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Qureshi N, Woods B, Neves de Faria R, Saramago Goncalves P, Cox E, Leonardi Bee J, Condon L, Weng S, Akyea RK, Iyen B, Roderick P, Humphries SE, Rowlands W, Watson M, Haralambos K, Kenny R, Datta D, Miedzybrodzka Z, Byrne C, Kai J. Alternative cascade-testing protocols for identifying and managing patients with familial hypercholesterolaemia: systematic reviews, qualitative study and cost-effectiveness analysis. Health Technol Assess 2023; 27:1-140. [PMID: 37924278 PMCID: PMC10658348 DOI: 10.3310/ctmd0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2023] Open
Abstract
Background Cascade testing the relatives of people with familial hypercholesterolaemia is an efficient approach to identifying familial hypercholesterolaemia. The cascade-testing protocol starts with identifying an index patient with familial hypercholesterolaemia, followed by one of three approaches to contact other relatives: indirect approach, whereby index patients contact their relatives; direct approach, whereby the specialist contacts the relatives; or a combination of both direct and indirect approaches. However, it is unclear which protocol may be most effective. Objectives The objectives were to determine the yield of cases from different cascade-testing protocols, treatment patterns, and short- and long-term outcomes for people with familial hypercholesterolaemia; to evaluate the cost-effectiveness of alternative protocols for familial hypercholesterolaemia cascade testing; and to qualitatively assess the acceptability of different cascade-testing protocols to individuals and families with familial hypercholesterolaemia, and to health-care providers. Design and methods This study comprised systematic reviews and analysis of three data sets: PASS (PASS Software, Rijswijk, the Netherlands) hospital familial hypercholesterolaemia databases, the Clinical Practice Research Datalink (CPRD)-Hospital Episode Statistics (HES) linked primary-secondary care data set, and a specialist familial hypercholesterolaemia register. Cost-effectiveness modelling, incorporating preceding analyses, was undertaken. Acceptability was examined in interviews with patients, relatives and health-care professionals. Result Systematic review of protocols: based on data from 4 of the 24 studies, the combined approach led to a slightly higher yield of relatives tested [40%, 95% confidence interval (CI) 37% to 42%] than the direct (33%, 95% CI 28% to 39%) or indirect approaches alone (34%, 95% CI 30% to 37%). The PASS databases identified that those contacted directly were more likely to complete cascade testing (p < 0.01); the CPRD-HES data set indicated that 70% did not achieve target treatment levels, and demonstrated increased cardiovascular disease risk among these individuals, compared with controls (hazard ratio 9.14, 95% CI 8.55 to 9.76). The specialist familial hypercholesterolaemia register confirmed excessive cardiovascular morbidity (standardised morbidity ratio 7.17, 95% CI 6.79 to 7.56). Cost-effectiveness modelling found a net health gain from diagnosis of -0.27 to 2.51 quality-adjusted life-years at the willingness-to-pay threshold of £15,000 per quality-adjusted life-year gained. The cost-effective protocols cascaded from genetically confirmed index cases by contacting first- and second-degree relatives simultaneously and directly. Interviews found a service-led direct-contact approach was more reliable, but combining direct and indirect approaches, guided by index patients and family relationships, may be more acceptable. Limitations Systematic reviews were not used in the economic analysis, as relevant studies were lacking or of poor quality. As only a proportion of those with primary care-coded familial hypercholesterolaemia are likely to actually have familial hypercholesterolaemia, CPRD analyses are likely to underestimate the true effect. The cost-effectiveness analysis required assumptions related to the long-term cardiovascular disease risk, the effect of treatment on cholesterol and the generalisability of estimates from the data sets. Interview recruitment was limited to white English-speaking participants. Conclusions Based on limited evidence, most cost-effective cascade-testing protocols, diagnosing most relatives, select index cases by genetic testing, with services directly contacting relatives, and contacting second-degree relatives even if first-degree relatives have not been tested. Combined approaches to contact relatives may be more suitable for some families. Future work Establish a long-term familial hypercholesterolaemia cohort, measuring cholesterol levels, treatment and cardiovascular outcomes. Conduct a randomised study comparing different approaches to contact relatives. Study registration This study is registered as PROSPERO CRD42018117445 and CRD42019125775. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nadeem Qureshi
- PRISM Research Group, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Bethan Woods
- Centre for Health Economics, University of York, York, UK
| | | | | | - Edward Cox
- Centre for Health Economics, University of York, York, UK
| | - Jo Leonardi Bee
- PRISM Research Group, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Laura Condon
- PRISM Research Group, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Stephen Weng
- Cardiovascular and Metabolism, Janssen Research and Development, High Wycombe, UK
| | - Ralph K Akyea
- PRISM Research Group, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Barbara Iyen
- PRISM Research Group, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Paul Roderick
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Steve E Humphries
- Centre for Cardiovascular Genetics, Institute for Cardiovascular Science, University College London, London, UK
| | | | - Melanie Watson
- Wessex Clinical Genetics Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kate Haralambos
- Familial Hypercholesterolaemia Service, University Hospital of Wales, Cardiff, UK
| | - Ryan Kenny
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Dev Datta
- Lipid Unit, University Hospital Llandough, Penarth, UK
| | | | - Christopher Byrne
- Southampton National Institute for Health and Care Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Joe Kai
- PRISM Research Group, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
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