Economic evaluation of a community-based diagnostic pathway to stratify adults for non-alcoholic fatty liver disease: a Markov model informed by a feasibility study

Tanajewski, Lukasz; Harris, Rebecca; Harman, D. J.; Aithal, Guruprasad P.; Card, Timothy R.; Gkountouras, Georgios; Berdunov, Vladislav; Guha, Indra Neil; Elliott, Rachel A.

doi:10.1136/bmjopen-2016-015659

Cited by 53 publications

(87 citation statements)

References 50 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…A further two articles were identified through supplementary searches of grey literature. As such, a total of 19 articles [11,[16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] (capturing 16 different models) were included in the review; summary details of identified studies are shown in Table 1.…”

Section: Literature Search Resultsmentioning

confidence: 99%

Systematic Literature Review and Critical Appraisal of Health Economic Models Used in Cost-Effectiveness Analyses in Non-Alcoholic Steatohepatitis: Potential for Improvements

Johansen

Howard²,

Bishop³

et al. 2020

PharmacoEconomics

View full text Add to dashboard Cite

Background Non-alcoholic steatohepatitis (NASH) is a severe, typically progressive form of non-alcoholic fatty liver disease (NAFLD). The global prevalence of NASH is increasing, driven partly by the global increase in obesity and type 2 diabetes mellitus (T2DM), such that NASH is now a leading cause of cirrhosis. There is currently an unmet clinical need for efficacious and cost-effective treatments for NASH; no pharmacologic agents have an approved indication for NASH. Objective Our objective was to summarise and critically appraise published health economic models of NASH, to evaluate their quality and suitability for use in the assessment of novel treatments for NASH, and to identify knowledge gaps, challenges and opportunities for future modelling. Methods A systematic literature review was performed using the MEDLINE, Embase, Cochrane Library and EconLit databases to identify published health economic analyses in patients with NAFLD or NASH. Supplementary hand searches of grey literature were also performed. Articles published up to November 2019 were included in the review. Quality assessment of identified studies was also performed. Results A total of 19 articles comprising 16 unique models including either NAFLD as a whole or NASH alone were included in the review. Structurally, most models had a state-transition component; in terms of health states, two different approaches to early disease states were used, modelling either progression through fibrosis stages or NAFLD/NASH-specific health states. Conditions that frequently co-exist with NASH, such as obesity, T2DM and cardiovascular disease were not captured in models identified here. Late-stage complications such as cirrhosis, decompensated cirrhosis and hepatocellular carcinoma were consistently included, but input data (e.g. costs, utilities and transition probabilities) for late-stage complications were frequently sourced from other liver disease areas. The quality of included studies was heterogenous, and only a small proportion of studies reported internal and external validation processes. Conclusion The health economic models identified in this review are associated with limitations primarily driven by a lack of NASH-specific data. Identified models also largely overlooked the intricate association between NASH and other conditions, including obesity and T2DM, and did not capture the increased risk of cardiovascular events associated with NASH. High-quality, transparent, validated health economic models of NASH will be required to evaluate the cost effectiveness of treatments currently in development, particularly compounds that may target other non-hepatic outcomes.

show abstract

Section: Literature Search Resultsmentioning

confidence: 99%

Systematic Literature Review and Critical Appraisal of Health Economic Models Used in Cost-Effectiveness Analyses in Non-Alcoholic Steatohepatitis: Potential for Improvements

Johansen

Howard²,

Bishop³

et al. 2020

PharmacoEconomics

View full text Add to dashboard Cite

show abstract

“…The Nottingham liver disease stratification pathway starts by targeting risk factors and uses non-invasive markers of liver fibrosis to identify more disease while remaining cost-effective to the National Health Service (NHS). 10 The importance of this is underlined by the fact that an additional 55 patients were found to have significant liver disease (TE ≥8 kPa) and would not have been diagnosed using established national guidelines.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, a formal economic evaluation showed this approach is cost-effective. 10 In 2016, through discussion with four clinical commissioning groups (CCGs) in Nottingham, we negotiated an agreed pathway for liver disease stratification of patients at risk of liver disease. This included patients with a history of harmful alcohol use, risk factors for NAFLD or an AST:ALT ratio >0.8 in the context of raised liver enzymes.…”

Section: Introductionmentioning

confidence: 99%

Development and implementation of a commissioned pathway for the identification and stratification of liver disease in the community

