Opportunistic Case Finding Research Articles

The role of the World Guidelines for Falls Prevention and Management's risk stratification algorithm in predicting falls: a retrospective analysis of the Osteoarthritis Initiative.

Recurrent falls are observed frequently among older people, and they are responsible for significant morbidity and mortality. The aim of the present study was to verify sensitivity, specificity and accuracy of World Guidelines for Falls Prevention and Management (WGFPM) falls risk stratification algorithm using data from the Osteoarthritis Initiative (OAI). Participants aged between 40 and 80years were stratified as 'low risk', 'intermediate risk' or 'high risk' as per WGFPM stratification. Data from the OAI cohort study were used, a multi-centre, longitudinal, observational study focusing primarily on knee osteoarthritis. The assessment of the outcome was carried out at baseline and during the follow-up visit at 24months. Data about sensitivity, specificity and accuracy were reported. Totally, 4796 participants were initially included. Participants were aged a mean of 61.4years (SD = 9.1) and were predominantly women (58.0%). The population was divided into three groups: low risk (n = 3266; 82%), intermediate risk (n = 25; 0.6%) and high risk (n = 690; 17.3%). WGFPM algorithm applied to OAI, excluding the intermediate-risk group, produced a sensitivity score of 33.7% and specificity of 89.9% for predicting one or more falls, with an accuracy of 72.4%. In our study, WGFPM risk assessment algorithm successfully distinguished older people at greater risk of falling using the opportunistic case finding method with a good specificity, but limited sensitivity, of WGFPM falls risk stratification algorithm.

American Geriatrics Society response to the World Falls Guidelines.

Falls are a major cause of preventable death, injury, and reduced independence in adults aged 65 years and older. The American Geriatrics Society and British Geriatrics Society (AGS/BGS) published a guideline in 2001, revised in 2011, addressing common risk factors for falls and providing recommendations to reduce fall risk in community-dwelling older adults. In 2022, the World Falls Guidelines (WFG) Task Force created updated, globally oriented fall prevention risk stratification, assessment, management, and interventions for older adults. Our objective was to briefly summarize the new WFG, compare them to the AGS/BGS guideline, and offer suggestions for implementation in the United States. We reviewed 11 of the 12 WFG topics related to community-dwelling older adults and agree with several additions to the prior AGS/BGS guideline, including assessment and intervention for hearing impairment and concern for falling, assessment and individualized exercises for older adults with cognitive impairment, and performing a standardized assessment such as STOPPFall before prescribing a medication that couldpotentially increase fall risk. Notable areas of difference include: (1) AGS continues to recommend screening all patients aged 65+ annually for falls, rather than just those with a history of falls or through opportunistic case finding; (2) AGS recommends continued use of the Timed Up and Go as a gait assessment, rather than relying on gait speed; and (3) AGS recommends clinical judgment on whether or not to check an ECG for those at risk for falling. Our review and translation of the WFG for a US audience offers guidance for healthcare and other providers and teams to reduce fall risk in older adults.

96 Implementing Multifactorial Falls Risk Assessments in the community for older adults at high risk of falls

Abstract Background Falls prevention improves health outcomes and reduces healthcare costs. New world guidelines for falls prevention and management in older adults exist. Older adults identified at high risk of falls should receive a Multifactorial Falls Risk Assessment (MFRA). A review of the use of MFRA across community healthcare divisions was undertaken in November 2022. It was noted that many variations of falls risk stratification existed, and implementation of a MFRA was not routine. This study aimed to implement a MFRA on all identified at high risk of falls. Methods Stakeholder engagement and project team (n = 14) development of physiotherapy, occupational therapy, podiatry, dietetics, and nursing was undertaken. A falls pathway was developed, outcome measures agreed, and a service user education booklet designed. Inclusion criteria incorporated older adults over 65 referred due to a fall, fall-related injury or through opportunistic case finding. A survey and focus group were undertaken. Qualitative and quantitative data was collated. Results 186 participants were risk stratified resulting in high (56%), moderate (29%), low (24%) risk. A MFRA was completed on all identified as high-risk. Their profile encompassed, 57% aged 80 and above; 35% opportunistic screening; 70% fell at home; 14% sustained a fracture; 64% presented as frail. Service user engagement themes; importance of good information ‘booklet very helpful’; under-reporting of falls ‘I feel embarrassed’. Conclusion Results highlighted 56% of older adults identified as high risk crossed all divisions of our healthcare system, indicating falls risk stratification and implementation of MFRA is every healthcare professional’s responsibility. Opportunistic case finding is necessary as older adults (35%) may not present following a fall. Good sources of information are needed to engage in falls prevention behaviours.

