Health Economic Decision Tree Models of Diagnostics for Dummies: A Pictorial Primer

Health economics is a discipline of economics applied to health care. One method used in health economics is decision tree modelling, which extrapolates the cost and effectiveness of competing interventions over time. Such decision tree models are the basis of reimbursement decisions in countries using health technology assessment for decision making. In many instances, these competing interventions are diagnostic technologies. Despite a wealth of excellent resources describing the decision analysis of diagnostics, two critical errors persist: not including diagnostic test accuracy in the structure of decision trees and treating sequential diagnostics as independent. These errors have consequences for the accuracy of model results, and thereby impact on decision making. This paper sets out to overcome these errors using color to link fundamental epidemiological calculations to decision tree models in a visually and intuitively appealing pictorial format. The paper is a must-read for modelers developing decision trees in the area of diagnostics for the first time and decision makers reviewing diagnostic reimbursement models.

[1]  Chris Hyde,et al.  Decision Making in Health and Medicine. Integrating Evidence and Values , 2005, ACP Journal Club.

[2]  G. Laszlo,et al.  Cost-effectiveness of diagnostic tests , 2002, The Lancet.

[3]  A. Mushlin,et al.  Focusing Technology Assessment Using Medical Decision Theory , 1988, Medical decision making : an international journal of the Society for Medical Decision Making.

[4]  Sabina Sanghera,et al.  ECONOMIC EVALUATIONS AND DIAGNOSTIC TESTING: AN ILLUSTRATIVE CASE STUDY APPROACH , 2013, International Journal of Technology Assessment in Health Care.

[5]  M. Zweig,et al.  Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool in clinical medicine. , 1993, Clinical chemistry.

[6]  J. C. Houwelingen,et al.  Bivariate Random Effects Meta-Analysis of ROC Curves , 2008, Medical decision making : an international journal of the Society for Medical Decision Making.

[7]  C M Rutter,et al.  A hierarchical regression approach to meta‐analysis of diagnostic test accuracy evaluations , 2001, Statistics in medicine.

[8]  C Gatsonis,et al.  Meta‐analysis of Diagnostic Test Accuracy Assessment Studies with Varying Number of Thresholds , 2003, Biometrics.

[9]  Mark J Sculpher,et al.  Establishing the Value of Diagnostic and Prognostic Tests in Health Technology Assessment , 2018, Medical decision making : an international journal of the Society for Medical Decision Making.

[10]  Yaling Yang,et al.  Use of Decision Modelling in Economic Evaluations of Diagnostic Tests: An Appraisal and Review of Health Technology Assessments in the UK , 2018, PharmacoEconomics - Open.

[11]  T. Trikalinos,et al.  Quantifying how diagnostic test accuracy depends on threshold in a meta‐analysis , 2019, Statistics in medicine.

[12]  P. Lorgelly,et al.  Modeling companion diagnostics in economic evaluations of targeted oncology therapies: systematic review and methodological checklist , 2015, Expert review of molecular diagnostics.

[13]  C. McCabe,et al.  Methods for Identifying the Cost-effective Case Definition Cut-Off for Sequential Monitoring Tests: An Extension of Phelps and Mushlin , 2014, PharmacoEconomics.

[14]  A. Šimundić.  Measures of Diagnostic Accuracy: Basic Definitions , 2009, EJIFCC.

[15]  Alastair Fischer,et al.  The economics of diagnosis. , 2006, Health economics.

[16]  M. Weinstein,et al.  HER-2 testing and trastuzumab therapy for metastatic breast cancer: a cost-effectiveness analysis. , 2004, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[17]  Joseph Lau,et al.  Decision-Analytic Modeling to Evaluate Benefits and Harms of Medical Tests: Uses and Limitations , 2009, Medical decision making : an international journal of the Society for Medical Decision Making.

[18]  Yaling Yang,et al.  Early Economic Evaluation of Diagnostic Technologies: Experiences of the NIHR Diagnostic Evidence Co-operatives , 2019, Medical decision making : an international journal of the Society for Medical Decision Making.

[19]  Paul Glasziou,et al.  Comparative accuracy: assessing new tests against existing diagnostic pathways , 2006, BMJ : British Medical Journal.

[20]  T J Ulahannan,et al.  Decision Making in Health and Medicine: Integrating Evidence and Values , 2002 .

[21]  Nicola J Cooper,et al.  Integration of Meta-analysis and Economic Decision Modeling for Evaluating Diagnostic Tests , 2008, Medical decision making : an international journal of the Society for Medical Decision Making.

[22]  Alvin I Mushlin,et al.  Costeffectiveness of diagnostic tests , 2001, The Lancet.

[23]  Robert D. Lieberthal,et al.  An economic model to value companion diagnostics in non-small-cell lung cancer. , 2013, Personalized medicine.

[24]  Carl van Walraven,et al.  Correlation between serial tests made disease probability estimates erroneous. , 2009, Journal of clinical epidemiology.

[25]  R. Trevethan,et al.  Sensitivity, Specificity, and Predictive Values: Foundations, Pliabilities, and Pitfalls in Research and Practice , 2017, Front. Public Health.

[26]  H. Grote,et al.  PD-L1 immunostaining scoring for non-small cell lung cancer based on immunosurveillance parameters , 2018, PloS one.

[27]  Jonathan J Deeks,et al.  Systematic reviews in health care: Systematic reviews of evaluations of diagnostic and screening tests. , 2001, BMJ.

[28]  Nicola J Cooper,et al.  Evaluating the cost-effectiveness of diagnostic tests in combination: is it important to allow for performance dependency? , 2013, Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research.