Discovery Unit, University of Exeter Medical School, University of Exeter, Exeter, England, UK.
Département d'opérations et systèmes de decision, Faculté des sciences de l'administration, Université Laval, Québec City, QC, Canada; Centre Hospitaliere Universitaire (CHU) de Québec - Université Laval, Québec City, QC, Canada.
Value Health. 2023 Jul;26(7):995-1002. doi: 10.1016/j.jval.2022.06.017. Epub 2022 Aug 8.
This study aimed to explore the impact of revising suspected-cancer referral guidelines on primary care contacts and costs.
Participants had incident cancer (colorectal, n = 2000; ovary, n = 763; and pancreas, n = 597) codes in the Clinical Practice Research Datalink or England cancer registry. Difference-in-differences analyses explored guideline impacts on contact days and nonzero costs between the first cancer feature and diagnosis. Participants were controls ("old National Institute for Health and Care Excellence [NICE]") or "new NICE" if their index feature was introduced during guideline revision. Model assumptions were inspected visually and by falsification tests. Sensitivity analyses reclassified participants who subsequently presented with features in the original guidelines as "old NICE." For colorectal cancer, sensitivity analysis (n = 3481) adjusted for multimorbidity burden.
Median contact days and costs were, respectively, 4 (interquartile range [IQR] 2-7) and £117.69 (IQR £53.23-£206.65) for colorectal, 5 (IQR 3-9) and £156.92 (IQR £78.46-£272.29) for ovary, and 7 (IQR 4-13) and £230.64 (IQR £120.78-£408.34) for pancreas. Revising ovary guidelines may have decreased contact days (incidence rate ratio [IRR] 0.74; 95% confidence interval 0.55-1.00; P = .05) with unchanged costs, but parallel trends assumptions were violated. Costs decreased by 13% (equivalent to -£28.05, -£50.43 to -£5.67) after colorectal guidance revision but only in sensitivity analyses adjusting for multimorbidity. Contact days and costs remained unchanged after pancreas guidance revision.
The main analyses of symptomatic patients suggested that prediagnosis primary care costs remained unchanged after guidance revision for pancreatic cancer. For colorectal cancer, contact days and costs decreased in analyses adjusting for multimorbidity. Revising ovarian cancer guidelines may have decreased primary care contact days but not costs, suggesting increased resource-use intensity; nevertheless, there is evidence of confounding.
本研究旨在探讨修订疑似癌症转诊指南对初级保健接触和成本的影响。
参与者具有临床实践研究数据链接或英格兰癌症登记处的癌症（结直肠，n=2000；卵巢，n=763；胰腺，n=597）特征。差异中的差异分析探讨了指南对首次癌症特征与诊断之间接触天数和非零成本的影响。参与者为对照组（“旧国家卫生与保健卓越研究所（NICE）”）或“新 NICE”，如果其索引特征在指南修订期间引入。通过视觉和伪造测试检查模型假设。敏感性分析将随后出现原始指南特征的参与者重新分类为“旧 NICE”。对于结直肠癌，敏感性分析（n=3481）调整了多因素发病负担。
中位数接触天数和费用分别为结直肠 4 天（四分位距[IQR] 2-7）和 117.69 英镑（IQR 53.23-206.65），卵巢 5 天（IQR 3-9）和 156.92 英镑（IQR 78.46-272.29），胰腺 7 天（IQR 4-13）和 230.64 英镑（IQR 120.78-408.34）。修订卵巢指南可能会降低接触天数（发病率比[IRR] 0.74；95%置信区间 0.55-1.00；P=0.05），但平行趋势假设被违反。结直肠癌指南修订后，成本降低了 13%（相当于-28.05 英镑，-50.43 英镑至-5.67 英镑），但仅在调整多因素发病负担的敏感性分析中。胰腺指南修订后，接触天数和费用保持不变。
对有症状患者的主要分析表明，在胰腺癌指南修订后，初级保健成本保持不变。对于结直肠癌，接触天数和成本在调整多因素发病负担的分析中有所下降。修订卵巢癌指南可能会降低初级保健接触天数，但不会降低成本，这表明资源利用强度增加；然而，存在混杂的证据。