101 An audit of falls risk assessment in older adults in an Irish general practice

Abstract Background Falls in older adults are common; 30% of over 65 s fall at least once a year, increasing to 50% in the over 80s. Falls are associated with significant morbidity and mortality. By 2020 the national economic burden of falls related injury is expected to exceed €2 billion. International guidance recommends annual screening for falls risk in older adults. The Chronic Disease Management programme (CDM) was introduced into Irish General Practice in 2020, but does not include falls risk assessment. The aim of our audit was to evaluate whether GPs are following international guidelines by routinely assessing falls risk in older adults. Methods A full audit cycle was completed in a large Irish general practice with a mixed population. Cycle 1: October 2022. Cycle 2: April 2023. Audit Standard: Opportunistic case finding as per the September 2022 World Guidelines for Falls Prevention and Management in Older Adults: A Global Initiative. Criteria: All patients 65 years of age and older should be asked 3 Key Questions (3KQ): (1) Any falls in the last year? (2) Any unsteadiness when standing or walking? (3) Any fear of falling? All patients meeting referral criteria should be referred. Falls prevention advice should be given routinely. Inclusion criteria: Patients aged 65 years and over attending for routine CDM GP review. Intervention: Practice education session, falls algorithm in every room, consensus meeting. Results Cycle 1, 34 patients: (a) 3KQ 0% (b) appropriate referrals 75% (c) falls risk advice 9%; Cycle 2, 32 patients: (a) 3KQ 50% (b) appropriate referrals 89% (c) falls risk advice 22%. Conclusion This audit shows that a targeted falls risk assessment, completed as part of the CDM reviews, leads to a significant improvement in adherence to international falls guidelines. We suggest that this is a feasible intervention, and recommend the incorporation of a falls risk assessment in the chronic disease management template.

Synthesis in French of the 2022 global recommendations for the management and prevention of falls in the elderly

Falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. To synthesize evidence-based and expert consensus-based 2022 world guidelines for the management and prevention of falls in older adults. These recommendations consider a person-centred approach that includes the preferences of the patient, caregivers and other stakeholders, gaps in previous guidelines, recent developments in e-health and both local context and resources. All older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for communitydwelling older adults. An algorithm is proposed to stratify falls risk and interventions for persons at low, moderate or high risk. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations. The core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

Cost-Effectiveness of Screening for Open Angle Glaucoma Compared With Opportunistic Case Finding.

The manuscript evaluates cost-effectiveness of glaucoma screening with imaging devices and telemedicine based on a screening campaign performed in Spain. The screening strategy implemented in our analysis was cost-effective compared with opportunistic case finding. Open angle glaucoma is an asymptomatic ocular disease that represents one of the first causes of blindness. Diagnosis is currently made by opportunistic case finding, usually by community optometrists or general ophthalmologists. The aim of this study was to assess the cost-effectiveness of a screening strategy based on optical coherence tomography and fundus photographs in glaucoma detection. A cost-effectiveness analysis was carried out to compare 2 alternative strategies: opportunistic finding versus screening. A Markov tree model was carried out with 10 health states according to disease progression. Quality-adjusted life years (QALYs) were used as a measure of effectiveness. We included short-term and long-term direct health costs and a discount rate of 3%. We performed a probabilistic sensitivity analysis and several 1-way sensitivity analyses. The cohort in the screening program entailed an increase in 0.097 QALYs and additional costs of €1187 versus opportunistic finding, with an incremental cost-effectiveness ratio of about €12.214/QALY. The 1-way sensitivity analysis showed that inputs related to age and screening program (cost and detection rate) were those most strongly influencing the results of the analysis. Probabilistic sensitivity analyses showed that the model was robust to significant changes in the main variables of the analysis. The screening strategy implemented in our analysis was cost-effective compared with opportunistic finding in patients with glaucoma in this Spanish setting.

