Cost-Effectiveness Analysis: Risk Stratification of Nonalcoholic Fatty Liver Disease (NAFLD) by the Primary Care Physician Using the NAFLD Fibrosis Score.
Cost-Effectiveness Analysis: Risk Stratification of Nonalcoholic Fatty Liver Disease (NAFLD) by the Primary Care Physician Using the NAFLD Fibrosis Score.
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DOI：
10.1371/journal.pone.0147237
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发表时间：
2016
期刊：
影响因子：
3.7
通讯作者：
Sengupta N
中科院分区：
文献类型：
--
作者：
Tapper EB;Hunink MG;Afdhal NH;Lai M;Sengupta N
非酒精性脂肪性肝病(NAFLD)的并发症依赖于晚期纤维化的存在。鉴于NAFLD在美国的高患病率，NAFLD的最佳评估可能包括由初级保健医生(PCP)对由胃肠病专家管理的晚期疾病进行分诊。我们使用决策分析微模拟状态转换模型，比较了在PCP或转诊诊所进行的10,000名模拟美国NAFLD患者的纤维化风险评估策略的成本效益。这些策略包括使用振动控制的瞬时弹性成像(VCTE)、NAFLD纤维化评分(NFS)、与NFS和VCTE的联合测试以及肝活检(通常仅由专家护理)。从164例NAFLD患者的前瞻性队列中获得了非酒精性脂肪肝和VCTE的表现。结果包括每质量调整生命年的成本(QALY)和正确的纤维化分类。PCP仅使用NFS进行风险分层的成本为每QALY 5,985美元，而通常的护理成本为每QALY 7,229美元。在微观模拟中，在100,000美元的支付意愿阈值下，在94.2%的样本中，在PCP诊所中单独使用NFS是最具成本效益的策略，其次是在PCP诊所中联合使用NFS/VCTE(5.6%)，在0.2%的样本中使用常规护理。基于NFS的策略产生最佳的活检正确分类比率(3.5)，而NFS/VCTE和常规护理策略产生更多的晚期纤维化的正确分类，每种分类的成本是3次和37次额外的活检。NAFLD初级保健诊所患者的风险分层是一种成本效益高的策略，应在临床实践中正式探索。
The complications of Nonalcoholic Fatty Liver Disease (NAFLD) are dependent on the presence of advanced fibrosis. Given the high prevalence of NAFLD in the US, the optimal evaluation of NAFLD likely involves triage by a primary care physician (PCP) with advanced disease managed by gastroenterologists. We compared the cost-effectiveness of fibrosis risk-assessment strategies in a cohort of 10,000 simulated American patients with NAFLD performed in either PCP or referral clinics using a decision analytical microsimulation state-transition model. The strategies included use of vibration-controlled transient elastography (VCTE), the NAFLD fibrosis score (NFS), combination testing with NFS and VCTE, and liver biopsy (usual care by a specialist only). NFS and VCTE performance was obtained from a prospective cohort of 164 patients with NAFLD. Outcomes included cost per quality adjusted life year (QALY) and correct classification of fibrosis. Risk-stratification by the PCP using the NFS alone costs $5,985 per QALY while usual care costs $7,229/QALY. In the microsimulation, at a willingness-to-pay threshold of $100,000, the NFS alone in PCP clinic was the most cost-effective strategy in 94.2% of samples, followed by combination NFS/VCTE in the PCP clinic (5.6%) and usual care in 0.2%. The NFS based strategies yield the best biopsy-correct classification ratios (3.5) while the NFS/VCTE and usual care strategies yield more correct-classifications of advanced fibrosis at the cost of 3 and 37 additional biopsies per classification. Risk-stratification of patients with NAFLD primary care clinic is a cost-effective strategy that should be formally explored in clinical practice.