Referral pathways for patients with NAFLD based on non-invasive fibrosis tests: Diagnostic accuracy and cost analysis
Referral pathways for patients with NAFLD based on non-invasive fibrosis tests: Diagnostic accuracy and cost analysis
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DOI：
10.1111/liv.14198
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发表时间：
2019-08-06
影响因子：
6.7
通讯作者：
Tsochatzis, Emmanuel A.
中科院分区：
文献类型：
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作者：
Crossan, Catriona;Majumdar, Avik;Tsochatzis, Emmanuel A.
背景/目的非侵入性纤维化试验（NIT）可用于对有晚期纤维化（AF）风险的非酒精性脂肪性肝病（NAFLD）患者进行分诊。我们模拟和调查了初级保健（PC）中双层NIT方法的诊断准确性和成本，以告知二级保健转诊（SCR）。方法对1,000例AF患病率为5%的NAFLD患者进行了假设队列研究。模拟了三种转诊策略：转诊所有患者（场景1），仅转诊在PC中进行NIT的AF患者（场景2），以及转诊活检后的AF患者（场景3）。如果患者的初始NIT不确定（FIB-4，然后是Fibroscan（R）、增强型肝纤维化（ELF）（R）或FibroTest（R）），则方案1和2中的患者将接受连续NIT。考虑的结果是真/假阳性和真/假阴性，以及相关的死亡率、并发症、治疗和随访，具体取决于护理环境。进行了决策曲线分析，该分析表示了不同情景在一系列阈值概率（Pt）上的净效益。结果5年来，与其他方案相比，顺序使用NIT提供了更低的SCR率和更大的成本节约，90%的患者在PC中管理，成本节约超过40%。在决策曲线分析中，FIB-4加ELF略上级FIB-4加Fibroscan，Pt >= 8%（1/12.5转诊）。低于此Pt，FIB-4加Fibroscan具有更大的净效益。两种序贯组合的SCR净减少相似。结论在PC中顺序使用NIT是合理化SCR的有效方法，并与显着的成本节约相关。
Background/aims Non-invasive fibrosis tests (NITs) can be used to triage non-alcoholic fatty liver disease (NAFLD) patients at risk of advanced fibrosis (AF). We modelled and investigated the diagnostic accuracy and costs of a two-tier NIT approach in primary care (PC) to inform secondary care referrals (SCRs). Methods A hypothetical cohort of 1,000 NAFLD patients with a 5% prevalence of AF was examined. Three referral strategies were modelled: refer all patients (Scenario 1), refer only patients with AF on NITs performed in PC (Scenario 2) and refer those with AF after biopsy (Scenario 3). Patients in Scenarios 1 and 2 would undergo sequential NITs if their initial NIT was indeterminate (FIB-4 followed by Fibroscan (R), enhanced liver fibrosis (ELF)(R) or FibroTest (R)). The outcomes considered were true/false positives and true/false negatives with associated mortality, complications, treatment and follow-up depending on the care setting. Decision curve analysis was performed, which expressed the net benefit of different scenarios over a range of threshold probabilities (Pt). Results Sequential use of NITs provided lower SCR rates and greater cost savings compared to other scenarios over 5 years, with 90% of patients managed in PC and cost savings of over 40%. On decision curve analysis, FIB-4 plus ELF was marginally superior to FIB-4 plus Fibroscan at Pt >= 8% (1/12.5 referrals). Below this Pt, FIB-4 plus Fibroscan had greater net benefit. The net reduction in SCRs was similar for both sequential combinations. Conclusions The sequential use of NITs in PC is an effective way to rationalize SCRs and is associated with significant cost savings.