Risk of Missed Diagnosis of Primary Open-Angle Glaucoma by Eye Care Providers.

To evaluate the efficacy of opportunistic case finding in glaucoma detection and to determine factors associated with failure of glaucoma detection by eye health providers. This study was conducted on 154 new definite primary open-angle glaucoma (POAG) patients presenting to our glaucoma clinic. A questionnaire was prepared to determine if these subjects had sought eye care up to 12 months before presentation. The type of eye care provider and the principal reason for the visit were probed. The primary outcome measure was the frequency of a correct glaucoma diagnosis in their index visit. The secondary outcomes were factors associated with missed POAG diagnosis. The great majority of study subjects (132 cases, 85.7%) had sought at least one ocular examination within 1 year before presentation. Among these patients, 73 cases (55.3%) had remained undiagnosed after the examination. Among the probed variables, age, gender, visual acuity, visual field defects, intraocular pressure, cup/disc ratio, nerve fiber layer thickness of the worse eye at presentation, and family history of glaucoma were comparable between correctly diagnosed and missed POAGs. The only factors significantly associated with missed POAG diagnosis were lack of significant refractive errors and visiting an optometrist rather than an ophthalmologist. The efficacy of opportunistic case finding for POAG seems to be less than ideal in our settings. Lack of a significant refractive error and visiting an optometrist rather than an ophthalmologist were associated with a missed diagnosis of POAG. These observations reflect the need to adopt policies to improve glaucoma screening by eye care providers.

World guidelines for falls prevention and management for older adults: a global initiative.

Backgroundfalls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present.Objectivesto create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries.Methodsa steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting.Recommendationsall older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations.Conclusionsthe core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

How Do Family Physicians Perceive Their Role in Providing Pre-exposure Prophylaxis for HIV Prevention?-An Online Qualitative Study in Flanders, Belgium.

Introduction:In Belgium, the provision of pre-exposure prophylaxis (PrEP) for HIV prevention is centralized in specialized HIV clinics. Engaging family physicians in PrEP care could help scale-up its delivery and reach underserved populations. The objective of this study was to gain insight into family physicians' self-perceived roles in providing PrEP.MethodsWe conducted 16 online group discussions with a total of 105 Flemish family physicians, between November 2020 and February 2021. A brief online questionnaire assessed their socio-demographics and experience with sexual health. We analyzed verbatim transcribed data using a grounded theory approach.ResultsDespite limited awareness and experience, participants reported a high willingness to be more actively involved in PrEP care. Four potential roles for the family physician in PrEP care were identified: acting as low-threshold entry point for advice; opportunistic case finding of PrEP candidates; initiating appropriate care for PrEP-eligible clients; and ensuring high-quality follow-up care for PrEP users. Participants framed each of these roles within their current activities and responsibilities as primary care providers. Yet, participants differed in their views on the concrete operationalization of these roles, and in the extent of their involvement in PrEP. Particular challenges were a lack of experience with antiretrovirals, perceived limited exposure to clients at high HIV risk, and a lack of expertise and resources to conduct time-intensive risk assessments and counseling related to PrEP.ConclusionBelgian family physicians demonstrated a keen willingness to be involved in PrEP care, but had differing views on the practical implementation into their practices. Providing tailored training on sexual health and PrEP, and investing in collaboration between primary and secondary care, could optimize the integration of PrEP in the primary care practice.

