Tanajewski Lukasz, Harris Rebecca, Harman David J, Aithal Guruprasad P, Card Timothy R, Gkountouras Georgios, Berdunov Vladislav, Guha Indra N, Elliott Rachel A
Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK.
Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham., Nottingham, United Kingdom.
BMJ Open. 2017 Jul 5;7(6):e015659. doi: 10.1136/bmjopen-2016-015659.
To assess the long-term cost-effectiveness of a risk stratification pathway, compared with standard care, for detecting non-alcoholic fatty liver disease (NAFLD) in primary care.
Primary care general practices in England.
Adults who have been identified in primary care to have a risk factor for developing NAFLD, that is, type 2 diabetes without a history of excessive alcohol use.
A community-based pathway, which uses transient elastography and hepatologists to stratify patients at risk of NAFLD, has been implemented and demonstrated to be feasible (NCT02037867). Earlier identification could mean earlier treatments, referral to specialist and enrolment into surveillance programmes.
The impact of earlier detection and treatment with the risk stratification pathway on progression to later stages of liver disease was examined using decision modelling with Markov chains to estimate lifetime health and economic effects of the two comparators.
Data from a prospective cross-sectional feasibility study indicating risk stratification pathway and standard care diagnostic accuracies were combined with a Markov model that comprised the following states: no/mild liver disease, significant liver disease, compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, liver transplant and death. The model data were chosen from up-to-date UK sources, published literature and an expert panel.
An incremental cost-effectiveness ratio (ICER) indicating cost per quality-adjusted life year (QALY) of the risk stratification pathway compared with standard care was estimated.
The risk stratification pathway was more effective than standard care and costs £2138 per QALY gained. The ICER was most sensitive to estimates of the rate of fibrosis progression and the effect of treatment on reducing this, and ranged from -£1895 to £7032/QALY. The risk stratification pathway demonstrated an 85% probability of cost-effectiveness at the UK willingness-to-pay threshold of £20 000/QALY.
Implementation of a community-based risk stratification pathway is likely to be cost-effective.
NCT02037867, ClinicalTrials.gov.
评估与标准护理相比，一种风险分层途径在基层医疗中检测非酒精性脂肪性肝病（NAFLD）的长期成本效益。
英格兰的基层医疗全科诊所。
在基层医疗中被确定有患NAFLD风险因素的成年人，即无过量饮酒史的2型糖尿病患者。
已实施一种基于社区的途径，该途径使用瞬时弹性成像和肝病专家对有NAFLD风险的患者进行分层，并已证明是可行的（NCT02037867）。更早的识别可能意味着更早的治疗、转诊至专科医生以及纳入监测项目。
使用马尔可夫链决策模型来估计两种比较方案的终身健康和经济影响，研究风险分层途径早期检测和治疗对肝病进展至后期阶段的影响。
一项前瞻性横断面可行性研究的数据表明风险分层途径和标准护理诊断准确性，这些数据与一个马尔可夫模型相结合，该模型包括以下状态：无/轻度肝病（no/mild liver disease）、显著肝病（significant liver disease）、代偿性肝硬化（compensated cirrhosis）、失代偿性肝硬化（decompensated cirrhosis）、肝细胞癌（hepatocellular carcinoma）、肝移植（liver transplant）和死亡（death）。模型数据选自最新的英国资料、已发表的文献以及一个专家小组。
估计了一个增量成本效益比（ICER），表明与标准护理相比，风险分层途径每获得一个质量调整生命年（QALY）的成本。
风险分层途径比标准护理更有效，每获得一个QALY的成本为2138英镑。ICER对纤维化进展率的估计以及治疗对降低纤维化的效果最为敏感，范围为-1895至7032英镑/QALY。在英国每QALY支付意愿阈值2000英镑的情况下，风险分层途径具有成本效益的概率为85%。
实施基于社区的风险分层途径可能具有成本效益。
NCT02037867，ClinicalTrials.gov。
