community nafld screening

Episode 13 looks at the NICE Draft Guidance Evaluating FibroScan use in Community and Primary Care settings. This conversation focuses on underlying tensions between a methodology designed to assess big-ticket spending on critical moments of disease and a population screening approach that centers on wellness care more than illness care.

This conversation starts with Roger Green noting an inherent tension between short-term health economic tests driving a decision not to compensate and longer-term healthcare priorities that rely on patients who cannot afford the test being able to take it. Ian Rowe describes this as a tension inherent in the UK system and therefore, not a "real issue." In contrast, Jörn Schattenberg notes a significant structural issue in that, as Ian noted earlier, NICE relies on companies to provide the necessary data, but the costs of providing that data might be excessive for a small diagnostics company like Echosens, although not for a major drug company. Jörn goes on to raise the issue of reimbursing wellness vs. illness; this is an economics of illness analysis done for a process that enhances wellness. Louise Campbell suggests a parallel analysis of the cost of expensive HCC drugs like sorafenib that are highly costly but provide only 3-6 months added longevity. In the end, Roger Green asks one thing each participant would like to see vs. something they are confident they will see. Answers vary, but they suggest that the current system is not a particularly effective way to assess this kind of analysis and that, beyond that, this specific analysis might benefit from some different looks at data. In the end, Louise Campbell notes that the comment period ends on March 9 and invites as many people as possible to comment before then.

Episode 13 looks at the NICE Draft Guidance Evaluating FibroScan use in Community and Primary Care settings. This conversation focuses on the real impact of a decision not to compensate at this time, with most discussion centering in some form around the idea that a positive NAFLD screen leads to what Chris Estes of the Center for Disease Analysis Foundation describes as a "Cascade of Care." 

Jörn Schattenberg leads this conversation by asking whether we can use an entry test or some other method to enrich the test and thereby speed development of the data necessary to answer the question. Chris Estes points out that the right analysis will require assessment of the entire care cascade, with all its tests and care for people who test positive. Roger Green asks Chris whether such data exists in another setting where we can extrapolate to this situation, to which Chris notes that the FibroScan studies are fairly early and done only in tertiary care centers. Louise Campbell asks Chris whether any post-COVID modeling has been done given that the downstream burdens COVID is placing on the healthcare system due to diseases being diagnosed later in course of disease. Chris refers to some viral hepatitis analysis that suggests that while analysts initially assumed a two-year lag in care due to COVID, the actual impacts on care and costs appear to last far longer. The rest of the discussion bounces back and forth between the question how to apply data that lead to clear inferences but is not directly applicable to this case and the lack of the continuum of data necessary to make clean comparisons. At the end, Louise Campbell suggests that a decision not to compensate will way most heavily on economically burdened and rural patients. Roger Green asks whether this becomes one more health burden on people who already have not received enough care and Chris Estes describes this combination of inability to travel and incur costs of care with COVID, the dramatic increases in opioid addiction in this population, and well-noted increases in drinking and obesity to create a "perfect storm" of risk factors.

Episode 13 looks at the NICE Draft Guidance Evaluating FibroScan use in Community and Primary Care settings. This conversation focuses on some of the data issues surrounding this evaluation, ranging from the lack of the long-term data necessary to make the wellness case to narrower, more case-specific flaws in how costing data was developed. 

The previous conversation looks at how NICE analyzes procedures and ways this approach might conflict with the economics of NAFLD screening. This conversation starts with Ian Rowe noting that NICE depends on the manufacturer to provide data for the analysis, but Echosens only presented one year data. Louise Campbell asks if advocates could put forward some of the Hepatitis C data to address the issue, but, as Ian points out, FibroScan is the index diagnostic for NAFLD; in contrast, it was used for disease staging in Hep C. Jörn Schattenberg joins the conversation to note ways in which Germany and the UK are similar in terms of the relationship between reimbursement and use and other ways in which they are different. Eventually, Jörn points out, we will have 10-year data, but he asks how this can benefit patients today. Louise suggests that data and analyses exist in other settings that can help address these issues for NICE, particularly if we consider biopsy (and its costs) as the option. Ian Rowe asks "a couple of questions from the NICE perspective," which make the point that this kind of screening probably is desirable but must be carefully managed because once tests are made available more widely, people will sign up quickly, backlogs will ensue and practices will be challenged and may wind up needing to add staff. Louise acknowledges all this and notes that this analysis places a higher training burden on the manufacturer than Phillips or GE face with ultrasound.

Episode 13 looks at the NICE Draft Guidance Evaluating FibroScan use in Community and Primary Care settings. This conversation focuses on the basic way that NICE approaches issues like this one and tensions between that approach and the health and wellness outcomes this kind of screening might provide.

As Roger Green mentions when starting this conversation, Surfing the NASH Tsunami usually advocates for early prevention and wellness care as key strategies for fighting the coming NASH pandemic. The issue is that NICE answers relatively specific questions using rigorous cost analyses. At this point in time, the caliber of longitudinal data necessary to make the optimal case for FibroScan simply does not exist.

After Roger describes the underlying issue, Ian Rowe focuses the conversation by discussing the approach that NICE takes to health economic analysis. Along the way, he notes that in cases like this one, the correct application of this generally valuable analysis might not lead to the best outcome in terms of the health of patients. Louise Campbell goes on to discuss three ways that this particular analysis fails to capture the situation accurately: (i) the test was viewed in a vacuum instead of in the context of the care it would trigger; (ii) the testing frequency was based solely on tests done in radiology departments, which appear to account for a small percentage of all FibroScan tests done in the UK; and (iii) it assumed uniform costing for FibroScan tests done in a radiology department, whereas Louise was able to point through personal experience to the deviations (both from the analysis and from each other) from the numbers used in the analysis. This conversation ends with Chris Estes discusses the idea that this should be a model of long-term inputs and outputs reflecting not only the cost of the test but also the costs and benefits of the downstream care that would result from testing.