INVESTIGADORES
AUGUSTOVSKI Federico Ariel
artículos
Título:
The cost-effectiveness of screening for oral cancer in primary care.
Autor/es:
SPEIGHT, P. M.; PALMER, S.; MOLES, D. R.; DOWNER, M. C.; SMITH, D. H.; HENRIKSSON, M.; AUGUSTOVSKI, F.
Revista:
HEALTH TECHNOLOGY ASSESSMENT
Editorial:
GRAY PUBLISHING
Referencias:
Año: 2006 p. 1 - 30
ISSN:
1366-5278
Resumen:
OBJECTIVES:
To use a decision-analytic model to determine the incremental costs and outcomes of alternative oral cancer screening programmes conducted in a primary care environment.
DESIGN:
The cost-effectiveness of oral cancer screening programmes in a number of primary care environments was simulated using a decision analysis
model. Primary data on actual resource use and costs were collected by
case note review in two hospitals. Additional data needed to inform the
model were obtained from published costs, from systematic reviews and by
expert opinion using the Trial Roulette approach. The value of future
research was determined using expected value of perfect information
(EVPI) for the decision to screen and for each of the model inputs.
SETTING:
Hypothetical screening
programmes conducted in a number of primary care settings. Eight
strategies were compared: (A) no screen; (B) invitational
screen--general medical practice; (C) invitational screen--general
dental practice; (D) opportunistic screen--general medical practice; (E)
opportunistic screen--general dental practice; (F) opportunistic
high-risk screen--general medical practice; (G) opportunistic high-risk
screen--general dental practice; and (H) invitational
screen--specialist.
PARTICIPANTS:
A hypothetical population over the age of 40 years was studied.
MAIN OUTCOME MEASURES:
The main measures were mean lifetime costs and quality-adjusted life-years (QALYs) of each alternative screening scenario and incremental cost-effectiveness ratios (ICERs) to determine the additional costs and benefits of each strategy over another.
RESULTS:
No screening (strategy A) was always the cheapest option. Strategies B, C, E and H were never cost-effective
and were ruled out by dominance or extended dominance. Of the remaining
strategies, the ICER for the whole population (age 49-79 years) ranged
from pound 15,790 to pound 25,961 per QALY. Modelling a 20% reduction in
disease progression always gave the lowest ICERs. Cost-effectiveness
acceptability curves showed that there is considerable uncertainty in
the optimal decision identified by the ICER, depending on both the
maximum amount that the NHS may be prepared to pay and the impact that
treatment has on the annual malignancy transformation rate. Overall,
however, high-risk opportunistic screening by a general dental or medical practitioner (strategies F and G) may be cost-effective.
EVPIs were high for all parameters with population values ranging from
pound 8 million to pound 462 million. However, the values were
significantly higher in males than females but also varied depending on
malignant transformation rate, effects of treatment and willingness to
pay. Partial EVPIs showed the highest values for malignant
transformation rate, disease progression, self-referral and costs of cancer treatment.
CONCLUSIONS:
Opportunistic high-risk screening, particularly in general dental practice, may be cost-effective. This screening
may more effectively be targeted to younger age groups, particularly
40-60 year olds. However, there is considerable uncertainty in the
parameters used in the model, particularly malignant transformation
rate, disease progression, patterns of self-referral and costs. Further
study is needed on malignant transformation rates of oral potentially malignant lesions and to determine the outcome of treatment of oral
potentially malignant lesions. Evidence has been published to suggest
that intervention has no greater benefit than 'watch and wait'. Hence a
properly planned randomised controlled trial may be justified. Research
is also needed into the rates of progression of oral cancer and on referral pathways from primary to secondary care and their effects on delay and stage of presentation.