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INFORMING DISINVESTMENT WITH LIMITED EVIDENCE: COBALAMIN DEFICIENCY IN THE FATIGUED

Published online by Cambridge University Press:  16 July 2015

George Mnatzaganian ,
Jonathan Karnon ,
John R. Moss ,
Adam G. Elshaug ,
Michael Metz ,
Oliver R. Frank  and
Janet E. Hiller
George Mnatzaganian
Affiliation:
School of Allied Health, Faculty of Health Sciences, Australian Catholic University
Jonathan Karnon
Affiliation:
Discipline of Public Health, School of Population Health, University of Adelaide
John R. Moss
Affiliation:
Discipline of Public Health, School of Population Health, University of Adelaide
Adam G. Elshaug
Affiliation:
Menzies Centre for Health Policy, Sydney School of Public Health, Sydney Medical School, The University of Sydney
Michael Metz
Affiliation:
ClinPath Laboratories, Adelaide
Oliver R. Frank
Affiliation:
Discipline of General Practice, School of Population Health, University of Adelaide
Janet E. Hiller
Affiliation:
Discipline of Public Health, School of Population Health, University of Adelaide; School of Health Sciences, Faculty of Health Arts and Design, Swinburne University of [email protected]
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Abstract

Objectives: Health technology reassessment and disinvestment can be difficult due to uncertainties regarding available evidence. Pathology testing to investigate cobalamin (vitamin B12) deficiency is a strong case in point. We conducted a 3-month economic evaluation of five strategies for diagnosing and treating cobalamin deficiency in adult patients hypothetically presenting with new unexplained fatigue in the primary care setting. The first consultation per patient was considered. Screening tests other than serum cobalamin were not included.

Methods: A cost-effectiveness analysis was undertaken using a decision tree to represent the diagnostic / treatment pathways, with relevant cost and utility scores assigned to different stages in the evaluation process. Input parameter values were estimated from published evidence, supplemented by expert opinion, with sensitivity analysis undertaken to represent parameter uncertainty.

Results: Ordering serum vitamin B12 to assess cobalamin deficiency among patients with unexplained fatigue was not cost-effective in any patient population, irrespective of pretest prevalence of this deficiency. For patients with a pretest prevalence above 1 percent, treating all with oral vitamin B12 supplements without testing was most cost-effective, whereas watchful waiting with symptoms monitoring was most cost-effective for patients with lower pretest prevalence probabilities.

Conclusions: Substantial evidence gaps exist for parameter estimation: questionable cobalamin deficiency levels in the fatigued; debatable treatment methods; unknown natural history of the condition. Despite this, we reveal a robust path for disinvestment decision making in the face of a paradox between the evidence required to inform disinvestment compared with its paucity in informing initial funding decisions.

Keywords

DisinvestmentPathology testingVitamin B12 deficiencyFatigueCost-effectiveness analysis
Type
Assessments
Information
International Journal of Technology Assessment in Health Care , Volume 31 , Issue 3 , 2015 , pp. 188 - 196
Copyright
Copyright © Cambridge University Press 2015 

