Cost-Effectiveness of Universal Serological Screening to Prevent Non-Traumatic Hip and Vertebral Fractures in Patients with Celiac Disease.
BACKGROUND & AIMS: Patients with asymptomatic or poorly managed celiac disease can experience bone loss, placing them at risk for hip and vertebral fractures. We analyzed the cost-effectiveness of universal serologic screening (USS) vs symptomatic at-risk screening (SAS) strategies for celiac disease, given the risk of non-traumatic hip and vertebral fractures if untreated or undiagnosed. METHOD: We developed a lifetime Markov model of the screening strategies, each with male or female cohorts of 1000 patients, 12 years old when screening began. We screened serum samples for levels of immunoglobulin A (IgA), compared with tissue transglutaminase and total IgA, and findings were confirmed by mucosal biopsy. Transition probabilities and quality of life estimates were obtained from the literature. We used generalizable cost estimates and Medicare reimbursement rates, and ran deterministic and probabilistic sensitivity analyses. RESULT: For men, the average life-time costs were $8532 and $8472 for USS and SAS strategies, respectively, corresponding to average quality adjusted life years (QALY) gains of 25.511 and 25.515. Similarly, for women, costs were $11,383 and $11,328 for USS and SAS strategies, corresponding to QALY gains of 25.74 and 25.75. Compared to the current standard of care (SAS), USS produced higher average lifetime costs and lower quality of life for each sex. Deterministic and probabilistic sensitivity analyses showed that the model was robust to realistic changes in all the variables, making USS cost ineffective, based on these outcomes. CONCLUSION: USS and SAS are similar in lifetime costs and quality of life, although the current SAS strategy was overall more cost effective in preventing bone loss and fractures among patients with undiagnosed or subclinical disease. Based on best available supportive evidence, it is more cost effective to maintain the standard celiac screening practices, although future robust population-based evidence in other health outcomes could be leveraged to re-evaluate current screening guidelines.
Available from: Peter H R Green
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ABSTRACT: Context: Celiac disease (CD) is associated with an increased fracture risk, an increase that persists after diagnosis. A significant proportion of patients with CD have persistent villous atrophy (VA) on follow-up biopsy. Objective: The objective of the study was to determine whether persistent VA impacts long-term fracture risk. Design: This was a cohort study. Setting and Patients: We identified all patients in Sweden with histological evidence of CD who underwent a follow-up biopsy and compared patients with persistent VA with those with mucosal healing. Main Outcome Measures: The following were measured: 1) any fracture; 2) likely osteoporotic fracture (defined as fractures of the hip, distal forearm, thoracic and lumbar spine, or proximal humerus); and 3) hip fracture. Results: Of 7146 patients, VA was present on follow-up biopsy in 43%. There was no significant association between persistent VA and overall fractures [hazard ratio (HR) of persistent VA compared with those with healing 0.93, 95% confidence interval (CI) 0.82-1.06] or with likely osteoporotic fractures (HR 1.11, 95% CI 0.84-1.46). Persistent VA was associated with an increased risk of hip fracture (HR 1.67, 95% CI 1.05-2.66). Hip fracture risk increased, depending on the degree of VA (HR for partial VA compared with those with healing 1.70, 95% CI 0.82-3.49, HR for subtotal/total VA compared with those with healing 2.16, 95% CI 1.06-4.41). Conclusions: Persistent VA on follow-up biopsy is predictive of hip fracture risk. The association between persistent VA and hip fractures, but not fractures overall, implies that thinner sc tissue and fall or trauma may be mechanisms by which persistent VA confers an increased fracture risk.
Available from: Julio C Bai
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ABSTRACT: Celiac disease (CD) occurs in approximately 1% of the Western population. It is a lifelong disorder that is associated with impaired quality of life (QOL) and an excessive risk of comorbidity and death.
To review the literature on screening for CD in relation to the current World Health Organization (WHO) criteria for mass screening.
We performed a PubMed search to identify indexed papers on CD screening with a publication date from 1900 until 1 June 2014. When we deemed an abstract relevant, we read the corresponding paper in detail.
CD fulfills several WHO criteria for mass screening (high prevalence, available treatment and difficult clinical detection), but it has not yet been established that treatment of asymptomatic CD may reduce the excessive risk of severe complications, leading to higher QOL nor that it is cost-effective.
Current evidence is not sufficient to support mass screening for CD, but active case-finding may be appropriate, as we recognize that most patients with CD will still be missed by this strategy. Although proof of benefit is still lacking, screening for CD may be appropriate in high-risk groups.
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