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Keeney E, Elwenspoek MMC, Jackson J, Roadevin C, Jones HE, O'Donnell R, Sheppard AL, Dawson S, Lane D, Stubbs J, Everitt H, Watson JC, Hay AD, Gillett P, Robins G, Mallett S, Whiting PF, Thom H. Identifying the Optimum Strategy for Identifying Adults and Children With Celiac Disease: A Cost-Effectiveness and Value of Information Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:301-312. [PMID: 38154593 DOI: 10.1016/j.jval.2023.12.010] [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: 04/04/2023] [Revised: 11/08/2023] [Accepted: 12/11/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVES Celiac disease (CD) is thought to affect around 1% of people in the United Kingdom, but only approximately 30% are diagnosed. The aim of this work was to assess the cost-effectiveness of strategies for identifying adults and children with CD in terms of who to test and which tests to use. METHODS A decision tree and Markov model were used to describe testing strategies and model long-term consequences of CD. The analysis compared a selection of pre-test probabilities of CD above which patients should be screened, as well as the use of different serological tests, with or without genetic testing. Value of information analysis was used to prioritize parameters for future research. RESULTS Using serological testing alone in adults, immunoglobulin A (IgA) tissue transglutaminase (tTG) at a 1% pre-test probability (equivalent to population screening) was most cost-effective. If combining serological testing with genetic testing, human leukocyte antigen combined with IgA tTG at a 5% pre-test probability was most cost-effective. In children, the most cost-effective strategy was a 10% pre-test probability with human leukocyte antigen plus IgA tTG. Value of information analysis highlighted the probability of late diagnosis of CD and the accuracy of serological tests as important parameters. The analysis also suggested prioritizing research in adult women over adult men or children. CONCLUSIONS For adults, these cost-effectiveness results suggest UK National Screening Committee Criteria for population-based screening for CD should be explored. Substantial uncertainty in the results indicate a high value in conducting further research.
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Affiliation(s)
- Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK.
| | - Martha M C Elwenspoek
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, England, UK
| | - Joni Jackson
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, England, UK
| | - Cristina Roadevin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Rachel O'Donnell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, England, UK
| | - Athena L Sheppard
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, England, UK; Swansea University Medical School, Swansea University, Swansea, England, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | | | | | - Hazel Everitt
- Primary Care Research Centre, Population Sciences and Medical Education, University of Southampton, Southampton, England, UK
| | - Jessica C Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Alastair D Hay
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Peter Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh EH9 1LF Scotland, England, UK
| | - Gerry Robins
- Department of Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, England, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London, London, England, UK
| | - Penny F Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Howard Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
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Kunst N, Siu A, Drummond M, Grimm SE, Grutters J, Husereau D, Koffijberg H, Rothery C, Wilson ECF, Heath A. Consolidated Health Economic Evaluation Reporting Standards - Value of Information (CHEERS-VOI): Explanation and Elaboration. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1461-1473. [PMID: 37414276 DOI: 10.1016/j.jval.2023.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 05/27/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVES Although the ISPOR Value of Information (VOI) Task Force's reports outline VOI concepts and provide good-practice recommendations, there is no guidance for reporting VOI analyses. VOI analyses are usually performed alongside economic evaluations for which the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 Statement provides reporting guidelines. Thus, we developed the CHEERS-VOI checklist to provide reporting guidance and checklist to support the transparent, reproducible, and high-quality reporting of VOI analyses. METHODS A comprehensive literature review generated a list of 26 candidate reporting items. These candidate items underwent a Delphi procedure with Delphi participants through 3 survey rounds. Participants rated each item on a 9-point Likert scale to indicate its relevance when reporting the minimal, essential information about VOI methods and provided comments. The Delphi results were reviewed at 2-day consensus meetings and the checklist was finalized using anonymous voting. RESULTS We had 30, 25, and 24 Delphi respondents in rounds 1, 2, and 3, respectively. After incorporating revisions recommended by the Delphi participants, all 26 candidate items proceeded to the 2-day consensus meetings. The final CHEERS-VOI checklist includes all CHEERS items, but 7 items require elaboration when reporting VOI. Further, 6 new items were added to report information relevant only to VOI (eg, VOI methods applied). CONCLUSIONS The CHEERS-VOI checklist should be used when a VOI analysis is performed alongside economic evaluations. The CHEERS-VOI checklist will help decision makers, analysts and peer reviewers in the assessment and interpretation of VOI analyses and thereby increase transparency and rigor in decision making.