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References

REFERENCES

1. Pearson, S, Littlejohns, P. Reallocating resources: How should the National Institute for Health and Clinical Excellence guide disinvestment efforts in the National Health Service? J Health Serv Res Policy. 2007;12:160–165.Google Scholar
2. Elshaug, AG, Hiller, JE, Tunis, SR, Moss, JR. Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices. Aust New Zealand Health Policy. 2007;4:23.CrossRefGoogle ScholarPubMed
3. Watt, AM, Hiller, JE, Braunack-Mayer, AJ, et al. The ASTUTE Health study protocol: Deliberative stakeholder engagements to inform implementation approaches to healthcare disinvestment. Implement Sci. 2012;7:101. doi: 10.1186/1748–5908-7-101.CrossRefGoogle ScholarPubMed
4. National Health and Medical Research Council (NHMRC). How to review the evidence: Systematic identification and review of the scientific literature. Available at: http://www.nhmrc.gov.au/guidelines/publications/cp65 (accessed February 2015).Google Scholar
5. Lindenbaum, J, Rosenberg, IH, Wilson, PWF, Stabler, SP, Allen, RH. Prevalence of cobalamin deficiency in the Framingham elderly population. Am J Clin Nutr. 1994;60:2–11.Google Scholar
6. Stabler, SP. Vitamin B12 deficiency. N Engl J Med. 2013;368:149–160.Google Scholar
7. Centers for Disease Control and Prevention. Vitamin B12 deficiency. 2011, http://www.cdc.gov/ncbddd/b12/goals.html (accessed February, 2015).Google Scholar
8. Willis, CD, Elshaug, AG, Milverton, JL, et al. Diagnostic performance of serum cobalamin tests: A systematic review and meta-analysis. Pathology. 2011;43:472–481.CrossRefGoogle ScholarPubMed
9. Solomon, LR. Cobalamin-responsive disorders in the ambulatory care setting: Unreliability of cobalamin, methylmalonic acid, and homocysteine testing. Blood. 2005;105:978–985.Google Scholar
10. Gallagher, AM, Thomas, JM, Hamilton, WT, White, PD. Incidence of fatigue symptoms and diagnoses presenting in UK primary care from 1990 to 2001. J R Soc Med. 2004;97:571–575.Google Scholar
11. Sharpe, M, Wilks, D. Fatigue. BMJ. 2002;325:480–483.Google Scholar
12. Werbach, MR. Nutritional strategies for treating chronic fatigue syndrome. Altern Med Rev. 2000;5:93–108.Google Scholar
13. Rolfe, A, Burton, C. Reassurance after diagnostic testing with a low pretest probability of serious disease: Systematic review and meta-analysis. JAMA Intern Med. 2013;173:407–416.CrossRefGoogle ScholarPubMed
14. Kassirer, JP, Milstein, A. Our failure to curb excessive testing. Arch Intern Med. 2012;172:1751–1753.Google Scholar
15. Kenter, EG, Okkes, IM, Oskam, SK, Lamberts, H. Tiredness in Dutch family practice. Data on patients complaining of and/or diagnosed with ‘tiredness’. Fam Pract. 2003;20:434–440.CrossRefGoogle ScholarPubMed
16. Office of population Censuses and Surveys. Living in Britain: Results from the 1998 General Household Survey. London: HMSO; 2000.Google Scholar
17. Britt, H, Miller, GC, Charles, J, et al. A decade of Australian general practice activity 2001–02 to 2010–11. BEACH. Family Medicine Research Centre, Sydney: The University of Sydney, School of Public Health; 2011.Google Scholar
18. Koch, H, van Bokhoven, MA, ter Riet, G, et al. Ordering blood tests for patients with unexplained fatigue in general practice: What does it yield? Results of the VAMPIRE trial. Br J Gen Pract. 2009;59:93–100.Google Scholar
19. Medicare Australia Statistics, 2012. https://www.medicareaustralia.gov.au/statistics/mbs_item.shtml (accessed February, 2015).Google Scholar
20. Godwin, M, Delva, D, Miller, K, et al. Investigating fatigue of less than 6 months’ duration. Guidelines for family physicians. Can Fam Physician. 1999;45:373–379.Google Scholar
21. bpacnz better medicine. The laboratory investigation of tiredness. Available at: http://www.bpac.org.nz/resources/campaign/tiredness/tiredness_bt.asp (accessed February 2015).Google Scholar
22. Nijrolder, I, van der Horst, H, van der Windt, D. Prognosis of fatigue. A systematic review. J Psychosom Res. 2008;64:335–349.CrossRefGoogle ScholarPubMed
23. Brooks, R. EuroQol: The current state of play. Health Policy. 1996;37:53–72.Google Scholar
24. Richardson, G, Epstein, D, Chew-Graham, C, et al. Cost-effectiveness of supported self-management for CFS/ME patients in primary care. BMC Fam Pract. 2013;14:12.Google Scholar
25. Lederle, FA. Oral cobalamin for pernicious anemia. Medicine's best kept secret? JAMA. 1991;265:94–95.CrossRefGoogle ScholarPubMed
26. Seal, EC, Metz, L, Flicker, L, Melny, J. A randomized, double-blind, placebo-controlled study of oral vitamin B12 supplementation in older patients with subnormal or borderline serum vitamin B12 concentrations. J Am Geriatr Soc. 2001;50:146–151.Google Scholar
27. Butler, CC, Vidal-Alaball, J, Cannings-John, R, et al. Oral vitamin B12 versus intramuscular vitamin B12 for vitamin B12 deficiency: A systematic review of randomized controlled trials. Fam Pract. 2006;23:279–285.Google Scholar
28. Vitamin B12 Blackmores, 2012. http://www.blackmores.com.au/ (accessed February, 2015).Google Scholar
29. Drummond, MF, Sculpher, MJ, Torrance, GW, O’Brien, BJ, Stoddart, GL. Methods for the economic evaluation of health care programmes. 3rd ed. Oxford: Oxford University Press; 2005.CrossRefGoogle Scholar
30. Evans, KW, Boan, JA, Evans, JL, Shuaib, A. Economic evaluation of oral sumatriptan compared with oral caffeine/ergotamine for migraine. Pharmacoeconomics. 1997;12:565–577.Google Scholar
31. Newchurch Ltd. National Pathology Alliance benchmarking Report 2000/1. London: Newchurch; 2002.Google Scholar
32. Carmel, R. Measuring and interpreting holo-transcobalamin (holo-transcobalamin II). Clin Chem. 2002;48:407–409.Google Scholar
33. Carmel, R, Green, R, Rosenblatt, DS, Watkins, D. Update on cobalamin, folate, and homocysteine. Hematology Am Soc Hematol Educ Program. 2003;62–81.Google Scholar
34. Savage, DG, Lindenbaum, J, Stabler, SP, Allen, RH. Sensitivity of serum methylmalonic acid and total homocysteine determinations for diagnosing cobalamin and folate deficiencies. Am J Med. 1994;96:239–246.Google Scholar
35. World Health Organization (WHO). The World Health Report. Health system financing: The path to universal coverage. Geneva: WHO; 2010. http://whqlibdoc.who.int/whr/2010/9789241564021_eng.pdf (accessed February 2015).Google Scholar
36. Karnon, J, Carlton, J, Czoski-Murray, C, Smith, K. Informing disinvestment through cost-effectiveness modelling. Is lack of data a surmountable barrier? Appl Health Econ Health Policy. 2009;7:1–9.Google Scholar
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