Optimising Risk-Based Screening: The Case of Diabetic Eye Disease
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Eligibility for national screening programmes can be personalised according to individual risk in order to improve outcomes and reduce costs. Existing methods of economic evaluation can be adapted to identify risk thresholds and help optimise services. We describe the development of a decision model used to evaluate the cost-effectiveness of risk-based screening for diabetic retinopathy. Author(s) and affiliation(s): Chris Sampson, Office of Health Economics Marilyn James, University of Nottingham David Whynes, University of Nottingham Antonio Eleuteri, University of Liverpool Simon Harding, University of Liverpool. Conference/meeting: Health Technology Assessment International (HTAi) 2018 Location: Vancouver, Canada Date: 03/06/2018
![Optimising Risk-Based Screening: The Case of
Diabetic Eye Disease
Chris Sampson1, Marilyn James2, Dave Whynes2, Antonio Eleuteri3,
Simon Harding3
[1] Office of Health Economics, UK [2] University of Nottingham, UK
[3] University of Liverpool, UK
HTAi 2018
3rd June 2018
This presentation represents independent research funded by the
National Institute for Health Research (NIHR) under the Programme
Grants for Applied Research programme (RP-PG-1210-12016). The
views expressed are those of the authors and not necessarily those
of the NHS, the NIHR or the Department of Health.](https://image.slidesharecdn.com/sampsonetaloralhtai2018-180705134246/85/optimising-riskbased-screening-the-case-of-diabetic-eye-disease-1-320.jpg)
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Optimising Risk-Based Screening: The Case of Diabetic Eye Disease
- 1. Optimising Risk-Based Screening: The Case of Diabetic Eye Disease Chris Sampson1, Marilyn James2, Dave Whynes2, Antonio Eleuteri3, Simon Harding3 [1] Office of Health Economics, UK [2] University of Nottingham, UK [3] University of Liverpool, UK HTAi 2018 3rd June 2018 This presentation represents independent research funded by the National Institute for Health Research (NIHR) under the Programme Grants for Applied Research programme (RP-PG-1210-12016). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
- 2. HTAi 2018 | Optimising Risk-Based Screening Background: diabetic retinopathy • Diabetic retinopathy is the leading cause of sight loss in working age people • Risk factors are well-understood • National screening programme in England • Annual photography of retinas – All people with diabetes over 12 • New recommendation for 2016 – Response to a growing evidence base Following a review of the evidence against strict criteria, the UK NSC recommended that the interval between screening tests should change from one year to two years for people with diabetes at low risk of sight loss
- 3. HTAi 2018 | Optimising Risk-Based Screening Background: ISDR study Introducing personalised risk based intervals in screening for diabetic retinopathy: development, implementation and assessment of safety, cost-effectiveness and patient experience • Cohort study • Risk calculation engine (RCE) development • Health economics • RCT (n=4400) • Qualitative
- 4. HTAi 2018 | Optimising Risk-Based Screening Methods: risk engine BL Age DiabD HbA1c Chol BP 1->2 -1.38 0.00 0.03 0.01 -0.04 0.00 2->1 0.19 0.01 -0.02 -0.00 0.02 -0.00 2->3 -0.74 -0.01 0.03 0.01 -0.04 -0.00 2->4 -4.28 0.02 -0.01 0.01 0.02 0.00 3->2 -0.04 0.01 -0.04 -0.01 0.08 -0.00 3->4 -2.48 -0.01 0.00 0.02 0.03 0.01 Eleuteri, A. et al., 2017. Individualised variable-interval risk-based screening for sight- threatening diabetic retinopathy: the Liverpool Risk Calculation Engine. Diabetologia. http://dx.doi.org/10.1007/s00125-017-4386-0 𝑄 = −𝜆11 𝜆12 0 0 𝜆21 −𝜆21 −𝜆23 −𝜆24 𝜆23 𝜆24 0 𝜆32 −𝜆32 −𝜆34 𝜆34 0 0 0 0 𝑃 𝑡 = exp(𝑄𝑡0.9)
- 5. HTAi 2018 | Optimising Risk-Based Screening Methods: comparators • Patient-level (semi-Markov) simulation • Built in Excel • Annual vs biennial vs ISDR • Annual = annual (standardisation) • Biennial = NSC recommendation (stratification) – 1-year recall for no disease – 2-year ‘background retinopathy’ • ISDR = risk-based screening (individualisation) – Estimation of individual risk of screen positive using RCE – 6-, 12-, or 24-month recall, 2.5% risk threshold
- 6. HTAi 2018 | Optimising Risk-Based Screening Methods: model structure Retinopathy R0: no retinopathy R1: background retinopathy R2: pre-proliferative retinopathy R3: proliferative retinopathy Maculopathy M0: no maculopathy M1: any maculopathy
- 7. HTAi 2018 | Optimising Risk-Based Screening Methods: model structure Retinopathy R0: no retinopathy R1: background retinopathy R2: pre-proliferative retinopathy R3: proliferative retinopathy Maculopathy M0: no maculopathy M1: any maculopathy RCE 1 RCE 2 RCE 3 RCE 4
