Background. Expansion of routine genetic testing for hereditary breast and ovarian cancer from conventional BRCA testing to a multigene test could improve diagnostic yield and increase the opportunity for cancer prevention in both identified carriers and their relatives. We use an economic decision model to assess whether the current knowledge on non-BRCA mutation prevalence, cancer risk, and patient preferences justifies switching to a multigene panel for testing of early-onset breast cancer patients. Methods. We evaluated routine testing by BRCA testing, a 7-gene panel, and a 14-gene panel using individual-level simulations of annual health state transitions over a lifetime perspective. Breast and ovarian cancer incidence is reduced and posttreatment survival is improved when high-risk mutations are detected and risk-reducing treatment offered. Most model inputs were synthesized from published literature. Intermediate health outcomes included breast and ovarian cancer incidence rates, along with organ-specific cancer mortality. Cost-effectiveness outcomes were health sector costs and quality-adjusted life years. Results. Intermediate health outcomes improved by testing with multigene panels. At a cost-effectiveness threshold of $77,000, a 7-gene panel test with five non-BRCA genes was the optimal strategy with an incremental cost-effectiveness ratio of $53,310 per quality-adjusted life year compared to BRCA-only testing. Limitations. Unable to stratify carriers to specific mutations within genes, we can only make predictions on the gene level, with combined risk estimates for known variants. As mutation prevalence is the absolute upper bound of returns to more expansive testing, the rarity of modelled mutations makes analysis outcomes sensitive to model implementation. Conclusions. A 7-gene panel to diagnose hereditary breast and ovarian cancer in early-onset breast cancer patients can be a cost-effective alternative to current BRCA-only testing in Norway.

on behalf of the GALAXY ConsortiumBaCKgRoUND aND aIMS: Alcohol-related liver disease is often undetected until irreversible late-stage decompensated disease manifests. Consequently, there is an unmet need for effective and economically reasonable pathways to screen for advanced alcohol-related fibrosis. appRoaCH aND ReSUltS: We used real-world data from a large biopsy-controlled study of excessive drinkers recruited from primary and secondary care, to evaluate the cost-effectiveness of four primary care initiated strategies:(1) routine liver function tests with follow-up ultrasonography for test-positives, (2) the enhanced liver fibrosis (ELF) test with hospital liver stiffness measurement (LSM) for positives, (3) a three-tier strategy using the Forns Index to control before strategy 2, and (4) direct referral of all to LSM. We used linked decision trees and Markov models to evaluate outcomes short term (cost-per-accurate diagnosis) and long term (quality-adjusted life-years [QALYs]). For lowprevalence populations, ELF with LSM follow-up was most cost-effective, both short term (accuracy 96%, $196 per patient) and long term (incremental cost-effectiveness ratio [ICER] $5,387-$8,430/QALY), depending on whether diagnostic testing had lasting or temporary effects on abstinence rates. Adding Forns Index decreased costs to $72 per patient and accuracy to 95%. The strategy resulted in fewer QALYs due to more false negatives but an ICER of $3,012, making this strategy suited for areas with restricted access to ELF and transient elastography or lower willingness-to-pay. For high-prevalence populations, direct referral to LSM was highly cost-effective (accuracy 93%, $297 per patient), with ICERs between $490 and $1,037/QALY. CoNClUSIoNS:Noninvasive screening for advanced alcoholrelated fibrosis is a cost-effective intervention when different referral pathways are used according to the prevalence of advanced fibrosis. Patients in the primary health care sector should be tested with the ELF test followed by LSM if the test was positive, whereas direct referral to LSM is highly cost-effective in high-prevalence cohorts. (Hepatology

