Should patients with abnormal liver function tests in primary care be tested for chronic viral hepatitis: cost minimisation analysis based on a comprehensively tested cohort
Should patients with abnormal liver function tests in primary care be tested for chronic viral hepatitis: cost minimisation analysis based on a comprehensively tested cohort
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DOI：
10.1186/1471-2296-12-9
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发表时间：
2011-03-03
影响因子：
2.9
通讯作者：
Girling, Alan J.
中科院分区：
文献类型：
--
作者：
Arnold, David T.;Bentham, Louise M.;Girling, Alan J.
背景：肝功能测试(LFT)在初级保健中被大量订购，伯明翰和兰贝斯肝脏评估测试策略(BLLETS)研究是为了评估它们对没有预先存在或不言而喻的肝病的患者的有效性。所有患者都接受了慢性病毒性肝炎的检测，从而提供了一个机会来比较检测这种严重的可治疗疾病的各种策略。方法：本研究使用芭蕾舞队列的数据来比较LFT结果异常的患者的各种病毒性肝炎检测策略。其目的是提供一种识别慢性病毒性肝炎患者的策略。我们使用成本最小化分析来定义基本病例，然后计算每个检测到的病例的增量成本，以提供指导慢性病毒性肝炎检测的策略。结果：在1236例LFT异常的研究患者中，13例患有慢性病毒性肝炎(9例乙肝和4例丙型肝炎)。现行指导方针所倡导的策略(重复LFT，以期在其仍然异常的情况下检测特定疾病)比不重复LFT而对所有患者进行病毒性肝炎检测的简单政策效率较低(每个检测病例的成本更高)。如果所有患者出生在病毒性肝炎流行的国家，则更有选择性地对所有患者进行病毒性肝炎病毒检测，这提供了高效率，而几乎不会造成敏感性损失。丙氨酸氨基转移酶(ALT)高水平(大于正常值上限的两倍以上)具有较高的预测价值，但缺乏敏感性，漏诊了一半的病毒感染病例。结论：基于这一分析和被广泛接受的临床原则，提出了一种“快速、经济”的启发式方法，用于指导全科医生诊断无症状LFTs异常患者的病毒性肝炎。它建议对所有有明确临床感染迹象的患者进行检测(例如，静脉注射药物的证据)，然后检测所有来自病毒性肝炎流行国家的患者，最后检测那些ALT水平显著升高的患者(超过正常上限的两倍)。没有被这一有效算法发现的患者患慢性病毒性肝炎的风险低于普通人群。
Background: Liver function tests (LFTs) are ordered in large numbers in primary care, and the Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS) study was set up to assess their usefulness in patients with no pre-existing or self-evident liver disease. All patients were tested for chronic viral hepatitis thereby providing an opportunity to compare various strategies for detection of this serious treatable disease.Methods: This study uses data from the BALLETS cohort to compare various testing strategies for viral hepatitis in patients who had received an abnormal LFT result. The aim was to inform a strategy for identification of patients with chronic viral hepatitis. We used a cost-minimisation analysis to define a base case and then calculated the incremental cost per case detected to inform a strategy that could guide testing for chronic viral hepatitis.Results: Of the 1,236 study patients with an abnormal LFT, 13 had chronic viral hepatitis (nine hepatitis B and four hepatitis C). The strategy advocated by the current guidelines (repeating the LFT with a view to testing for specific disease if it remained abnormal) was less efficient (more expensive per case detected) than a simple policy of testing all patients for viral hepatitis without repeating LFTs. A more selective strategy of viral testing all patients for viral hepatitis if they were born in countries where viral hepatitis was prevalent provided high efficiency with little loss of sensitivity. A notably high alanine aminotransferase (ALT) level (greater than twice the upper limit of normal) on the initial ALT test had high predictive value, but was insensitive, missing half the cases of viral infection.Conclusions: Based on this analysis and on widely accepted clinical principles, a "fast and frugal" heuristic was produced to guide general practitioners with respect to diagnosing cases of viral hepatitis in asymptomatic patients with abnormal LFTs. It recommends testing all patients where a clear clinical indication of infection is present (e. g. evidence of intravenous drug use), followed by testing all patients who originated from countries where viral hepatitis is prevalent, and finally testing those who have a notably raised ALT level (more than twice the upper limit of normal). Patients not picked up by this efficient algorithm had a risk of chronic viral hepatitis that is lower than the general population.