73 THE NEW CHRONIC DISEASE MANAGEMENT PROGRAMME FOR GENERAL PRACTITIONERS: MAKING THE CASE FOR ITS REVISION TO INCLUDE DEMENTIA

Abstract Background A significant component of the new contract for general practitioners is the chronic disease management programme (CDMP for GPs). Although dementia can be framed as a chronic disease, it was not included in this programme. Its exclusion raises a number of questions including: Should dementia be framed as a chronic disease? Is it feasible to include dementia in a future revised CDMP for GPs? What are the likely benefits and potential risks? Methods This presentation focuses on two elements of a larger mixed-methods study, namely: (i) in-depth analysis of the CDMP for GPs, involving a review of the programme’s three main components to test the feasibility of extending it to incorporate dementia; and (ii) qualitative content analysis of data from semi-structured interviews with 12 stakeholders whose expertise is in dementia, chronic disease or both. Both elements were informed by a literature review. Results No consensus was found about whether dementia should be framed as a chronic disease. Results showed that it is feasible to extend the annual preventative programme of the CDMP for GPs to include additional modifiable dementia risk factors. While opportunistic case finding for identifying undiagnosed dementia cannot be recommended, a tool is available that would enable GPs identify people with dementia for enrolment on the structured treatment programme. Expected benefits from including dementia in the CDMP for GPs include integrated care pathways, better GP access and record-keeping and greater emphasis on primary and secondary prevention. Expected risks include excessive costs, caregiver burden, increased GP workload and sub-optimal care due to lack of specialist dementia training. Conclusion There is a compelling case to support dementia risk reduction in the CDMP for GPs. However, the programme’s current emphasis on self-management and rigidly planned visits could prove problematic for people with dementia and would need substantial revision.

Early Detection of COPD: An Opportunistic Case Finding Study in Smokers and Ex-Smokers Visiting a Medical Centre.

BackgroundDifferent case finding approaches have been used to identify early COPD. The objective of this study was to assess the feasibility and the yield of opportunistic early COPD case finding in visitors to a large medical centre.Patients and MethodsFrom May 2014 to June 2017, we consecutively recruited adults aged ≥ 18 years visiting the Shaare Zedek Medical Center, in Jerusalem. Our 3-step intervention included: a) pre-screening for symptoms with the 5-item “Could it be COPD?” questionnaire (score= 0–5 pts); b) pre-BD spirometry; and c) referral to a caregiver. Airflow obstruction was defined by a FEV1/FVC < 0.7. Spirometry results were used as an incentive to promote smoking cessation and quit rates were verified by phone survey 3 months after the intervention.ResultsA total of 1001 subjects (956 smokers; 45 ex-smokers) were recruited. Mean (SD) age was 48.3 years (13.5). Airflow obstruction was detected in 180 (18%) subjects of whom 142 (78.9%) were unaware of it, including 27 subjects with severe (50% ≥ FEV1 ≤ 30% predicted) (n=25) or very severe (FEV1 < 30% predicted) (n=2) obstruction. Multiple logistic regression analysis found that age, BMI, cigarette smoking (p.y.) and a “Could it be COPD?” questionnaire score ≥ 3 points correctly classified 83.3% of cases of airflow obstruction. At follow-up, 54.5% of participants reported smoking as usual, 30.9% reduced smoking [mean (SD) = 10.1 ± 7.8 cigarettes/day], 7.4% increased smoking [mean (SD) = 9.2 ± 6.3 cigarettes/day] and 7.2% claimed smoking cessation. Among obstructed subjects, 38.7% had visited a physician because of COPD, while 20.7% were taking a new respiratory medication.ConclusionEarly COPD case finding was feasible and effective in identifying undiagnosed airflow obstruction among visitors to a medical centre. Smoking cessation counselling based on spirometry promoted a small but clinically meaningful cessation rate.

