Case Study 1 - Intro
Congrats on being invited to join the prestigious economic modeling lab of Dr. Grooves.
There has been an increase in cases of Disease X within your country and you’ve been assigned to look into methods other countries near by have implemented.
You find that one country has implemented screening for all and provides treatment only for those that test positive. Another country has launched a campaign to treat everyone regardless of having the disease. The Ministry of Health has asked us to determine the cost effectiveness of the different strategies.
No Screen, No Treat
Screen All, then Treat
No Screen, Treat All
We will break into 6 teams. Each team will review a resource below for 5 minutes. Then we will discuss how the strategies compare.
Disease X Surveillance Bulletin
National Institute of Public Health, Department of Epidemiology
Quarterly Report Q3 2024
Prevalence Update: Disease X in Adults
Our national disease registry continues to track Disease X cases across all 47 provinces. Recent analysis of the 2024 cohort provides updated prevalence estimates for the target population.
Key Findings:
Among adults aged 50 years:
- Point prevalence: 8.0% (95% CI: 7.4-8.6%)
- No significant gender differences observed (p=0.34)
- Urban vs rural rates similar (8.1% vs 8.3%, p=0.19)
The 8% prevalence at age 50 represents a critical window for intervention, as this is the age when both screening and treatment are most feasible.
Disease Characteristics:
Disease X typically has minor symptoms in early stages. Among untreated patients in our longitudinal cohort (n=1,240), approximately 30% eventually developed clinical symptoms requiring medical attention.
For individuals who remain symptomatic and untreated, our cost analysis shows substantial healthcare utilization. Annual palliative care costs average $15,000 per patient for ongoing symptom management, routine monitoring, and supportive care. This includes outpatient visits, medications, and periodic procedures to manage disease burden.
Lifetime healthcare costs from age 50 for untreated symptomatic patients average $35,000 when accounting for reduced survival. In contrast, healthy 50-year-olds without Disease X incur baseline healthcare costs of approximately $20,000 over their remaining lifespan.
Geographic Distribution:
Cases reported across all provinces with clustering in three northern regions (prevalence 10-12%). This geographic variation may reflect differences in environmental exposures, genetic factors, or reporting practices. Further investigation planned for 2025.
Data source: National Health Information System, complete coverage 2023-2024
Regional Medical Journal - Research Article
Efficacy of Surgical Intervention for Disease X: Results from a Multicenter Trial
Southeast Asian Clinical Research Network, 2023
Background: Disease X affects approximately 8% of adults aged 50, with significant morbidity in untreated cases. We evaluated outcomes of a novel one-time outpatient surgical procedure compared to standard palliative care.
Methods: Multicenter randomized trial (n=840) comparing surgical intervention to palliative care in patients aged 48-52 with confirmed Disease X. Participants were followed for median 8.2 years (range 5-12 years). Primary outcome was quality-adjusted survival. Secondary outcomes included disease progression and healthcare costs.
Intervention: One-time outpatient procedure performed under local anesthesia (3-4 hours, same-day discharge). Direct procedure cost: $30,000 including pre-operative workup, surgical fees, facility costs, and immediate post-operative monitoring.
Results:
Survival outcomes: Treated patients demonstrated 9.0 additional life-years compared to controls (17.0 vs 8.0 years from baseline, p<0.001). Treatment success rate: 92%.
Quality of life considerations: Successfully treated patients experienced excellent long-term quality of life. However, there was a small reduction in life expectancy compared to healthy individuals (17 years for treated patients vs. 20 years for healthy 50-year-olds). This 3-year difference reflects both the burden of prior disease and minor long-term effects from the procedure itself.
For healthy individuals who undergo the procedure unnecessarily, the impact is smaller but measurable. Such individuals average 19.7 life years - a 0.3 year reduction compared to healthy individuals who don’t undergo surgery. This modest decrease reflects procedure-related risks and minor long-term effects.
Disease progression: Among successfully treated patients, 8% experienced disease recurrence. Recurrence rate: 3% annually vs. 8% baseline disease incidence (see separate cohort study for detailed recurrence analysis).
Ongoing care costs: Successfully treated patients require continued monitoring and medication. These ongoing costs are substantially lower than palliative care costs for untreated disease, averaging $5,000 annually vs. $15,000 for palliative care.
Limitations: Study conducted in tertiary centers. Generalizability to primary care settings unclear. Treatment cannot be repeated if disease recurs. Long-term follow-up beyond 12 years needed.
Conclusions: Single surgical intervention significantly improves survival and quality of life in Disease X patients, though requires substantial upfront investment. Benefits must be weighed against costs and the small reduction in life expectancy even for successfully treated patients.
