Lauren E. Cipriano

• Hafeez, A.; Cipriano, L. E.; Kim, R.; Zaric, G.; Schwarz, U.; Sarma, S., 2023, "Cost‑Effectiveness Analysis of Pharmacogenomics (PGx)‑Based Warfarin, Apixaban, andRivaroxaban Versus Standard Warfarin for the Management of Atrial Fibrillation in Ontario, Canada", Pharmacoeconomics
  Abstract: Objective To assess the cost-effectiveness of pharmacogenomics (PGx)-based warfarin (i.e., warfarin dosing following genetic testing), apixaban, and rivaroxaban oral anticoagulation versus standard warfarin for the treatment of newly diagnosed patients with nonvalvular atrial fibrillation (AF) aged ≥ 65 years. Methods We developed a Markov decision-analytic model to compare costs [2017 Canadian dollars (C$)] and qualityadjusted life years (QALYs) from the Ontario health care payer perspective over a life-time horizon. The parameters used in the model were derived from the published literature, the Ontario health care administrative database, and expert opinion. To account for the uncertainty of model parameters, we conducted extensive deterministic and probabilistic sensitivity analyses. The results were summarized using incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves. Results We found that PGx-based warfarin had an ICER of C$17,584/QALY compared with standard warfarin, and apixaban had an ICER of C$64,590/QALY compared with PGx-based warfarin in our base-case analysis. Rivaroxaban was extendedly dominated by PGx-based warfarin and apixaban. The probabilistic sensitivity analysis showed that apixaban, rivaroxaban, PGx-based warfarin, and standard warfarin were cost-effective at some willingness-to-pay (WTP) thresholds. PGx-based warfarin had a higher probability of being cost-effective than apixaban (51.3% versus 14.3%) at a WTP threshold of C$50,000/QALY. At a WTP threshold of C$100,000/QALY, apixaban had a higher probability of being cost-effective than PGx-based warfarin (54.6% versus 22.6%). Conclusion We found that PGx-based warfarin for patients with AF is cost-effective at a WTP threshold of C$50,000/QALY. Apixaban had a higher probability of being cost-effective (> 50%) at a WTP threshold of C$93,000/QALY.

  Link(s) to publication:

  https://link.springer.com/epdf/10.1007/s40273-023-01309-z?sharing_token=230MWYDDAt7tCH1nQCeMr_e4RwlQNchNByi7wbcMAY7GYp9w-EfUo1-eMtTizQ0X7peo2rGSsdRypD5MEZ9GjpXVl9QB-qhQvfqz1q4FuiSfuejw_nw0NCN1fRUsB_3mLIUTHBI7vN7XQDv50MqelkiSj2ZoOFV_xgn8B0PmppE=

  http://dx.doi.org/10.1007/s40273-023-01309-z

• Roseborough, A. D.; Saad, L.; Goodman, M.; Cipriano, L. E.; Hachinski, V. C.; Whitehead, S. N., 2023, "White matter hyperintensities and longitudinal cognitive decline in cognitively normal populations and across diagnostic categories: A meta‐analysis, systematic review, and recommendations for future study harmonization", Alzheimers & Dementia, January 19(1): 194 - 207.
  Abstract: Abstract Introduction The primary aim of this paper is to improve the clinical interpretation of white matter hyperintensities (WMHs) and provide an overarching summary of methodological approaches, allowing researchers to design future studies targeting current knowledge gaps. Methods A meta-analysis and systematic review was performed investigating associations between baseline WMHs and longitudinal cognitive outcomes in cognitively normal populations, and populations with mild cognitive impairment (MCI), Alzheimer's disease (AD), and stroke. Results Baseline WMHs increase the risk of cognitive impairment and dementia across diagnostic categories and most consistently in MCI and post-stroke populations. Apolipoprotein E (APOE) genotype and domain-specific cognitive changes relating to strategic anatomical locations, such as frontal WMH and executive decline, represent important considerations. Meta-analysis reliability was assessed using multiple methods of estimation, and results suggest that heterogeneity in study design and reporting remains a significant barrier. Discussion Recommendations and future directions for study of WMHs are provided to improve cross-study comparison and translation of research into consistent clinical interpretation.

