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Health Economic Evaluations of Screening Programs - Applications and Method Improvements
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Screening to detect diseases early is attractive as it can improve the prognosis and decrease costs, but it is often a problematic concept and there are several pitfalls. Many healthy individuals have to be investigated to avoid a disease in a few, which results in a dilemma because to save a few, many are exposed to a procedure that could potentially harm them. Other examples of problems associated with screening are latent diseases and over-treating. The question of optimal design of a screening program is another source of uncertainty for decision-makers, as a screening program may potentially be implemented in very different ways. This highlights the need for structured analyses that weigh benefits against the harms and costs that occur as consequences of the screening.

The aim of this thesis is, therefore, to explore, develop and implement methods for health economic evaluations of screening programs. This is done to identify problems and suggest solutions to improve future evaluations and in extension policy making.

This aim was analysed using decision analytic cost-effectiveness analyses constructed as Markov models. These are well-suited for this task given the sequential management approach where all relevant data are unlikely to come from a single source of evidence. The input data were in this thesis obtained from the published literature and were complemented with data from Swedish registries and the included case studies. The case studies were two different types of screening programs; a program of screening for unknown atrial fibrillation and a program to detect colorectal cancer early. Further, the implementation of treatment with thrombectomy and novel oral anticoagulants were used to illustrate how factors outside the screening program itself have an impact on the evaluations.

As shown by the result of the performed analyses, the major contribution of this thesis was that it provided a simple and systematic approach for the economic evaluation of multiple screening designs to identify an optimal design.

In both the included case studies, the screening was considered costeffective in detecting the disease; unknown atrial fibrillation and colorectal cancer, respectively. Further, the optimal way to implement these screening programs is dependent on the threshold value for cost-effectiveness in the health care sector and the characteristics of the investigated cohort. This is because it is possible to gain increasingly more health benefits by changing the design of the screening program, but that the change in design also results in higher marginal costs. Additionally, changes in the screening setting were shown to be important as they affect the cost-effectiveness of the screening. This implies that flexible modelling with continuously updated models are necessary for an optimal resource allocation.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2017. , p. 84
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1578
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:liu:diva-141556DOI: 10.3384/diss.diva-141556ISBN: 9789176854914 (print)OAI: oai:DiVA.org:liu-141556DiVA, id: diva2:1145702
Public defence
2017-10-06, Belladonna, Campus US, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2017-09-29 Created: 2017-09-29 Last updated: 2017-09-29Bibliographically approved
List of papers
1. Cost-effectiveness of high-sensitivity faecal immunochemical test and colonoscopy screening for colorectal cancer
Open this publication in new window or tab >>Cost-effectiveness of high-sensitivity faecal immunochemical test and colonoscopy screening for colorectal cancer
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2017 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 104, no 8, p. 1078-1086Article in journal (Refereed) Published
Abstract [en]

Background: Colorectal cancer screening can decrease morbidity and mortality. However, there are widespread differences in the implementation of programmes and choice of strategy. The primary objective of this study was to estimate lifelong costs and health outcomes of two of the currently most preferred methods of screening for colorectal cancer: colonoscopy and sensitive faecal immunochemical test (FIT). Methods: A cost-effectiveness analysis of colorectal cancer screening in a Swedish population was performed using a decision analysis model, based on the design of the Screening of Swedish Colons (SCREESCO) study, and data from the published literature and registries. Lifelong cost and effects of colonoscopy once, colonoscopy every 10 years, FIT twice, FIT biennially and no screening were estimated using simulations. Results: For 1000 individuals invited to screening, it was estimated that screening once with colonoscopy yielded 49 more quality-adjusted life-years (QALYs) and a cost saving of (sic)64 800 compared with no screening. Similarly, screening twice with FIT gave 26 more QALYs and a cost saving of (sic)17 600. When the colonoscopic screening was repeated every tenth year, 7 additional QALYs were gained at a cost of (sic)189 400 compared with a single colonoscopy. The additional gain with biennial FIT screening was 25 QALYs at a cost of (sic)154 300 compared with two FITs. Conclusion: All screening strategies were cost-effective compared with no screening. Repeated and single screening strategies with colonoscopy were more cost-effective than FIT when lifelong effects and costs were considered. However, other factors such as patient acceptability of the test and availability of human resources also have to be taken into account.

Place, publisher, year, edition, pages
WILEY, 2017
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-139394 (URN)10.1002/bjs.10536 (DOI)000403158800015 ()28561259 (PubMedID)
Note

Funding Agencies|SCREESCO; Regionala Cancer-centrum i samverkan; Swedish Cancer Foundation; Karolinska Institute

Available from: 2017-08-24 Created: 2017-08-24 Last updated: 2018-04-16
2. Cost-effectiveness of mass screening for untreated atrial fibrillation using intermittent ECG recording
Open this publication in new window or tab >>Cost-effectiveness of mass screening for untreated atrial fibrillation using intermittent ECG recording
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2015 (English)In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 17, no 7, p. 1023-1029Article in journal (Refereed) Published
Abstract [en]

