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Is stratification testing for treatment of chronic obstructive pulmonary disease exacerbations cost-effective in primary care? an early cost-utility analysis

  • Lucy Abel (a1), Helen A. Dakin (a2), Nia Roberts (a3), Helen F. Ashdown (a1), Chris C. Butler (a1), Gail Hayward (a1), Ann Van den Bruel (a1), Philip J. Turner (a1) and Yaling Yang (a1)...

Abstract

Objectives

Patients with chronic obstructive pulmonary disease (COPD) who experience acute exacerbations usually require treatment with oral steroids or antibiotics, depending on the etiology of the exacerbation. Current management is based on clinician's assessment and judgement, which lacks diagnostic accuracy and results in overtreatment. A test to guide these decisions in primary care is in development. We developed an early decision model to evaluate the cost-effectiveness of this treatment stratification test in the primary care setting in the United Kingdom.

Methods

A combined decision tree and Markov model was developed of COPD progression and the exacerbation care pathway. Sensitivity analysis was carried out to guide technology development and inform evidence generation requirements.

Results

The base case test strategy cost GBP 423 (USD 542) less and resulted in a health gain of 0.15 quality-adjusted life-years per patient compared with not testing. Testing reduced antibiotic prescriptions by 30 percent, potentially lowering the risk of antimicrobial resistance developing. In sensitivity analysis, the result depended on the clinical effects of treating patients according to the test result, as opposed to treating according to clinical judgement alone, for which there is limited evidence. The results were less sensitive to the accuracy of the test.

Conclusions

Testing may be cost-saving in primary care, but this requires robust evidence on whether test-guided treatment is effective. High quality evidence on the clinical utility of testing is required for early modeling of diagnostic tests generally.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