  Link(s) to publication:

  http://dx.doi.org/10.1002/alz.12642

• Vilches, T. N.; Abdollahi, E.; Cipriano, L. E.; Haworth-Brockman, M.; Keynan, Y.; Sheffield, H.; Langley, J. M.; Moghadas, S. M., 2022, "Impact of non-pharmaceutical interventions and vaccination on COVID-19 outbreaks in Nunavut, Canada: a Canadian Immunization Research Network (CIRN) study", Bmc Public Health, May 22(1): 1042 - 1042.
  Abstract: Background Nunavut, the northernmost Arctic territory of Canada, experienced three community outbreaks of the coronavirus disease 2019 (COVID-19) from early November 2020 to mid-June 2021. We sought to investigate how non-pharmaceutical interventions (NPIs) and vaccination affected the course of these outbreaks. Methods We used an agent-based model of disease transmission to simulate COVID-19 outbreaks in Nunavut. The model encapsulated demographics and household structure of the population, the effect of NPIs, and daily number of vaccine doses administered. We fitted the model to inferred, back-calculated infections from incidence data reported from October 2020 to June 2021. We then compared the fit of the scenario based on case count data with several counterfactual scenarios without the effect of NPIs, without vaccination, and with a hypothetical accelerated vaccination program whereby 98% of the vaccine supply was administered to eligible individuals. Results We found that, without a territory-wide lockdown during the first COVID-19 outbreak in November 2020, the peak of infections would have been 4.7 times higher with a total of 5,404 (95% CrI: 5,015—5,798) infections before the start of vaccination on January 6, 2021. Without effective NPIs, we estimated a total of 4,290 (95% CrI: 3,880—4,708) infections during the second outbreak under the pace of vaccination administered in Nunavut. In a hypothetical accelerated vaccine rollout, the total infections during the second Nunavut outbreak would have been 58% lower, to 1,812 (95% CrI: 1,593—2,039) infections. Vaccination was estimated to have the largest impact during the outbreak in April 2021, averting 15,196 (95% CrI: 14,798—15,591) infections if the disease had spread through Nunavut communities. Accelerated vaccination would have further reduced the total infections to 243 (95% CrI: 222—265) even in the absence of NPIs. Conclusions NPIs have been essential in mitigating pandemic outbreaks in this large, geographically distanced and remote territory. While vaccination has the greatest impact to prevent infection and severe outcomes, public health implementation of NPIs play an essential role in the short term before attaining high levels of immunity in the population.

  Link(s) to publication:

  http://dx.doi.org/10.1186/s12889-022-13432-1

• Bansback, N. J.; Barbosa, C.; Barocas, J.; Bayoumi, A. M.; Behrends, C.; Chhatwal, J.; Cipriano, L. E.; Coffin, P.; Goldhaber-Fiebert, J. D.; Hoch, J., et al., 2021, "How simulation modeling can support the public health response to the opioid crisis in North America: Setting priorities and assessing value", International Journal of Drug Policy, April 88: 102726 - 102726.
• Yarmol-Matusiak, E. A.; Cipriano, L. E.; Stranges, S., 2021, "A comparison of COVID-19 epidemiological indicators in Sweden, Norway, Denmark, and Finland", SCANDINAVIAN JOURNAL OF PUBLIC HEALTH, February 49(1): 69 - 78.
  Abstract: Aims: To compare the early impact of COVID-19 infections and mortality from February to July 2020 across the Nordic nations of Sweden, Norway, Denmark, and Finland through available public data sources and conduct a descriptive analysis of the potential factors that drove different epidemiological outcomes, with a focus on Sweden’s response. Methods: COVID-19 cases, deaths, tests, case age distribution, and the difference between 2020 all-cause mortality and the average mortality of the previous 5 years were compared across nations. Patterns in cell phone mobility data, testing strategies, and seniors’ care home deaths were also compared. Data for each nation were based on publicly available sources as of July 31, 2020. Results: Compared with its Nordic peers, Sweden had a higher incidence rate across all ages, a higher COVID-19-related death rate only partially explained by population demographics, a higher death rate in seniors’ care, and higher all-cause mortality. Sweden had approximately half as much mobility change as its Nordic neighbours until April and followed similar rates as its neighbours from April to July. Denmark led its Nordic peers in testing rates, while Sweden had the highest cumulative test-positivity rate continuously from mid-March. Conclusions: COVID-19 pushed Sweden’s health system to its capacity, exposed systemic weaknesses in the seniors’ care system, and revealed challenges with implementing effective contact tracing and testing strategies while experiencing a high case burden. Looser government restrictions at the beginning of the outbreak are likely to have played a role in the impact of COVID-19 in Sweden. In an effort to improve epidemic control, Sweden has increased testing rates, implemented more restrictive prevention measures, and increased their intensive care unit bed capacity.