Published in Regional Medical Journal, Vol 47(3), pp. 234-248
Diagnostic Performance Study
Validation of QuickTest-X Rapid Screening Protocol in Community Settings
Journal of Diagnostic Medicine, 2024
Background: Current clinical practice relies on symptomatic presentation for Disease X diagnosis, missing opportunities for early intervention. We evaluated a rapid screening test in community-dwelling adults.
Methods: Cross-sectional study across 12 primary care clinics (n=5,000 adults aged 50). All participants completed screening using QuickTest-X (blood-based assay, $2,510 per test including phlebotomy, laboratory processing, physician interpretation, and patient counseling). Results available within 24 hours.
Test Protocol:
- Standard venipuncture (3mL sample)
- Automated immunoassay processing in basic phlebotomy labs
- Binary result (positive/negative)
- Physician counseling and result disclosure included in cost
Reference Standard: Participants with positive tests underwent confirmatory diagnostic procedures during surgical intervention. Those with negative tests were followed prospectively to identify missed cases.
Results:
Test performance metrics:
- Sensitivity: 90% (95% CI: 86-93%)
- Specificity: 100% (95% CI: 99-100%)
- Positive predictive value: 100% (given perfect specificity)
- Negative predictive value: 98.9%
Key finding: 10% of true Disease X cases received false-negative results. These individuals continued standard care pathways, eventually presenting symptomatically. No healthy individuals were incorrectly classified as diseased (zero false positives observed across entire study population).
Clinical implications: Perfect specificity means no healthy person will undergo unnecessary treatment based on false-positive screening. However, 1 in 10 Disease X cases will be missed and present later when symptomatic. These missed cases face the same outcomes as if no screening program existed.
Acceptability: 89% of participants rated the test as “acceptable” or “very acceptable.” Primary concerns were venipuncture discomfort (11%) and anxiety waiting for results (8%). The 24-hour turnaround was viewed favorably compared to other diagnostic procedures requiring longer wait times.
Limitations: Study conducted in relatively healthy community sample. Performance in higher-risk populations requires further investigation. Long-term psychological impacts of false-negative results not assessed.
Conclusions: QuickTest-X demonstrates excellent specificity with good sensitivity. Perfect specificity eliminates treatment of healthy individuals, though 10% false-negative rate means some cases will be missed. Cost-effectiveness modeling needed to determine optimal implementation strategy.
National Laboratory Services Technical Report 2024-08
Health Policy Quarterly - Field Notes
Managing Disease X in Primary Care: A Conversation with Dr. Maria Santos
Community Health Director, Regional Medical Center
Q: Walk us through how Disease X typically progresses in your patient population.
A: Well, most of our Disease X patients start with what we call “mild disease” - they’re managing okay, coming in for regular check-ups. We’re talking basic symptom management, monitoring visits. That runs about $1,000 per year per patient for the routine care.
But here’s the thing - about 12% of those patients progress to severe disease each year. When that happens, everything changes. They need hospitalization, we do this intensive intervention to get them stabilized, set up home care… that transition alone costs around $50,000.
Q: And once they’re in that severe stage?
A: They’re in palliative care at that point. Much higher intensity than the mild cases. We’re seeing disease-specific mortality of about 15% per year in the severe group on top of normal age-related mortality. It’s tough.
Q: What about patients who’ve had the surgical treatment?
A: That’s interesting. Treatment works really well initially - most patients do great. But we’ve noticed that if Disease X comes back after treatment, the progression pattern is the same. So if a treated patient develops disease again - which happens to a small percentage - and they progress to severe disease, we see that same 12% annual progression rate to severe.
The frustrating part is we can’t repeat the surgery. So those patients end up in the same palliative care pathway as if they’d never been treated. That’s why timing matters so much.
Q: How does treatment affect the recurrence risk?
A: Yeah, our data shows treated patients have much lower rates of developing Disease X again. We’re seeing about 3% per year develop Disease X versus the natural 3% annual incidence we’d expect in an at-risk 50-year-old population - wait, let me clarify that. In the general population of 50-year-olds, about 3% develop Disease X each year. For our treated patients, we’re also seeing about 3% annual recurrence, but what’s important is the hazard ratio of 0.5 - so treatment cuts the risk in half compared to what their risk would be without treatment.
Q: What keeps you up at night about Disease X management?
A: Honestly? The progression to severe disease. Once patients are there, we’re looking at such poor outcomes and quality of life. If we could intervene earlier - catch people before they hit that severe stage - I think we’d see dramatically different trajectories. But that means either screening programs or broader treatment access, and those are resource questions beyond my clinic.
