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Graziadio S, Gregg E, Allen AJ, Neveux P, Monz BU, Davenport C, Mealing S, Holmes H, Ferrante di Ruffano L. Is the Comparator in Your Diagnostic Cost-Effectiveness Model "Standard of Care"? Recommendations from Literature Reviews and Expert Interviews on How to Identify and Operationalize It. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:585-597. [PMID: 38401794 DOI: 10.1016/j.jval.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVES This research aimed to develop best-practice recommendations for identifying the "standard of care" (SoC) and integrate it when it is the comparator in diagnostic economic models (SoC comparator). METHODS A multi-methods approach comprising 2 pragmatic literature reviews and 9 expert interviews was used. Experts rated their agreement with draft recommendations based on the authors' analysis of the reviews. These were refined iteratively to produce final recommendations. RESULTS Fourteen best-practice recommendations are provided. Care pathway mapping (using quantitative, qualitative, or mixed-methods approaches) should be used for identifying the SoC comparator. Guidelines analysis can be integrated with expert opinion to identify pathway variability and discrepancies from clinical practice. For integrating the SoC comparator into the model, recommendations around structure, input sourcing, data aggregation and reporting, input uncertainty, and model variability are presented. For example, modelers should consider that the reference standard is not synonymous with the SoC, and the SoC may not be the only comparator. The comparator limitations should be discussed with clinical experts, but elicitation of its diagnostic accuracy is not recommended. Probabilistic sensitivity analysis is recommended when evaluating the overall input uncertainty, and deterministic sensitivity analysis is useful when there is high model uncertainty or SoC variability. Consensus could not be reached for some topics (eg, the role of real-world data, model averaging, and alternative model structures), but the reported discussions provide points for consideration. CONCLUSIONS To our knowledge, this is the first guidance to support modelers when identifying and operationalizing the SoC comparator in diagnostic cost-effectiveness models.
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Affiliation(s)
- Sara Graziadio
- York Health Economics Consortium, Enterprise House, University of York, Innovation Way, York, England, UK.
| | - Emily Gregg
- York Health Economics Consortium, Enterprise House, University of York, Innovation Way, York, England, UK
| | - A Joy Allen
- Health Economics, Roche Diagnostics UK and Ireland, Burgess Hill, England, UK
| | - Paul Neveux
- Global Access & Policy, Roche Diagnostics International AG, Rotkreuz, Switzerland
| | - Brigitta U Monz
- Global Access & Policy, Roche Diagnostics International AG, Rotkreuz, Switzerland
| | - Clare Davenport
- Institute of Applied Health Research, University of Birmingham, Birmingham, England, UK
| | - Stuart Mealing
- York Health Economics Consortium, Enterprise House, University of York, Innovation Way, York, England, UK
| | - Hayden Holmes
- York Health Economics Consortium, Enterprise House, University of York, Innovation Way, York, England, UK
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Ursini F, Gregg E, Canon-Garcia V, Rabijns H, Toennessen K, Bartlett K, Graziadio S. Care pathway analysis and evidence gaps in adult-onset Still's disease: interviews with experts from the UK, France, Italy, and Germany. Front Med (Lausanne) 2023; 10:1257413. [PMID: 37771977 PMCID: PMC10523327 DOI: 10.3389/fmed.2023.1257413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/28/2023] [Indexed: 09/30/2023] Open
Abstract
Introduction Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disease of unknown etiology. Published AOSD data are limited, and clinical guidelines were lacking until recently. Managing AOSD remains largely empirical with uncertainties and high variability about the optimal care pathway. Therefore, we used a qualitative approach to collect clinical judgments from the UK, Italy, France and Germany to inform the development of an agreed care pathway. Our work aimed to decrease the uncertainty associated with clinical practice, inform future research in AOSD, and help identify standardized definitions and outcomes in this population. Methods Semi-structured interviews and thematic analysis were conducted. Eleven clinicians were interviewed between May and July 2022: four were based in Italy, three in the UK, two in France, and two in Germany. Results In this work, we identified the structure of the typical care pathway for AOSD patients, which can be used to inform future economic models in AOSD. The general structure of the pathway was similar across countries. Non-steroidal anti-inflammatory drugs are prescribed during the diagnostic workup while an additive approach is commonly used in confirmed cases: corticosteroids, conventional synthetic disease-modifying antirheumatic drugs, then biologic disease-modifying antirheumatic drugs (bDMARDs) (dose increased before switching). For severe presentations, more aggressive approaches with higher doses and early use of bDMARDs are used. The main elements of variation among countries and clinicians were the criteria used for diagnosis; order of bDMARDs and preferential treatments for articular and systemic patients; and tests for patient monitoring. There is also a lack of standardized outcome measures making comparisons and evidence synthesis challenging. Conclusion We identified important evidence gaps for clinical practice, e.g., reliable tests or scores predictive of disease progression and treatment outcome, and recommendations for research, e.g., reporting of compliance rates and use of the Yamaguchi criteria for clinical study inclusion. Consensus is needed around the use of the Systemic score in clinical practice and the clinical utility of this score. A standardized definition of remission is also required in AOSD, and further research should look to identify and validate the specific laboratory markers to be considered when assessing remission.