- 8. HTAi 2018 | Optimising Risk-Based Screening Methods: model structure Retinopathy R0: no retinopathy R1: background retinopathy R2: pre-proliferative retinopathy R3: proliferative retinopathy Maculopathy M0: no maculopathy M1: any maculopathy RCE 1 RCE 2 RCE 3 RCE 4 6-month 12-month 24-month Pre-treatment Six possible screening ‘states’ within each disease statePost-treatment
- 9. HTAi 2018 | Optimising Risk-Based Screening Methods: individual simulation • Risk calculation at the start of each cycle • Parameters depend on disease and treatment pathways • Individual risk determines recall period • Demanding • Matrix exponential Parameter Mean (s.d) Markov state RCE 1 (R0M0) 74.1% RCE 2 (R1M0|R0M0) 16.0% RCE 3 (R1M0|R1M0) 9.1% RCE 4 (R2M0 0.8% Male 58% Age (years) 62.7 (12.5) Duration of diabetes (years) 6.5 (5.4) HbA1c 54.7 (15.6) Total cholesterol 4.2 (1.0) Systolic blood pressure 131.8 (14.4)
- 10. HTAi 2018 | Optimising Risk-Based Screening Results • Individualisation cost-saving compared with current practice • Cost-effective compared to biennial stratification • Lots of uncertainty (we’re dealing with this) • But… it would be better to optimise the screening programme Per person ISDR vs annual ISDR vs biennial Incremental cost -£212.73 £75.82 Incremental QALYs 0.0046 0.0138 ICER dominates £5513
- 11. HTAi 2018 | Optimising Risk-Based Screening Discussion: risk-based screening Standardisation • Fixed screening intervals • Clinically- determined eligibility Stratification • Clinically- determined subgroups • Alternative screening intervals Individualisation • Use of a risk calculation engine • Allocation of individuals to alternative recall periods Optimisation • Mathematical estimation of the optimal recall period for each recall period for each individual following each screening outcome Sampson, C.J. et al., 2016. Stratifying the NHS Diabetic Eye Screening Programme: into the unknown? Diabetic medicine: a journal of the British Diabetic Association, 33(12), pp.1612–1614. http://dx.doi.org/10.1111/dme.13192
- 12. HTAi 2018 | Optimising Risk-Based Screening Discussion: risk-based screening Standardisation • Fixed screening intervals • Clinically- determined eligibility Stratification • Clinically- determined subgroups • Alternative screening intervals Individualisation • Use of a risk calculation engine • Allocation of individuals to alternative recall periods Optimisation • Mathematical estimation of the optimal recall period for each recall period for each individual following each screening outcome Sampson, C.J. et al., 2016. Stratifying the NHS Diabetic Eye Screening Programme: into the unknown? Diabetic medicine: a journal of the British Diabetic Association, 33(12), pp.1612–1614. http://dx.doi.org/10.1111/dme.13192
- 13. HTAi 2018 | Optimising Risk-Based Screening Discussion: risk-based screening Standardisation • Fixed screening intervals • Clinically- determined eligibility Stratification • Clinically- determined subgroups • Alternative screening intervals Individualisation • Use of a risk calculation engine • Allocation of individuals to alternative recall periods Optimisation • Mathematical estimation of the optimal recall period for each recall period for each individual following each screening outcome Sampson, C.J. et al., 2016. Stratifying the NHS Diabetic Eye Screening Programme: into the unknown? Diabetic medicine: a journal of the British Diabetic Association, 33(12), pp.1612–1614. http://dx.doi.org/10.1111/dme.13192
- 14. HTAi 2018 | Optimising Risk-Based Screening Discussion: iCEA (next steps) Individualised cost-effectiveness analysis • The estimation of expected costs and outcomes at the individual level 𝑁𝐵𝑖 = 𝜆 1 − 𝛽 𝑟𝑖 𝐸𝑆 − 𝐶𝑆 𝑟 = −𝐶𝑆 𝜆(𝛽 − 1)𝐸𝑆
- 15. HTAi 2018 | Optimising Risk-Based Screening Conclusions • Risk-based screening for diabetic retinopathy is cost- effective • Always will be if risk engine is i) accurate, ii) low-cost – [these questions remain largely unanswered] • Building an RCE into a cost-effectiveness model is feasible • But you probably shouldn’t use Excel • Individualised cost-effectiveness analysis can be used to define optimised risk-based screening programmes • But more methods development needed
- 16. HTAi 2018 | Optimising Risk-Based Screening Thank you for listening To enquire about additional information and analyses, please contact Chris Sampson at csampson@ohe.org To keep up with the latest news and research, subscribe to our blog, OHE News Follow us on Twitter @OHENews, LinkedIn and SlideShare Office of Health Economics (OHE) Southside, 7th Floor 105 Victoria Street London SW1E 6QT United Kingdom +44 20 7747 8850 www.ohe.org OHE’s publications may be downloaded free of charge from our website.