Please use this identifier to cite or link to this item: http://hdl.handle.net/2440/93856
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Type: Journal article
Title: Informing disinvestment with limited evidence: cobalamin deficiency in the fatigued
Author: Mnatzaganian, G.
Karnon, J.
Moss, J.
Elshaug, A.
Metz, M.
Frank, O.
Hiller, J.
Citation: International Journal of Technology Assessment in Health Care, 2015; 31(3):188-196
Publisher: Cambridge University Press (CUP)
Issue Date: 2015
ISSN: 1471-6348
1471-6348
Statement of
Responsibility: 
George Mnatzaganian, Jonathan Karnon, John R. Moss, Adam G. Elshaug, Michael Metz, Oliver R. Frank, Janet E. Hiller
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: Cost-effectiveness analysis; Disinvestment; Fatigue; Pathology testing; Vitamin B12 deficiency
Rights: © Cambridge University Press 2015
RMID: 0030031695
DOI: 10.1017/S0266462315000331
Appears in Collections:Public Health publications

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