  Link(s) to publication:

  http://dx.doi.org/10.1177/1403494820980264

• Fairley, M.; Cipriano, L. E.; Goldhaber-Fiebert, J. D., 2020, "Optimal Allocation of Research Funds under a Budget Constraint", Medical Decision Making, August 40(6): 797 - 814.
  Abstract: Purpose. Health economic evaluations that include the expected value of sample information support implementation decisions as well as decisions about further research. However, just as decision makers must consider portfolios of implementation spending, they must also identify the optimal portfolio of research investments. Methods. Under a fixed research budget, a decision maker determines which studies to fund; additional budget allocated to one study to increase the study sample size implies less budget available to collect information to reduce decision uncertainty in other implementation decisions. We employ a budget-constrained portfolio optimization framework in which the decisions are whether to invest in a study and at what sample size. The objective is to maximize the sum of the studies’ population expected net benefit of sampling (ENBS). We show how to determine the optimal research portfolio and study-specific levels of investment. We demonstrate our framework with a stylized example to illustrate solution features and a real-world application using 6 published cost-effectiveness analyses. Results. Among the studies selected for nonzero investment, the optimal sample size occurs at the point at which the marginal population ENBS divided by the marginal cost of additional sampling is the same for all studies. Compared with standard ENBS optimization without a research budget constraint, optimal budget-constrained sample sizes are typically smaller but allow more studies to be funded. Conclusions. The budget constraint for research studies directly implies that the optimal sample size for additional research is not the point at which the ENBS is maximized for individual studies. A portfolio optimization approach can yield higher total ENBS. Ultimately, there is a maximum willingness to pay for incremental information that determines optimal sample sizes.

  Link(s) to publication:

  http://dx.doi.org/10.1177/0272989X20944875

• Roseborough, A. D.; Langdon, K. D.; Hammond, R.; Cipriano, L. E.; Pasternak, S. H.; Whitehead, S. N.; Khan, A. R., 2020, "Post-mortem 7 Tesla MRI detection of white matter hyperintensities: A multidisciplinary voxel-wise comparison of imaging and histological correlates", NeuroImage: Clinical, July 27
  Abstract: White matter hyperintensities (WMH) occur in normal aging and across diagnostic categories of neurodegeneration. Ultra-high field imaging (UHF) MRI machines offer the potential to improve our understanding of WMH. Post-mortem imaging using UHF magnetic resonance imaging (MRI) is a useful way of assessing WMH, however, the responsiveness of UHF-MRI to pathological changes within the white matter has not been characterized. In this study we report post-mortem MRI sequences of white matter hyperintensities in normal aging, Alzheimer’s disease, and cerebrovascular disease. Seven Tesla post-mortem MRI reliably detected periventricular WMH using both FLAIR and T2 sequences and reflects underlying pathology of myelin and axon density despite prolonged fixation time. Co-registration of histological images to MRI allowed for direct voxel- wise comparison of imaging findings and pathological changes. Myelin content and cerebrovascular pathology were the most significant predictors of MRI white matter intensity as revealed by linear mixed models. Future work investigating the utility of UHF- MRI in studying cell-specific changes within WMH is required to better understand radio-pathologic correlations.

