Cost-effectiveness of universal serologic screening to prevent nontraumatic hip and vertebral fractures in patients with celiac disease.
OBJECTIVE
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 because of the risk of nontraumatic hip and vertebral fractures if untreated or undiagnosed.


METHODS
We developed a lifetime Markov model of the screening strategies, each with male or female cohorts of 1000 patients who were 12 years old when screening began. We screened serum samples for levels of immunoglobulin A, compared with tissue transglutaminase and total immunoglobulin A, 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.


RESULTS
For men, the average lifetime costs were $8532 and $8472 for USS and SAS strategies, respectively, corresponding to average quality-adjusted life year gains of 25.511 and 25.515. Similarly for women, costs were $11,383 and $11,328 for USS and SAS strategies, respectively, corresponding to quality-adjusted life year gains of 25.74 and 25.75. Compared with 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 on the basis of these outcomes.


CONCLUSIONS
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. On the basis of 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 reevaluate current screening guidelines.
Division of Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, California, USA. ktpark@stanford.edu
K T
KT
Park
Raymond
R
Tsai
Louise
L
Wang
Nasim
N
Khavari
Laura
L
Bachrach
Dorsey
D
Bass
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy; D002446:Celiac Disease / Q000150:complications*; D002648:Child; D003362:Cost-Benefit Analysis; D005260:Female; D006620:Hip Fractures / Q000517:prevention & control*; D006801:Humans; D007070:Immunoglobulin A / Q000097:blood; D008297:Male; D008403:Mass Screening / Q000191:economics* / Q000379:methods*; D008875:Middle Aged; D012698:Serologic Tests / Q000191:economics / Q000379:methods; D016103:Spinal Fractures / Q000517:prevention & control*; D011503:Transglutaminases / Q000032:analysis; D055815:Young Adult
D007070:Immunoglobulin A; D011503:Transglutaminases