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Affiliation(s)
- Francesco Ursini
- Medicine and Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Emily Gregg
- York Health Economics Consortium Ltd., York, United Kingdom
| | | | | | | | - Kaz Bartlett
- York Health Economics Consortium Ltd., York, United Kingdom
| | - Sara Graziadio
- York Health Economics Consortium Ltd., York, United Kingdom
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Charman SJ, Okwose NC, Taylor CJ, Bailey K, Fuat A, Ristic A, Mant J, Deaton C, Seferovic PM, Coats AJS, Hobbs FDR, MacGowan GA, Jakovljevic DG. Feasibility of the cardiac output response to stress test in suspected heart failure patients. Fam Pract 2022; 39:805-812. [PMID: 35083480 PMCID: PMC9508869 DOI: 10.1093/fampra/cmab184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Diagnostic tools available to support general practitioners diagnose heart failure (HF) are limited. OBJECTIVES (i) Determine the feasibility of the novel cardiac output response to stress (CORS) test in suspected HF patients, and (ii) Identify differences in the CORS results between (a) confirmed HF patients from non-HF patients, and (b) HF reduced (HFrEF) vs HF preserved (HFpEF) ejection fraction. METHODS Single centre, prospective, observational, feasibility study. Consecutive patients with suspected HF (N = 105; mean age: 72 ± 10 years) were recruited from specialized HF diagnostic clinics in secondary care. The consultant cardiologist confirmed or refuted a HF diagnosis. The patient completed the CORS but the researcher administering the test was blinded from the diagnosis. The CORS assessed cardiac function (stroke volume index, SVI) noninvasively using the bioreactance technology at rest-supine, challenge-standing, and stress-step exercise phases. RESULTS A total of 38 patients were newly diagnosed with HF (HFrEF, n = 21) with 79% being able to complete all phases of the CORS (91% of non-HF patients). A 17% lower SVI was found in HF compared with non-HF patients at rest-supine (43 ± 15 vs 51 ± 16 mL/beat/m2, P = 0.02) and stress-step exercise phase (49 ± 16 vs 58 ± 17 mL/beat/m2, P = 0.02). HFrEF patients demonstrated a lower SVI at rest (39 ± 15 vs 48 ± 13 mL/beat/m2, P = 0.02) and challenge-standing phase (34 ± 9 vs 42 ± 12 mL/beat/m2, P = 0.03) than HFpEF patients. CONCLUSION The CORS is feasible and patients with HF responded differently to non-HF, and HFrEF from HFpEF. These findings provide further evidence for the potential use of the CORS to improve HF diagnostic and referral accuracy in primary care.
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Affiliation(s)
- Sarah J Charman
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Nduka C Okwose
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.,Research Centre (CSELS), Institute for Health and Wellbeing, Faculty of Health and Life Sciences, Coventry University, and University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Clare J Taylor
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Kristian Bailey
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ahmet Fuat
- Darlington Memorial Hospital, County Durham and Darlington NHS Foundation Trust & School of Medicine, Pharmacy and Health, Durham University, Durham, United Kingdom
| | - Arsen Ristic
- Department of Cardiology, Faculty of Medicine, University of Belgrade, Clinical Centre of Serbia, Belgrade, Serbia
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Christi Deaton
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Petar M Seferovic
- Department of Cardiology, Faculty of Medicine, University of Belgrade, Clinical Centre of Serbia, Belgrade, Serbia
| | - Andrew J S Coats
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | - F D Richard Hobbs
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Guy A MacGowan
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.,Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Djordje G Jakovljevic
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.,Research Centre (CSELS), Institute for Health and Wellbeing, Faculty of Health and Life Sciences, Coventry University, and University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
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Jones WS, Suklan J, Winter A, Green K, Craven T, Bruce A, Mair J, Dhaliwal K, Walsh T, Simpson AJ, Graziadio S, Allen AJ. Diagnosing ventilator-associated pneumonia (VAP) in UK NHS ICUs: the perceived value and role of a novel optical technology. Diagn Progn Res 2022; 6:5. [PMID: 35144691 PMCID: PMC8830125 DOI: 10.1186/s41512-022-00117-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diagnosing ventilator-associated pneumonia (VAP) in an intensive care unit (ICU) is a complex process. Our aim was to collect, evaluate and represent the information relating to current clinical practice for the diagnosis of VAP in UK NHS ICUs, and to explore the potential value and role of a novel diagnostic for VAP, which uses optical molecular alveoscopy to visualise the alveolar space. METHODS Qualitative study performing semi-structured interviews with clinical experts. Interviews were recorded, transcribed, and thematically analysed. A flow diagram of the VAP patient pathway was elicited and validated with the expert interviewees. Fourteen clinicians were interviewed from a range of UK NHS hospitals: 12 ICU consultants, 1 professor of respiratory medicine and 1 professor of critical care. RESULTS Five themes were identified, relating to [1] current practice for the diagnosis of VAP, [2] current clinical need in VAP diagnostics, [3] the potential value and role of the technology, [4] the barriers to adoption and [5] the evidence requirements for the technology, to help facilitate a successful adoption. These themes indicated that diagnosis of VAP is extremely difficult, as is the decision to stop antibiotic treatment. The analysis revealed that there is a clinical need for a diagnostic that provides an accurate and timely diagnosis of the causative pathogen, without the long delays associated with return of culture results, and which is not dangerous to the patient. It was determined that the technology would satisfy important aspects of this clinical need for diagnosing VAP (and pneumonia, more generally), but would require further evidence on safety and efficacy in the patient population to facilitate adoption. CONCLUSIONS Care pathway analysis performed in this study was deemed accurate and representative of current practice for diagnosing VAP in a UK ICU as determined by relevant clinical experts, and explored the value and role of a novel diagnostic, which uses optical technology, and could streamline the diagnostic pathway for VAP and other pneumonias.
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Affiliation(s)
- W S Jones
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK.
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.
| | - J Suklan
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - A Winter
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - K Green
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - T Craven
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, EH16 4TJ, UK
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - A Bruce
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - J Mair
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - K Dhaliwal
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - T Walsh
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - A J Simpson
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - S Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - A J Allen
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
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