Developing of a Simple Screening Tool for Opportunistic COPD Case Finding

Abstract Background Under diagnosis of COPD is serious problem in many countries world-wide because there are no generally detection tools available to detect high-risk patients for spirometry, and patients will not go for COPD check-up until a serious issue happens like exacerbation. Objective The aim of the work is trying to assess a new screening tool for early diagnosis of COPD. Patients and Methods The present study was conducted upon 500 subjects during the period from march 2018 to august 2018 who admitted to our chest department or visit our outpatient clinic, employees and visitors to Ain Sham hospitals.All subjects &amp;gt;40yrs who smoker or ex-smoker(≥10pack-years) applied a six variants(age,sex,packed years smoked during life ,dyspnea,chronic phlegmand chronic cohgh)questionnaire modified from PUMA questionnaire Subjects with score ≥5 did spirometry Results 500 subjects shared in the study 497 of them were males ( 99.4% )and 3 were females (.6%). 152of them(30.4%) had score &amp;lt;5 and 348 of them (69.6%)had score ≥5 who did spirometry.152 subjects did not perform spirometry. By spirometry we diagnosed 81(23.3) case COPD (fev1-fvc &amp;lt;.7) out of 348 subjects under gone spirometry and 16.2% of total subjects(500) . Conclusion Modified puma score is a simple and easy screening questionnaire for early detection of COPD cases and spirometry should be done to confirm the diagnosis or rule out.COPD is prevalent in many healthy apparent persons.

Cost-effectiveness and cost-utility of population-based glaucoma screening in China: a decision-analytic Markov model

Glaucoma, particularly primary angle closure glaucoma (PACG), is a leading cause of global blindness. Nearly half of all people with PACG are of Chinese descent. Population-level glaucoma screening has generally not been found to be cost-effective in high-income countries; however, this assessment has rarely been done in low-income or middle-income countries. We aimed to assess the cost-effectiveness and cost-utility of population-level glaucoma screening in China. We developed decision-analytic Markov models for separate and combined screening for PACG and primary open angle glaucoma (POAG) to evaluate costs and benefits of community-level screening versus opportunistic case finding from a societal perspective. A cohort of individuals was followed in the model from age 50 years through a total of 30 1-year Markov cycles. Analyses were done separately for rural and urban settings. We did a meta-analysis of glaucoma prevalence studies in China to obtain prevalence estimates for PACG and POAG. Screening costs were taken from a Chinese screening programme and treatment costs from a tertiary Chinese eye hospital. Main outcomes were incremental cost-utility ratios (ICURs) using quality-adjusted life-years and incremental cost-effectiveness ratios (ICERs) using years of blindness avoided. We did one-way deterministic and simulated probabilistic sensitivity analyses to reflect uncertainty around ICURs and ICERs. Compared with no screening, combined screening of POAG and PACG in rural China is predicted to result in an ICUR of US$569 (95% CI 17 to 4180) and an ICER of $1280 (-58 to 7940), both of which are below the WHO cost-effectiveness threshold of one to three times rural gross domestic product. For the urban China setting, combined screening is predicted to result in fewer net costs and greater gain in health benefits than no screening. Findings were robust in all sensitivity analyses. Over 30 years, a total of 246 (95% CI 63 to 628) and 1325 (510 to 2828) years of blindness are predicted to be avoided for every 100 000 rural and urban residents screened, respectively. Population screening for glaucoma (POAG and PACG combined) is likely to be cost-effective in both urban and rural China. Future studies should investigate the effectiveness of interventions to improve acceptance of definitive care among people screened. Ulverscroft Foundation, Wenzhou Medical University Research Fund, Zhejiang Province Health Innovation Talents Project, and Wenzhou's Ten Major Livelihood Issues 2015.