Chalmers

Wilkes

Harris

et al. 2019

Frontline Gastroenterol

Self Cite

View full text Add to dashboard Cite

ObjectiveTo describe the development of the Nottingham liver disease stratification pathway, present a 12-month evaluation of uptake and stratification results, and compare the pathway with current British Society of Gastroenterology (BSG) guidelines.DesignA referral pathway between primary and secondary care for the detection and risk stratification of liver disease.SettingFour Nottinghamshire clinical commissioning groups (700 000 population).PatientsPatients are referred to the pathway with (1) raised aspartate aminotransferase to alanine aminotransferase (AST:ALT) ratio, (2) harmful alcohol use or (3) risk or presence of non-alcoholic fatty liver disease (NAFLD).InterventionsWe report on clinic attendance within secondary care for transient elastography (TE) and brief lifestyle intervention. The TE result is reported back to the general practitioner with advice on interpretation and referral guidance.Main outcome measuresPathway uptake, patient characteristics, liver disease stratification results and stakeholder feedback.ResultsOver the first 12 months 968 patients attended a TE clinic appointment, with raised AST:ALT ratio being the most common single reason for referral (36.9%). Of the total, 222 (22.9%) patients had an elevated liver stiffness (≥8 kPa), in whom 57 (25.7%) had a liver stiffness which was indicative of advanced chronic liver disease. If a traditional approach based on raised liver enzymes (BSG guidance) had been followed, 38.7% of those with significant liver disease (≥8 kPa) would have gone undetected among those referred for either NAFLD or raised AST:ALT ratio.ConclusionsTargeting patients with risk factors for chronic liver disease and stratifying them using TE can detect significant chronic liver disease above and beyond the approach based on liver enzyme elevation.

show abstract

“…Patients are counselled with a brief intervention at the time of their scan before results and recommendations are returned to the referring GP. The pathway has been demonstrated to be cost effective (incremental cost effectiveness ratio [ICER] per quality adjusted life year [QALY] £2,138 for NAFLD and £6,537 for ALD) and has seen over 2000 patients in 18 months since full implementation in September 2016 (67,68). https://www.scarredliverproject.org.uk/ Box 3: Case Study -Tayside, intelligent LiverFunctionTesting (iLFT) Scottish Government supported research funded development of an automated investigation algorithm which maximises diagnosis and management.…”

Section: Box 2: Case Study -Scarred Liver Project Nottinghammentioning

confidence: 99%

Gathering momentum for the way ahead: fifth report of the Lancet Standing Commission on Liver Disease in the UK

et al. 2018

View full text Add to dashboard Cite

Much has been achieved over the past five years in describing the escalating burden of liver disease from lifestyle causes and the impact on hospital and primary care. The section on alcohol in this report reiterates the need for fiscal regulation by Government if overall consumption in the country is to be reduced to improve health, voluntary agreements with the drinks industry having repeatedly been shown to fail. The influence of the industry in its lobbying activities is highlighted in a separate account and myths around the 'nanny state' are also exposed, with the Minimum Unit Pricing (MUP) policy having little influence on average drinkers, affecting mainly heavy drinkers of low cost alcohol products. Results from Scotland following introduction of MUP and with Wales to follow, are likely to seriously expose the weakness of England's position. Further data on the prevalence of obesity makes the need for a policy on adults even more apparent. The number of people with Type 2 diabetes and its complications continue to rise, as do cases of end-stage liver disease and primary liver cancers from Non-Alcoholic Fatty Fiver Disease (NAFLD). Also covered are the increased risks of co-existing obesity and alcohol as causes of the ten most common cancers, including breast and colon. An indepth analysis of both NHS and total societal costs is summarised, showing the extraordinarily large sums that could be saved or redeployed elsewhere in the NHS. On the plus side are the excellent results being obtained with the new antiviral drugs for hepatitis C (HCV) infection, making elimination of chronic infection a real possibility ahead of the World Health Organisation (WHO) target of 2030. Efforts to improve standards of hospital care for liver disease are described and new commissioning arrangements for primary and community care represent some progress in effective screening of high-risk subjects and the early detection of liver disease.

show abstract

Economic evaluation of a community-based diagnostic pathway to stratify adults for non-alcoholic fatty liver disease: a Markov model informed by a feasibility study

Cited by 53 publications

References 50 publications

Systematic Literature Review and Critical Appraisal of Health Economic Models Used in Cost-Effectiveness Analyses in Non-Alcoholic Steatohepatitis: Potential for Improvements

Systematic Literature Review and Critical Appraisal of Health Economic Models Used in Cost-Effectiveness Analyses in Non-Alcoholic Steatohepatitis: Potential for Improvements

Development and implementation of a commissioned pathway for the identification and stratification of liver disease in the community

Gathering momentum for the way ahead: fifth report of the Lancet Standing Commission on Liver Disease in the UK

Contact Info

Product

Resources

About