BackgroundHand-osteoarthritis (HOA) is a prevalent rheumatic joint disease that significantly reduces quality of life. In Norway, HOA should mainly be managed in primary care, but patients often have insufficient access to recommended treatment options there and are instead frequently referred to rheumatologists. This leads to high healthcare costs and reduces the access to rheumatologists for patients with inflammatory rheumatic diseases, for whom early diagnosis, disease modifying medication and tight controls may induce remission and prevent irreversible joint damage and long-term disability. Delegating the healthcare management and treatment of HOA to allied health professions such as occupational therapists may therefore free scarce healthcare resources and improve overall health economics.ObjectivesIn this study we evaluated a new model of care in specialist healthcare, where HOA patients receive their first consultation by occupational therapists instead of rheumatologists. The objective was to test the non-inferiority of occupational therapist-led care (OTC) compared to rheumatologist-led care (RC) with regards to effectiveness defined as proportion of responders (based on OMERACT/OARSI criteria) and safety. In addition, we conducted a health economics evaluation comparing Quality-adjusted life years (QUALYs) and treatment costs between the treatment groups and conducted a cost-economics analysis.MethodsWe conducted a randomized controlled multicentre parallel group trial in which we recruited 400 patients with symptomatic HOA and no signs of possible inflammatory rheumatic disease at two Norwegian hospitals. Participants were randomized (1:1, computer-based) to either OTC (n=200) or RC (n=200). Various demographic and clinical parameters were registered at baseline. Disease activity (numeric rating scale, NRS, 0-10, 0=no disease activity), pain (NRS, 0-10, 0=no pain) and function (using the MAP-hand questionnaire, 18 items averaged to a 1-4 score, 1=no problems) were registered at baseline and 6 months post-intervention, and the delta was used to determine if patients were responders/non-responders based on OMERACT/OARSI criteria. Chi2-test and logistic regression were used to compare the proportion of responders/non-responder per treatment arm, and to analyse the relationship between response status (as dependent variable) and treatment arm (as independent variables). Results of the logistic regression are presented as odds ratio (OR) with 95% confidence interval (CI). Safety analysis was conducted by screening healthcare journals 12 months post-baseline for new diagnoses and adverse events related to musculoskeletal diseases. QUALYs were calculated using data from EQ-5D weighted with preference weights from the general population. To evaluate cost-effectiveness, we calculated and compared the incremental cost-effectiveness ratio (ICER).ResultsMean age was 63.6 years (SD=10.01), 80.8 % were female. No statistical difference between the treatment arms was found in any baseline variables. In the RC group, 48 patients (25.8%) met the primary outcome criteria for treatment response. In the OTC group, also 48 (25.4%) were classified as responders. The proportion of responders did not differ by treatment group (X2 (1, N = 337) = 0.0012, p =.97). Treatment group did not significantly predict response status (OR=0.99, CI=0.62-1.59, p = 0.97). No notable safety-related events were found in either group. No statistically significant differences were found regarding QUALYs and overall treatment costs, and cost-effectiveness was marginal.ConclusionWe found no statistically significant difference regarding proportion of treatment responders between the two treatment arms, suggesting non-inferiority of OTC compared to RC with regards to effectiveness and safety. While the cost-effectiveness analysis showed no clear benefit for either of the treatment options, delegating HOA treatment to OTs may free RT time and improve healthcare accessibility for urgent diagnoses, and thus prove a valuable opportunity to optimize future healthcare allocation.REFERENCES:NIL.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

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S73 for positives, 2) serial testing with the Enhanced Liver Fibrosis (ELF) test and liver stiffness measurement (LSM) for ELF positives, 3) serial testing with the Forns index followed by ELF for index positives and referral to LSM for ELF positives, or 4) liver biopsy. RESULTS: At a prevalence of advanced fibrosis of 6% among Danish excessive drinkers the correct-diagnoses-to-unnecessary-referrals ratio per 1000 tested was 0.24 for strategy 1, 10.1 for strategy 2, 65.8 for strategy 3, and 0.063 for strategy 4. CONCLUSIONS: With an objective of maximising the correct number of advanced fibrosis diagnoses, and minimising unnecessary referrals to the secondary care sector, triaging patients first with the non-commercial Forns index, followed by ELF and LSM in serial for positive patients was optimal.