Comparison of glaucoma patients referred by glaucoma screening versus referral from primary eye clinic

PurposeTo investigate whether mass glaucoma screening relative to opportunistic case finding at a primary eye clinic is helpful for early detection of glaucoma.MethodsSubjects referred by glaucoma screening (by non-contact tonometry and non-mydriatic fundus photography; group A, n = 220) and from a primary eye clinic (group B, n = 327) were retrospectively recruited. The positive predictive value (PPV) for glaucoma and the rate of glaucoma awareness were compared. Also, for the newly diagnosed glaucoma (‘definite glaucoma’) patients, the demographics and structural and functional severities of glaucoma were compared.ResultsThe PPV for definite glaucoma was 25.5% for group A and 52.4% for group B. The rate of false-positive for ‘glaucoma referral to tertiary hospital’ was significantly higher for group A than for group B (38.6 vs. 18.3%, P < 0.001). Among the definite-glaucoma patients (group A: n = 56; group B: n = 182), the proportion of glaucoma awareness was significantly higher in group B (69.2%) than in group A (8.9%, P < 0.001). The mean deviation (MD) of visual field (VF) was significantly higher in group A than in group B (–3.08 ± 3.99 vs. –6.70 ± 7.29 dB, Padjusted = 0.040), and the inferior and inferotemporal ganglion cell-inner plexiform layer (GCIPL) thicknesses tended to be greater in group A than in group B, with marginal significance (Padjusted < 0.10).ConclusionsGlaucoma screening can be helpful for early detection of glaucoma. However, improvement of the screening strategy is needed in order to enhance its specificity for glaucoma.

Cost-effectiveness of community screening for glaucoma in rural India: a decision analytical model

ObjectivesStudies in several countries have demonstrated the cost-effectiveness of population-based screening for glaucoma when targeted at high-risk groups such as older adults and with familial history of disease. This study conducts a cost-effective analysis of a hypothetical community screening and subsequent treatment programme in comparison to opportunistic case finding for glaucoma in rural India. Study designA hypothetical screening programme for both primary open-angle glaucoma and angle-closure disease was built for a population aged between 40 and 69 years in rural areas of India. MethodsA decision analytical model was built to model events, costs and treatment pathways with and without a hypothetical screening programme for glaucoma for a rural-based population aged between 40 and 69 years in India. The treatment pathway included both primary open-angle glaucoma and angle-closure disease. The data on costs of screening and treatment were provided by an administrator of a tertiary eye hospital in Eastern India. The probabilities for the screening and treatment pathway were derived from published literature and a glaucoma specialist. The glaucoma prevalence rates were adapted from the Chennai Glaucoma Study findings. ResultsAn incremental cost-effectiveness ratio value of ₹7292.30 per quality-adjusted life-year was calculated for a community-screening programme for glaucoma in rural India. The community screening for glaucoma would treat an additional 2872 cases and prevent 2190 person-years of blindness over a 10-year period. ConclusionsCommunity screening for glaucoma in rural India appears to be cost-effective when judged by a ratio of willingness-to-pay thresholds as per WHO-CHOICE guidelines. For community screening to be cost-effective, adequate resources, such as trained medical personnel and equipment would need to be made available.

A qualitative study of GP, nurse and practice manager views on using targeted case-finding to identify patients with COPD in primary care

‘Finding the missing millions’ with chronic obstructive pulmonary disease became part of the Department of Health strategy for England in 2010. Targeted case-finding within primary care is one potential pro-active strategy, but currently little is known about the views of healthcare professionals on this approach. In this study, 36 healthcare professionals (12 GPs, 14 nurses, and 10 practice managers) from 34 UK practices participated in semi-structured telephone interviews about targeted case-finding. Interviews followed an interview guide, were audio-recorded, transcribed verbatim, coded and analysed using ‘Framework Approach’. Most of those interviewed practiced opportunistic case-finding. The main perceived barriers to wider case-finding programmes were the resource implications associated with running such programmes and identifying more chronic obstructive pulmonary disease patients. Financial incentives, support from specialist clinicians, and comprehensive guidance were viewed as facilitators. While targeted case-finding is conceptually accepted by primary care staff, scepticism surrounding (1) the value of identifying those with mild disease and (2) the availability of effective targeted case-finding methods, may lead some to favour an opportunistic approach. Key concerns were a lack of unequivocal evidence for the relative benefits vs. disadvantages of diagnosing patients earlier, and resource constraints in an already over-burdened system. Barriers to practical implementation of case-finding studies may be addressed with financial, human and educational resources, such as additional staff to undertake searches and perform spirometry tests, and practical and educational support from specialist teams.