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Affiliation(s)
- Natalia Kunst
- Centre for Health Economics, University of York, York, England, UK; Yale University School of Public Health, New Haven, CT, USA.
| | - Annisa Siu
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Drummond
- Centre for Health Economics, University of York, York, England, UK
| | - Sabine E Grimm
- Department of Epidemiology and Medical Technology Assessment (KEMTA), Maastricht Health Economics and Technology Assessment (Maastricht HETA) Center, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Janneke Grutters
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Don Husereau
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada and Institute of Health Economics, Edmonton, Alberta, Canada
| | - Hendrik Koffijberg
- Department of Health Technology & Services Research, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Claire Rothery
- Centre for Health Economics, University of York, York, England, UK
| | - Edward C F Wilson
- Peninsula Technology Assessment Group, University of Exeter, Exeter, England, UK
| | - Anna Heath
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Department of Statistical Science, University College London, London, England, UK
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Elwenspoek MM, Thom H, Sheppard AL, Keeney E, O'Donnell R, Jackson J, Roadevin C, Dawson S, Lane D, Stubbs J, Everitt H, Watson JC, Hay AD, Gillett P, Robins G, Jones HE, Mallett S, Whiting PF. Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling. Health Technol Assess 2022; 26:1-310. [PMID: 36321689 PMCID: PMC9638887 DOI: 10.3310/zuce8371] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Coeliac disease is an autoimmune disorder triggered by ingesting gluten. It affects approximately 1% of the UK population, but only one in three people is thought to have a diagnosis. Untreated coeliac disease may lead to malnutrition, anaemia, osteoporosis and lymphoma. OBJECTIVES The objectives were to define at-risk groups and determine the cost-effectiveness of active case-finding strategies in primary care. DESIGN (1) Systematic review of the accuracy of potential diagnostic indicators for coeliac disease. (2) Routine data analysis to develop prediction models for identification of people who may benefit from testing for coeliac disease. (3) Systematic review of the accuracy of diagnostic tests for coeliac disease. (4) Systematic review of the accuracy of genetic tests for coeliac disease (literature search conducted in April 2021). (5) Online survey to identify diagnostic thresholds for testing, starting treatment and referral for biopsy. (6) Economic modelling to identify the cost-effectiveness of different active case-finding strategies, informed by the findings from previous objectives. DATA SOURCES For the first systematic review, the following databases were searched from 1997 to April 2021: MEDLINE® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), Cochrane Library, Web of Science™ (Clarivate™, Philadelphia, PA, USA), the World Health Organization International Clinical Trials Registry Platform ( WHO ICTRP ) and the National Institutes of Health Clinical Trials database. For the second systematic review, the following databases were searched from January 1990 to August 2020: MEDLINE, Embase, Cochrane Library, Web of Science, Kleijnen Systematic Reviews ( KSR ) Evidence, WHO ICTRP and the National Institutes of Health Clinical Trials database. For prediction model development, Clinical Practice Research Datalink GOLD, Clinical Practice Research Datalink Aurum and a subcohort of the Avon Longitudinal Study of Parents and Children were used; for estimates for the economic models, Clinical Practice Research Datalink Aurum was used. REVIEW METHODS For review 1, cohort and case-control studies reporting on a diagnostic indicator in a population with and a population without coeliac disease were eligible. For review 2, diagnostic cohort studies including patients presenting with coeliac disease symptoms who were tested with serological tests for coeliac disease and underwent a duodenal biopsy as reference standard were eligible. In both reviews, risk of bias was assessed using the quality assessment of diagnostic accuracy studies 2 tool. Bivariate random-effects meta-analyses were fitted, in which binomial likelihoods for the numbers of true positives and true negatives were assumed. RESULTS People with dermatitis herpetiformis, a family history of coeliac disease, migraine, anaemia, type 1 diabetes, osteoporosis or chronic liver disease are 1.5-2 times more likely than the general population to have coeliac disease; individual gastrointestinal symptoms were not useful for identifying coeliac disease. For children, women and men, prediction models included 24, 24 and 21 indicators of coeliac disease, respectively. The models showed good discrimination between patients with and patients without coeliac disease, but performed less well when externally validated. Serological tests were found to have good diagnostic accuracy for coeliac disease. Immunoglobulin A tissue transglutaminase had the highest sensitivity and endomysial antibody the highest specificity. There was little improvement when tests were used in combination. Survey respondents (n = 472) wanted to be 66% certain of the diagnosis from a blood test before starting a gluten-free diet if symptomatic, and 90% certain if asymptomatic. Cost-effectiveness analyses found that, among adults, and using serological testing alone, immunoglobulin