Aims The aim of this study was to estimate the cost-effectiveness of 2 weeks of intermittent screening for asymptomatic atrial fibrillation (AF) in 75/76-year-old individuals. Methods and results The cost-effectiveness analysis of screening in 75-year-old individuals was based on a lifelong decision analytic Markov model. In this model, 1000 hypothetical individuals, who matched the population of the STROKESTOP study, were simulated. The population was analysed for different parameters such as prevalence, AF status, treatment with oral anticoagulation, stroke risk, utility, and costs. In the base-case scenario, screening of 1000 individuals resulted in 263 fewer patient-years with undetected AF. This implies eight fewer strokes, 11 more life-years, and 12 more quality-adjusted life years (QALYs) per 1000 screened individuals. The screening implies an incremental cost of (sic)50 012, resulting in a cost of (sic)4313 per gained QALY and (sic)6583 per avoided stroke. Conclusions With the use of a decision analytic simulation model, it has been shown that screening for asymptomatic AF in 75/76-year-old individuals is cost-effective.

Place, publisher, year, edition, pages
Oxford University Press (OUP): Policy B - Oxford Open Option B - CC-BY, 2015
Keywords
Atrial fibrillation; Screening; Hand-held ECG; Quality-adjusted life year ( QALY); Cost-effectiveness
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-120879 (URN)10.1093/europace/euv083 (DOI)000359153000006 ()25868469 (PubMedID)
Note

Funding Agencies|Swedish Heart and Lung Foundation; Board of Benevolence of the Swedish Order of Freemasons; Tornspiran

Available from: 2015-08-28 Created: 2015-08-28 Last updated: 2017-12-04
3. Cost-effectiveness of endovascular thrombectomy in patients with acute ischemic stroke
Open this publication in new window or tab >>Cost-effectiveness of endovascular thrombectomy in patients with acute ischemic stroke
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2016 (English)In: Neurology, ISSN 0028-3878, E-ISSN 1526-632X, Vol. 86, no 11, p. 1053-1059Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To evaluate the cost-effectiveness of adding endovascular thrombectomy to standard care in patients with acute ischemic stroke.

METHODS: The cost-effectiveness analysis of endovascular thrombectomy in patients with acute ischemic stroke was based on a decision-analytic Markov model. Primary outcomes from ESCAPE, Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial (EXTEND-IA), Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours (REVASCAT), and Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) along with data from published studies and registries were used in this analysis. We used a health care payer perspective and a lifelong time horizon to estimate costs and effects.

RESULTS: The model showed that adding thrombectomy with stent retrievers to guideline-based care (including IV thrombolysis) resulted in a gain of 0.40 life-years and 0.99 quality-adjusted life-years along with a cost savings of approximately $221 per patient. The sensitivity analysis showed that the results were not sensitive to changes in uncertain parameters or assumptions.

CONCLUSIONS: Adding endovascular treatment to standard care resulted in substantial clinical benefits at low costs. The results were consistent throughout irrespective of whether data from ESCAPE, EXTEND-IA, MR CLEAN, REVASCAT, or SWIFT PRIME were used in this model.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2016
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-126429 (URN)10.1212/WNL.0000000000002439 (DOI)000371887200012 ()26873954 (PubMedID)
Note

Funding agencies: Dental and Pharmaceutical Benefits Agency

Available from: 2016-03-24 Created: 2016-03-24 Last updated: 2017-11-30
4. Designing an optimal screening program for unknown atrial fibrillation: a cost-effectiveness analysis.
Open this publication in new window or tab >>Designing an optimal screening program for unknown atrial fibrillation: a cost-effectiveness analysis.
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2017 (English)In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 19, no 10, p. 1650-1656Article in journal (Refereed) Published
Abstract [en]

Aims: The primary objective of this study was to use computer simulations to suggest an optimal age for initiation of screening for unknown atrial fibrillation and to evaluate if repeated screening will add value.

Methods and results: In the absence of relevant clinical studies, this analysis was based on a simulation model. More than two billion different designs of screening programs for unknown atrial fibrillation were simulated and analysed. Data from the published scientific literature and registries were used to construct the model and estimate lifelong effects and costs. Costs and effects generated by 2 147 483 648 different screening designs were calculated and compared. Program designs that implied worse clinical outcome and were less cost-effective compared to other programs were excluded from the analysis. Seven program designs were identified, and considered to be cost effective depending on what the health-care decision makers are ready to pay for gaining a quality-adjusted life-year (QALY). Screening at the age of 75 implied the lowest cost per gained QALY (€4 800/QALY).

Conclusion: In conclusion, examining the results of more than two billion simulated screening program designs for unknown atrial fibrillation, seven designs were deemed cost-effective depending on how much we are prepared to pay for gaining QALYs. Our results showed that repeated screening for atrial fibrillation implied additional health benefits to a reasonable cost compared to one-off screening.

Place, publisher, year, edition, pages
Oxford: Oxford University Press, 2017
Keywords
Atrial fibrillation, Cost-utility analysis, Optimization analysis, Screening
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-141557 (URN)10.1093/europace/eux002 (DOI)000412840300006 ()28340009 (PubMedID)
Note

Funding agencies: Dental and Pharmaceutical Benefits Agency

Available from: 2017-09-29 Created: 2017-09-29 Last updated: 2017-10-31

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