Cost-effectiveness and cost utility of community screening for glaucoma in urban India

ObjectivesPopulation-based screening for glaucoma has been demonstrated to be cost-effective if targeted at high-risk groups such as older adults and those with a family history of glaucoma, and through use of a technician for conducting initial assessment rather than a medical specialist. This study attempts to investigate the cost-effectiveness of a hypothetical community screening and subsequent treatment programme for glaucoma in comparison with current practice (i.e. with no screening programme but with some opportunistic case finding) in the urban areas of India. Study designA hypothetical screening programme for both primary open-angle glaucoma and angle-closure disease was built for a population aged between 40 and 69 years in the urban areas of India. MethodsScreening and treatment costs were obtained from an administrator of a tertiary eye hospital in India. The probabilities for the screening pathway were derived from published literature and expert opinion. The glaucoma prevalence rates for urban areas were adapted from the Chennai Glaucoma Study findings. A decision-analytical model using TreeAge Pro 2015 was built to model events, costs and treatment pathways. One-way sensitivity analyses were conducted. ResultsThe introduction of a community screening programme for glaucoma is likely to be cost-effective, the estimated incremental cost-effectiveness ratio (ICER) values being ▪10,668.68 when compared with no screening programme and would treat an additional 4443 cases and prevent 1790 person-years of blindness over a 10-year period in the urban areas of India. Sensitivity analyses revealed that glaucoma prevalence rates across various age groups, screening uptake rate, follow-up compliance after screening, treatment costs and utility values of health states associated with medical and surgical treatment of glaucoma had an impact on the ICER values of the screening programme. ConclusionsIn comparison with current practice (i.e. without a screening programme but with some opportunistic case finding), the introduction of a community screening programme for glaucoma for the 40–69 years age group is likely to be relatively cost-effective if implemented in the urban areas of India.

Cost effectiveness of case-finding strategies for primary prevention of cardiovascular disease: a modelling study.

Policies of active case finding for cardiovascular disease (CVD) prevention in healthy adults are common, but economic evaluation has not investigated targeting such strategies at those who are most likely to benefit. To assess the cost effectiveness of targeted case finding for CVD prevention. Cost-effectiveness modelling in an English primary care population. A cohort of 10 000 individuals aged 30-74 years and without existing CVD or diabetes was sampled from The Health Improvement Network database, a large primary care database. A discrete-event simulation was used to model the process of inviting people for assessment, assessing cardiovascular risk, and initiation and persistence with drug treatment. Risk factors and drug cessation rates were obtained from primary care data. Published sources provided estimates of uptake of assessment, treatment initiation, and treatment effects. The researchers determined the lifetime costs and quality-adjusted life years (QALYs) with opportunistic case finding, and strategies prioritising and targeting patients by age or prior estimate of cardiovascular risk. This study reports on the optimum strategy if a QALY is valued at £20 000. Compared with no case finding, inviting all adults aged 30-74 years in a population of 10 000 yields 30.32 QALYs at a total cost of £705 732. The optimum strategy is to rank patients by prior risk estimate and invite 8% of those who are assessed as being at highest risk (those at ≥12.76% predicted 10-year CVD risk), yielding 17.53 QALYs at a cost of £162 280. There is an 89.4% probability that the optimum strategy is to invite <35% of patients for assessment. Across all age ranges, targeted case finding using a prior estimate of CVD risk is more efficient than universal case finding in healthy adults.