A tissue transglutaminase was most cost-effective at a 1% pre-test probability (equivalent to population screening). Strategies using immunoglobulin A endomysial antibody plus human leucocyte antigen or human leucocyte antigen plus immunoglobulin A tissue transglutaminase with any pre-test probability had similar cost-effectiveness results, which were also similar to the cost-effectiveness results of immunoglobulin A tissue transglutaminase at a 1% pre-test probability. The most practical alternative for implementation within the NHS is likely to be a combination of human leucocyte antigen and immunoglobulin A tissue transglutaminase testing among those with a pre-test probability above 1.5%. Among children, the most cost-effective strategy was a 10% pre-test probability with human leucocyte antigen plus immunoglobulin A tissue transglutaminase, but there was uncertainty around the most cost-effective pre-test probability. There was substantial uncertainty in economic model results, which means that there would be great value in conducting further research. LIMITATIONS The interpretation of meta-analyses was limited by the substantial heterogeneity between the included studies, and most included studies were judged to be at high risk of bias. The main limitations of the prediction models were that we were restricted to diagnostic indicators that were recorded by general practitioners and that, because coeliac disease is underdiagnosed, it is also under-reported in health-care data. The cost-effectiveness model is a simplification of coeliac disease and modelled an average cohort rather than individuals. Evidence was weak on the probability of routine coeliac disease diagnosis, the accuracy of serological and genetic tests and the utility of a gluten-free diet. CONCLUSIONS Population screening with immunoglobulin A tissue transglutaminase (1% pre-test probability) and of immunoglobulin A endomysial antibody followed by human leucocyte antigen testing or human leucocyte antigen testing followed by immunoglobulin A tissue transglutaminase with any pre-test probability appear to have similar cost-effectiveness results. As decisions to implement population screening cannot be made based on our economic analysis alone, and given the practical challenges of identifying patients with higher pre-test probabilities, we recommend that human leucocyte antigen combined with immunoglobulin A tissue transglutaminase testing should be considered for adults with at least a 1.5% pre-test probability of coeliac disease, equivalent to having at least one predictor. A more targeted strategy of 10% pre-test probability is recommended for children (e.g. children with anaemia). FUTURE WORK Future work should consider whether or not population-based screening for coeliac disease could meet the UK National Screening Committee criteria and whether or not it necessitates a long-term randomised controlled trial of screening strategies. Large prospective cohort studies in which all participants receive accurate tests for coeliac disease are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42019115506 and CRD42020170766. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 44. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martha Mc Elwenspoek
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Howard Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athena L Sheppard
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachel O'Donnell
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joni Jackson
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cristina Roadevin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Hazel Everitt
- Primary Care Research Centre, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Jessica C Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, UK
| | - Gerry Robins
- Department of Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London, London, UK
| | - Penny F Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Jackson CH, Baio G, Heath A, Strong M, Welton NJ, Wilson EC. Value of Information Analysis in Models to Inform Health Policy. ANNUAL REVIEW OF STATISTICS AND ITS APPLICATION 2022; 9:95-118. [PMID: 35415193 PMCID: PMC7612603 DOI: 10.1146/annurev-statistics-040120-010730] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Value of information (VoI) is a decision-theoretic approach to estimating the expected benefits from collecting further information of different kinds, in scientific problems based on combining one or more sources of data. VoI methods can assess the sensitivity of models to different sources of uncertainty and help to set priorities for further data collection. They have been widely applied in healthcare policy making, but the ideas are general to a range of evidence synthesis and decision problems. This article gives a broad overview of VoI methods, explaining the principles behind them, the range of problems that can be tackled with them, and how they can be implemented, and discusses the ongoing challenges in the area.
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Affiliation(s)
| | - Gianluca Baio
- Department of Statistical Science, University College London, London WC1E 6BT, United Kingdom
| | - Anna Heath
- The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada
| | - Mark Strong
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, United Kingdom
| | - Nicky J. Welton
- Bristol Medical School (PHS), University of Bristol, Bristol BS8 1QU, United Kingdom
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