  Link(s) to publication:

  http://dx.doi.org/10.1016/j.nicl.2020.102340

• Azarpazhooh, M. R.; Avan, A.; Cipriano, L. E.; Munoz, D. G.; Erfanian, M.; Amiri, A.; Stranges, S.; Hachinski, V., 2020, "A third of community-dwelling elderly with intermediate and high level of Alzheimer's neuropathologic changes are not demented: A meta-analysis", Ageing Research Reviews, March 58
  Abstract: This systematic review and meta-analysis assessed the bidirectional association between AD pathology and dementia in community-dwelling elderly populations. We searched PubMed/MEDLINE, Embase, Scopus, Web of Science, and references of the pertinent articles for community/population-based longitudinal cohorts with regular assessment of cognitive status of participants followed by postmortem neuropathology data, with no language and date restrictions, until 20 September 2019. Finally, we retrieved 18 articles with data from 17 cohorts comprising 4677 persons. Dementia was twice as likely in participants with definitive neuropathological indicator for AD compared to those without it: moderate/high Braak and Braak (BB) stages III–VI of neurofibrillary tangles (54 % vs. 26 % in participants with BB stages 0–II), the Consortium to Establish a Registry for AD (CERAD) moderate/frequent neuritic plaques scores (64 % vs. 33 % in participants with CERAD none/infrequent), and National Institute on Aging and the Reagan Institute of the Alzheimer's Association criteria intermediate/high AD probability (52 % vs. 28 % in participants with no/low AD probability). Accordingly, a substantial proportion of community-dwelling elderly people with definitive AD pathology may not develop dementia. Brain reserve or contribution of other factors and pathologies, such as vascular and degenerative pathology to dementia might explain this apparent discrepancy. These findings also suggest caution in equating Alzheimer pathology biomarkers with dementia.

  Link(s) to publication:

  http://dx.doi.org/10.1016/j.arr.2019.101002

• Cipriano, L. E.; Goldhaber-Fiebert, J. D., 2019, "Population health and cost-effectiveness implications of a “treat all” recommendation for HCV: A review of the model-based evidence", Medical Decision Making: Policy & Practice, June 3(1)
  Abstract: The World Health Organization HCV Guideline Development Group is considering a “treat all” recommendation for persons infected with hepatitis C virus (HCV). We reviewed the model-based evidence of cost-effectiveness and population health impacts comparing expanded treatment policies to more limited treatment access policies, focusing primarily on evaluations of all-oral directly acting antivirals published after 2012. Searching PubMed, we identified 2,917 unique titles. Sequentially reviewing titles and abstracts identified 226 potentially relevant articles for full-text review. Sixty-nine articles met all inclusion criteria—42 cost-effectiveness analyses and 30 models of population-health impacts, with 3 articles presenting both types of analysis. Cost-effectiveness studies for many countries concluded that expanding treatment to people with mild liver fibrosis, who inject drugs (PWID), or who are incarcerated is generally cost-effective compared to more restrictive treatment access policies at country-specific prices. For certain patient subpopulations in some countries—for example, elderly individuals without fibrosis—treatment is only cost-effective at lower prices. A frequent limitation is the omission of benefits and consequences of HCV transmission (i.e., treatment as prevention; risks of reinfection), which may underestimate or overestimate the cost-effectiveness of a “treat all” policy. Epidemiologic modeling studies project that through a combination of prevention, aggressive screening and diagnosis, and prompt treatment for all fibrosis stages, it may be possible to virtually eliminate HCV in many countries. Studies show that if resources are not available to diagnose and treat all HCV-infected individuals, treatment prioritization may be needed, with alternative prioritization strategies resulting in tradeoffs between reducing mortality or reducing incidence. Notably, because most new HCV infections are among PWID in many settings, HCV elimination requires unrestricted treatment access combined with injection transmission disruption strategies. The model-based evidence suggests that a properly constructed strategy that substantially expands HCV treatment could achieve cost-effective improvements in population health in many countries.

  Link(s) to publication:

  http://dx.doi.org/10.1177/2381468318776634

• Chehrazi, N.; Cipriano, L. E.; Enns, E. A., 2019, "Dynamics of drug resistance: Optimal control of an infectious disease", Operations Research, June 67(3): 599 - 904.
  Abstract: Antimicrobial resistance is a significant public health threat. In the United States alone, two million people are infected, and 23,000 die each year from antibiotic-resistant bacterial infections. In many cases, infections are resistant to all but a few remaining drugs. We examine the case in which a single drug remains and solve for the optimal treatment policy for a susceptible–infected–susceptible infectious disease model, incorporating the effects of drug resistance. The problem is formulated as an optimal control problem with two continuous state variables: the disease prevalence and drug’s “quality” (the fraction of infections that are drug-susceptible). The decision maker’s objective is to minimize the discounted cost of the disease to society over an infinite horizon. We provide a new generalizable solution approach that allows us to thoroughly characterize the optimal treatment policy analytically. We prove that the optimal treatment policy is a bang-bang policy with a single switching time. The action/inaction regions can be described by a single boundary that is strictly increasing when viewed as a function of drug quality, indicating that, when the disease transmission rate is constant, the policy of withholding treatment to preserve the drug for a potentially more serious future outbreak is not optimal. We show that the optimal value function and/or its derivatives are neither C1 nor Lipschitz continuous, suggesting that numerical approaches to this family of dynamic infectious disease models may not be computationally stable. Furthermore, we demonstrate that relaxing the standard assumption of a constant disease transmission rate can fundamentally change the shape of the action region, add a singular arc to the optimal control, and make preserving the drug for a serious outbreak optimal. In addition, we apply our framework to the case of antibiotic-resistant gonorrhea.

