Health Economics Research Group, Brunel University, London, UK.
UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
Liver Int. 2019 Nov;39(11):2052-2060. doi: 10.1111/liv.14198. Epub 2019 Aug 6.
BACKGROUND/AIMS: Non-invasive fibrosis tests (NITs) can be used to triage non-alcoholic fatty liver disease (NAFLD) patients at risk of advanced fibrosis (AF). We modelled and investigated the diagnostic accuracy and costs of a two-tier NIT approach in primary care (PC) to inform secondary care referrals (SCRs).
A hypothetical cohort of 1,000 NAFLD patients with a 5% prevalence of AF was examined. Three referral strategies were modelled: refer all patients (Scenario 1), refer only patients with AF on NITs performed in PC (Scenario 2) and refer those with AF after biopsy (Scenario 3). Patients in Scenarios 1 and 2 would undergo sequential NITs if their initial NIT was indeterminate (FIB-4 followed by Fibroscan®, enhanced liver fibrosis (ELF)® or FibroTest®). The outcomes considered were true/false positives and true/false negatives with associated mortality, complications, treatment and follow-up depending on the care setting. Decision curve analysis was performed, which expressed the net benefit of different scenarios over a range of threshold probabilities (Pt).
Sequential use of NITs provided lower SCR rates and greater cost savings compared to other scenarios over 5 years, with 90% of patients managed in PC and cost savings of over 40%. On decision curve analysis, FIB-4 plus ELF was marginally superior to FIB-4 plus Fibroscan at Pt ≥8% (1/12.5 referrals). Below this Pt, FIB-4 plus Fibroscan had greater net benefit. The net reduction in SCRs was similar for both sequential combinations.
The sequential use of NITs in PC is an effective way to rationalize SCRs and is associated with significant cost savings.
背景/目的：非侵入性纤维化检测（NITs）可用于对患有进展性肝纤维化（AF）风险的非酒精性脂肪性肝病（NAFLD）患者进行分诊。我们建立模型并研究了初级保健（PC）中两阶段 NIT 方法对二级保健转诊（SCR）的诊断准确性和成本的影响，以便为 SCR 提供信息。
检查了一个具有 5% AF 患病率的 1000 例 NAFLD 患者的假设队列。对三种转诊策略进行建模：转诊所有患者（方案 1）、仅转诊在 PC 中进行的 NIT 检测阳性的患者（方案 2）以及仅转诊经活检诊断为 AF 的患者（方案 3）。如果初始 NIT 不确定（FIB-4 后进行 Fibroscan®、增强型肝纤维化（ELF）®或 FibroTest®），方案 1 和 2 中的患者将进行连续 NIT。考虑的结果是阳性/阴性的真阳性和假阳性，以及与治疗和随访相关的死亡率、并发症，具体取决于治疗环境。进行了决策曲线分析，该分析在一系列阈值概率（Pt）范围内表达了不同方案的净收益。
与其他方案相比，连续使用 NIT 可在 5 年内降低 SCR 率并节省更多成本，90%的患者在 PC 中接受治疗，节省成本超过 40%。在决策曲线分析中，FIB-4 加 ELF 在 Pt≥8%（1/12.5 转诊）时略优于 FIB-4 加 Fibroscan。在低于此 Pt 值时，FIB-4 加 Fibroscan 的净收益更大。两种连续组合的 SCR 减少量相似。
PC 中连续使用 NITs 是一种合理的 SCR 方法，可显著节省成本。