Interview conducted September 2024
National Health Service - Fee Schedule
Disease X Related Services - Standard Reimbursement Rates
Effective January 2024 - Ministry of Health Price List
DIAGNOSTIC SERVICES
| Service Code | Description | Unit Cost |
|---|---|---|
| DX-SCREEN-001 | QuickTest-X Screening (includes phlebotomy, lab processing, interpretation, counseling) | $2,510 |
| DX-CONF-002 | Confirmatory diagnostic panel | $890 |
| LAB-BAS-003 | Basic blood work (routine monitoring) | $120 |
| IMG-XR-004 | Standard radiograph | $180 |
TREATMENT SERVICES - DISEASE X
| Service Code | Description | Unit Cost |
|---|---|---|
| SURG-DX-100 | Disease X Surgical Procedure (one-time, outpatient) | $30,000 |
| Includes: pre-op assessment, surgical intervention, post-op monitoring | ||
| PALL-MLD-200 | Palliative Care - Mild Disease (annual package) | $1,000 |
| Includes: quarterly visits, basic symptom management | ||
| PALL-SEV-201 | Palliative Care - Severe Disease (annual package) | $15,000 |
| Includes: intensive symptom management, regular monitoring | ||
| TRANS-MLD-SEV | Transition Care - Mild to Severe (one-time) | $50,000 |
| Includes: hospitalization, stabilization, intensive care setup | ||
| POST-TX-300 | Post-Treatment Monitoring (annual package) | $5,000 |
| Includes: follow-up visits, medication management |
GENERAL MEDICAL SERVICES
| Service Code | Description | Unit Cost |
|---|---|---|
| VISIT-PCP-400 | Primary care consultation | $85 |
| VISIT-SPEC-401 | Specialist consultation | $165 |
| MED-BAS-500 | Basic medication (monthly supply) | $45 |
| MED-ADV-501 | Advanced medication (monthly supply) | $280 |
| HOSP-DAY-600 | Hospital day (general ward) | $1,200 |
| ER-VISIT-700 | Emergency room visit | $450 |
OTHER CONDITIONS (for reference)
| Service Code | Description | Unit Cost |
|---|---|---|
| CARD-SCREEN | Cardiovascular screening panel | $380 |
| DIAB-MGT | Diabetes management (annual) | $2,800 |
| HTN-MGT | Hypertension management (annual) | $1,500 |
| CANC-CHEM | Chemotherapy (per cycle) | $8,500 |
For billing questions contact: billing@nationalhealth.gov
For clinical guidelines contact: clinicalpolicy@nationalhealth.gov
Implementation Science Journal
Real-World Implementation of Disease X Screening in Primary Care
Excerpt from: “Translating Evidence to Practice: A 24-Month Implementation Study”
Setting: Network of 8 community health centers serving mixed urban/rural population (catchment: 180,000 adults).
Implementation Strategy:
We integrated Disease X screening into routine preventive care visits for adults aged 50. Rather than launching a standalone screening program, we embedded the test into existing annual wellness visit workflows.
Operational Details:
Medical assistants were trained to identify eligible patients during intake. During vital signs collection, they would mention: “You’re due for your Disease X screening today - can we add that to your blood work?”
Sample collection occurred during the same venipuncture as routine labs (cholesterol, glucose, etc.). No additional clinic visit required. Results typically returned within 24 hours via our existing lab information system.
Positive results triggered an automatic alert in our EHR. Care coordinators contacted patients within 48 hours to schedule treatment consultation. Average time from positive test to treatment initiation: 8 days (range 4-18 days).
Uptake and Yield:
In our first 24 months, we screened 45,000 patients. Uptake rate: 78% of eligible patients accepted when offered. Primary reasons for declining: “I feel fine” (52%), “too many tests already” (28%), time constraints (20%).
We identified 3,600 positive cases (8.0% positivity rate, consistent with prevalence estimates). Of these, 85% were completely asymptomatic at diagnosis. The remaining 15% had vague symptoms they hadn’t connected to Disease X.
Lessons Learned:
Integration with existing workflows was critical - standalone screening programs have much lower uptake. The 24-hour turnaround time reduced patient anxiety compared to longer wait times. Having care coordinators proactively reach out to positive patients improved treatment initiation rates.
Main challenge: managing the volume. With 8% positivity, screening 45,000 patients meant coordinating treatment for 3,600 people. This required significant surgical capacity expansion.
Next Steps:
We’re exploring targeted screening strategies - focusing on highest-risk populations rather than universal screening. Preliminary analysis suggests this could maintain 70-80% of case detection while reducing screening volume by 40-50%.
Published in Implementation Science, Volume 19, 2024