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S3-E13 – Community Screening for NAFLD: What Must Advocates Prove?

What can we learn about prospects for community screening for NAFLD from the NICE draft guidance on this issue?

The UK’s National Institute for Health and Care Excellence (NICE) issues health economics-based decisions on whether therapies and diagnostics should be reimbursed by the British government. In a recent draft guidance titled FibroScan for assessing liver fibrosis and cirrhosis outside secondary and specialist care, NICE has stated that “there is not enough certainty for [using FibroScan to assess liver fibrosis or cirrhosis for adults in primary or community care] to recommend it as a clinically effective and cost saving option for routine use.” This episode centers around understanding the draft guidance and what it means for out of hospital screening.

In addition to Louise, Jörn Schattenberg, Ian Rowe and Roger, this panel includes a first-time: lead modeler and epidemiologist Chris Estes of the Center for Disease Analysis Foundation. Chris has been lead modeler on some of the 2015-2030 projects previously discussed on the podcast.

The question driving this episode is: what about the NICE decision makes sense and what might not. Ian started by providing context about NICE: its mission is to “allow ‘rational’ in inverted commas decisions to be made about health care spend, mostly from a cost effectiveness and clinical effectiveness perspective.” He noted that this decision revolves around a fairly narrow target: FibroScan in a community or primary setting, as compared to its delivery or secondary care. Ian goes on to note that two sets of data that would help drive a decision are scarce: how well the test works and, separately, how well learning test results causes patients to improve their health. Against that backdrop, he noted that a decision not to fund might be “regrettable” and not in the interest of patients, but a logical outcome of the presenting question, organizational mission and lack of existing data.

Louise Campbell followed Ian and question some specifics of how the analysis was conducted and the source and nature of cost data NICE used. On the “nature of data” issue, she noted that the NICE review team presented FibroScan costs as a single, fixed variable, whereas in the “real world,” the ways and amounts that different institutions charge vary widely.

Roger Green then broadened the question to ask what the outcome might be with a broader question or approach the economics of the situation. Chris Estes discussed the direct and indirect costs that would go into a complete calculation and then to note that if you could prevent disease before it began (by addressing obesity or early NAFLD, this would be the most cost effective strategy. Ian noted it was also one on which the manufacturer seemed unable to provide data.

The rest of the episode focused on issues such as how this question would be treated differently in Germany, what data sources or facts might drive a different decision and how to research or acquire this data. Louise noted several examples of areas where she felt the costing analysis might not have reflected the realities of the market and patient care cases. The conversation jumps from one topic to another. Toward the end, Jörn notes that while our primary focus should be to support wellness, the easier economics to evaluate are those of treating illness and it becomes clear that this tension between illness that provides hard data and wellness that is a softer measure but clearly of greater benefit to society is a significant source of friction.

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