Author for correspondence: Yaling Yang, E-mail: yaling.yang@phc.ox.ac.uk

References

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1.Annemans, L, Genesté, B and Jolain, B (2000) Early modelling for assessing health and economic outcomes of drug therapy. Value Health 3, 427434.
2.NICE. Diagnostics Assessment Programme [Internet]. [cited June 19, 2017]. https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-diagnostics-guidance (accessed January 2, 2019).
3.Buisman, LR, Rutten-van Mölken, MPMH, Postmus, D, Luime, JJ, Uyl-de Groot, CA, Redekop, WK, et al. (2016) The early bird catches the worm: Early cost-effectiveness analysis of new medical tests. Int J Technol Assess Health Care 32, 4653.
4.Smith, AF, Sutton, A and Shinkins, B (2016) Early cost-effectiveness analysis of new medical tests: Response. Int J Technol Assess Health Care 32, 324325.
5.Turner, PJ, Van den Bruel, A, Jones, CHD, Plüddemann, A, Heneghan, C, Thompson, MJ, et al. (2016) Point-of-care testing in UK primary care: A survey to establish clinical needs. Fam Pract 33, 388394.
6.Jones, R, Gruffydd-Jones, K, Pinnock, H, Peffers, SJ, Lawrence, J, Scullion, J, et al. (2010) Summary of the consultation on a strategy for services for chronic obstructive pulmonary disease (COPD) in England. Prim Care Respir J 19, S1S17.
7.Burge, S and Wedzicha, JA (2003) COPD exacerbations: Definitions and classifications. Eur Respir J Suppl 41, 46s53s.
8.NICE (2010) Chronic obstructive obstructive pulmonary disease in over 16s: Diagnosis and management. NICE Guid, 131.
9.Papi, A, Bellettato, CM, Braccioni, F, Romagnoli, M, Casolari, P, Caramori, G, et al. (2006) Infections and airway inflammation in chronic obstructive pulmonary disease severe exacerbations. Am J Respir Crit Care Med 173, 11141121.
10.Bafadhel, M, McKenna, S, Terry, S, Mistry, V, Pancholi, M, Venge, P, et al. (2012) Blood eosinophils to direct corticosteroid treatment of exacerbations of chronic obstructive pulmonary disease: A randomized placebo-controlled trial. Am J Respir Crit Care Med 186, 4855.
11.Waljee, AK, Rogers, MAM, Lin, P, Singal, AG, Stein, JD, Marks, RM, et al. (2017) Short term use of oral corticosteroids and related harms among adults in the United States: Population based cohort study. BMJ, 357.
12.Vollenweider, DJ, Jarrett, H, Steurer-Stey, CA, Garcia-Aymerich, J and Puhan, MA (2012) Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 12, CD010257.
13.Karner, C and Cates, CJ (2011) The effect of adding inhaled corticosteroids to tiotropium and long-acting beta2-agonists for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. London: John Wiley & Sons, Ltd.
14.World Health Organisation (2000) Overcoming anticrobial resistance - WHO report on infectious diseases 2000. Geneva: WHO.
15.Oppong, R, Smith, RD, Little, P, Verheij, T, Butler, CC, Goossens, H, et al. (2016) Cost effectiveness of amoxicillin for lower respiratory tract infections in primary care: An economic evaluation accounting for the cost of antimicrobial resistance. Br J Gen Pract 66, e633e639.
16.Decision model code for an early economic evaluation of testing for treatment guidance in COPD exacerbations [Internet]. Figshare. (2017) DOI: 10.6084/m9.figshare.5074465.
17.Jordan, RE, Majothi, S, Heneghan, NR, Blissett, DB, Riley, RD, Sitch, AJ, et al. (2015) Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): An evidence synthesis and economic analysis. Health Technol Assess 19, 1516.
18.Rabe, KF, Hurd, S, Anzueto, A, Barnes, PJ, Buist, SA, Calverley, P, et al. (2007) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 176, 532555.
19.Antonelli-Incalzi, R, Imperiale, C, Bellia, V, Catalano, F, Scichilone, N, Pistelli, R, et al. (2003) Do GOLD stages of COPD severity really correspond to differences in health status? Eur Respir J 22, 444449.
20.Boggon, R, Hubbard, R, Smeeth, L, Gulliford, M, Cassell, J, Eaton, S, et al. (2013) Variability of antibiotic prescribing in patients with chronic obstructive pulmonary disease exacerbations: A cohort study. BMC Pulm Med 13, 32.
21.Bafadhel, M, Davies, L, Calverley, PMA, Aaron, SD, Brightling, CE and Pavord, ID (2014) Blood eosinophil guided prednisolone therapy for exacerbations of COPD: A further analysis. Eur Respir J 44, 789791.
22.Jones, P, Higenbottam, T (2007) Quantifying of severity of exacerbations in chronic obstructive pulmonary disease: Adaptations to the definition to allow quantification. Proc Am Thorac Soc 4, 597601.
23.Calverley, PMA, Anderson, JA, Celli, B, Ferguson, GT, Jenkins, C, Jones, PW, et al. (2007) Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med 356, 775789.
24.van Hout, B, Janssen, MF, Feng, Y-S, Kohlmann, T, Busschbach, J, Golicki, D, et al. (2012) Interim scoring for the EQ-5D-5L: Mapping the EQ-5D-5L to EQ-5D-3L value sets. Value Health 15, 708715.
25.Atsou, K, Chouaid, C and Hejblum, G (2011) Simulation-based estimates of effectiveness and cost-effectiveness of smoking cessation in patients with chronic obstructive pulmonary disease. PLoS One 6, e24870.
26.Walters, JAE, Tan, DJ, White, CJ, Gibson, PG, Wood-Baker, R, Walters, EH (2014) Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 9, CD001288.
27.Department of Health. NHS Reference Costs [Internet]. (2015) [cited May 20, 2016]. https://www.gov.uk/government/collections/nhs-reference-costs (accessed January 3, 2019).
28.Joint Formulary Committee (2016) British National Formulary (online) [Internet]. London: BMJ Group and Pharamceutical Press. [cited May 20, 2016]. http://www.medicinescomplete.com (accessed January 3, 2019).
29.Curtis, L, ed. (2014) Unit costs of health and social care 2014. Kent: Personal Social Services Research Unit.
30.HM Treasury (2013) The Green Book: Appraisal and evaluation in central government. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/685903/The_Green_Book.pdf (accessed January 3, 2019).
31.Smith, R, Coast, J (2013) The true cost of antimicrobial resistance. BMJ 346, f1493.
32.Vogelmeier, CF, Criner, GJ, Martinez, FJ, Anzueto, A, Barnes, PJ, Bourbeau, J, et al. (2017) Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease 2017 report: GOLD Executive Summary. Respirology 22, 575601.
33.Novielli, N, Cooper, NJ, Abrams, KR and Sutton, AJ (2010) How is evidence on test performance synthesized for economic decision models of diagnostic tests? A systematic appraisal of health technology assessments in the UK since 1997. Value Health 13, 952957.
34.Novielli, N, Cooper, NJ and Sutton, AJ (2013) Evaluating the cost-effectiveness of diagnostic tests in combination: Is it important to allow for performance dependency? Value Health 16, 536541.
35.Parkinson, DR, McCormack, RT, Keating, SM, Gutman, SI, Hamilton, SR, Mansfield, EA, et al. (2014) Evidence of clinical utility: An unmet need in molecular diagnostics for patients with cancer. Clinical Cancer Research 20, 14281444.

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