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Designing an optimal screening program for unknown atrial fibrillation: a cost-effectiveness analysis.
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
Karolinska Institutet, Department of Clinical Science, Cardiology Unit, Danderyd University Hospital, Stockholm, Sweden..
Karolinska Institutet, Department of Clinical Science, Cardiology Unit, Danderyd University Hospital, Stockholm, Sweden..
Karolinska Institutet, Department of Clinical Science, Cardiology Unit, Danderyd University Hospital, Stockholm, Sweden..
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2017 (English)In: Europace, ISSN 1099-5129, E-ISSN 1532-2092Article in journal (Refereed) Epub ahead of print
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.
Keyword [en]
Atrial fibrillation, Cost-utility analysis, Optimization analysis, Screening
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:liu:diva-141557DOI: 10.1093/europace/eux002PubMedID: 28340009OAI: oai:DiVA.org:liu-141557DiVA: diva2:1145660
Available from: 2017-09-29 Created: 2017-09-29 Last updated: 2017-10-09
In thesis
1. Health Economic Evaluations of Screening Programs - Applications and Method Improvements
Open this publication in new window or tab >>Health Economic Evaluations of Screening Programs - Applications and Method Improvements
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. 84 p.
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:nbn:se:liu:diva-141556 (URN)10.3384/diss.diva-141556 (DOI)9789176854914 (ISBN)
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

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