Targeted case finding for chronic obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial

Many individuals with chronic obstructive pulmonary disease (COPD) remain undiagnosed worldwide. Health-care organisations are implementing case-finding programmes without good evidence of which are the most effective and cost-effective approaches. We assessed the effectiveness and cost-effectiveness of two alternative approaches to targeted case finding for COPD compared with routine practice. In this cluster-randomised controlled trial, participating general practices in the West Midlands, UK, were randomly assigned (1:1), via a computer-generated block randomisation sequence, to either a targeted case-finding group or a routine care group. Eligible patients were ever-smokers aged 40-79 years without a previously recorded diagnosis of COPD. Patients in the targeted case-finding group were further randomly assigned (1:1) via their household to receive either a screening questionnaire at the general practitioner (GP) consultation (opportunistic) or a screening questionnaire at the GP consultation plus a mailed questionnaire (active). Respondents reporting relevant respiratory symptoms were invited for post-bronchodilator spirometry. Patients, clinicians, and investigators were not masked to allocation, but group allocation was concealed from the researchers who performed the spirometry assessments. Primary outcomes were the percentage of the eligible population diagnosed with COPD within 1 year (defined as post-bronchodilator forced expiratory volume in 1 s [FEV1] to forced vital capacity [FVC] ratio <0·7 in patients with symptoms or a new diagnosis on their GP record) and cost per new COPD diagnosis. Multiple logistic and Poisson regression were used to estimate effect sizes. Costs were obtained from the trial. This trial is registered with ISRCTN, number ISRCTN14930255. From Aug 10, 2012, to June 22, 2014, 74 818 eligible patients from 54 diverse general practices were randomly assigned and completed the trial. At 1 year, 1278 (4%) cases of COPD were newly detected in 32 789 eligible patients in the targeted case-finding group compared with 337 (1%) cases in 42 029 patients in the routine care group (adjusted odds ratio [OR] 7·45 [95% CI 4·80-11·55], p<0·0001). The percentage of newly detected COPD cases was higher in the active case-finding group (822 [5%] of 15 378) than in the opportunistic case-finding group (370 [2%] of 15 387; adjusted OR 2·34 [2·06-2·66], p<0·0001; adjusted risk difference 2·9 per 100 patients [95% CI 2·3-3·6], p<0·0001). Active case finding was more cost-effective than opportunistic case finding (£333 vs £376 per case detected, respectively). In this well established primary care system, routine practice identified few new cases of COPD. An active targeted approach to case finding including mailed screening questionnaires before spirometry is a cost-effective way to identify undiagnosed patients and has the potential to improve their health. National Institute for Health Research.

Development of a simple screening tool for opportunistic COPD case finding in primary care in Latin America: The PUMA study.

Opportunistic chronic obstructive pulmonary disease (COPD) case finding approaches for high-risk individuals with or without symptoms is a feasible option for disease identification. PUMA is an opportunistic case finding study conducted in primary care setting of Argentina, Colombia, Venezuela and Uruguay. The objectives were to measure COPD prevalence in an at-risk population visiting primary care for any reason, to assess the yield of this opportunistic approach and the accuracy of a score developed to detect COPD. Subjects attending routine primary care visits, ≥40 years of age, current or former smokers or exposed to biomass smoke, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator (post-BD) forced expiratory volume in 1 s (FEV1 )/forced vital capacity (FVC) < 0.70 and the lower limit of normal of FEV1 /FVC. A total of 1743 subjects completed the interview; 1540 performed acceptable spirometry. COPD prevalence was 20.1% (n = 309; ranging from 11.0% in Venezuela to 29.6% in Argentina) when defined using post-BD FEV1 /FVC < 0.70, and 14.7% (n = 226; ranging from 8.3% in Venezuela to 21.8% in Colombia) using the lower limit of normal. Logistic regression analysis for both definitions showed that the risk of COPD was significantly higher for persons >50 years, heavy smokers (>30 pack-years), with dyspnoea, and having prior spirometry. A simple score and a weighted score constructed using the following predictive factors: gender, age, pack-years smoking, dyspnoea, sputum, cough and spirometry, had a mean accuracy for detecting COPD (post-BD FEV1 /FVC < 0.70) of 76% and 79% for the simple and weighted scores, respectively. This simple seven-item score is an accurate screening tool to select subjects for spirometry in primary care.