顾AF筛查的观察性研究以为该模型提供输入数据。
系统评价、荟萃分析和成本效益分析。
初级保健。
成年人。
筛查策略，由筛查试验、初次和末次筛查的年龄、筛查间隔以及筛查形式（系统机会性筛查[如果个体咨询其全科医生（GP）则为其提供筛查]或系统人群筛查[当邀请所有符合条件的个体进行筛查时]）定义。
敏感性、特异性和诊断比值比；与未筛查相比检测到新发AF病例的比值比；以及与未筛查相比的平均增量净效益。
两名综述作者筛选检索结果、提取数据并评估偏倚风险。进行了DTA荟萃分析，并使用决策树和马尔可夫模型评估筛查策略的成本效益。
诊断试验准确性取决于筛查试验及其解读方式。一般来说，我们综述中确定的筛查试验具有较高的敏感性（>0.9）。发现系统人群筛查和系统机会性筛查策略同样有效，与未筛查相比，估计需要筛查170个人才能多检测出1例AF病例。只要随机对照试验中观察到的机会性筛查的接受率能够转化为实际应用，系统机会性筛查比系统人群筛查更有可能具有成本效益。改良血压计监测、光电容积脉搏波描记法或护士触诊脉搏比其他筛查试验更有可能具有成本效益。如果依从治疗不随年龄增长而下降，初始筛查年龄为65岁且每5年重复筛查直至80岁的筛查策略可能具有成本效益。
一项全国性的AF筛查计划可能代表资源的成本效益利用。系统机会性筛查比系统人群筛查更有可能具有成本效益。护士触诊脉搏或改良血压计监测将是合适的筛查试验，由经过培训的GP解读诊断性12导联心电图进行确认，诊断不明确时转诊至专科医生。在提出任何筛查建议时，应同时采取在初级保健中实施系统机会性筛查接受率的实施策略。
经济模型的许多输入数据依赖于一项单一试验[老年人房颤筛查（SAFE）研究]，且DTA结果基于少数偏倚风险高/适用性低的研究。
测量筛查策略长期结局的比较研究以及针对新兴技术的DTA研究，并在筛查人群中重复光电容积脉搏波描记法和GP对12导联心电图解读的结果。
本研究注册为PROSPERO CRD42014013739。
英国国家卫生研究院卫生技术评估计划。