  Link(s) to publication:

  http://dx.doi.org/10.1287/opre.2018.1817

• Ma, C.; Guizzetti, L.; Cipriano, L. E.; Parker, C.; Nguyen, T.; Gregor, J.; Chande, N.; Feagan, B.; Jairath, V., 2019, "Systematic review and meta-analysis: high prevalence and cost of continued aminosalicylate use in patients with ulcerative colitis escalated to immunosuppressive and biological therapies", Alimentary Pharmacology and Therapeutics, February 49(4): 364 - 374.
• Cerasuolo, J. O.; Azarpazhooh, M. R.; Kapral, M. K.; Cipriano, L. E.; Hachinski, V., 2019, "Evidence of Concomitantly Increasing Stroke and Dementia Prevalence among those 80 Years and Older in Ontario, Canada, 2003-04 to 2012-13", Canadian Journal of Neurological Sciences, January 46(1): 105 - 107.
  Abstract: Among those aged 80 years and older in Ontario, Canada, stroke and dementia incidence declined concomitantly from 2002-03 to 2013-14. This study aimed to report the concurrent temporal trends of stroke and dementia prevalence in Ontario among the same age demographic. The prevalence of both stroke and dementia increased from 2003-04 to 2012-13 in both sexes and the magnitude in which prevalence of dementia increased over time exceeded that of stroke. The substantial increase in the prevalence of dementia may be because of increased recognition and diagnoses of dementia and increased survival of stroke patients who are at higher risk of developing dementia.

  Link(s) to publication:

  https://www.ncbi.nlm.nih.gov/pubmed/30449286

  http://dx.doi.org/10.1017/cjn.2018.347

• Sheehan, D.; Criss, S.; Chen, Y.; Eckel, A.; Palazzo, L.; Tramontano, A.; Hur, C.; Cipriano, L. E.; Kong, C. Y., 2019, "Lung cancer costs by treatment strategy and phase of care among patients enrolled in Medicare", Cancer Medicine, January 8(1): 94 - 103.
  Abstract: Background: We studied trends in lung cancer treatment cost over time by phase of care, treatment strategy, age, stage at diagnosis, and histology. Methods: Using the Surveillance, Epidemiology, and End Results (SEER)‐Medicare database for years 1998‐2013, we allocated total and patient‐liability costs into the following phases of care for 145 988 lung cancer patients: prediagnosis, staging, surgery, initial, continuing, and terminal. Patients served as self‐controls to determine cancer‐attributable costs based on individual precancer diagnosis healthcare costs. We fit linear regression models to determine cost by age and calendar year for each stage at diagnosis, histology, and treatment strategy and presented all costs in 2017 US dollars. Results: Monthly healthcare costs prior to lung cancer diagnosis were $861 for a 70 years old in 2017 and rose by an average of $17 per year (P < 0.001). Surgery in 2017 cost $30 096, decreasing by $257 per year (P = 0.007). Chemotherapy and radiation costs remained stable or increased for most stage and histology groups, ranging from $4242 to $8287 per month during the initial six months of care. Costs during the final six months of life decreased for those who died of lung cancer or other causes. Conclusions: Cost‐effectiveness analyses of lung cancer control interventions in the United States have been using outdated and incomplete treatment cost estimates. Our cost estimates enable updated cost‐effectiveness analyses to determine the benefit of lung cancer control from a health economics point of view.

  Link(s) to publication:

  http://dx.doi.org/10.1002/cam4.1896

• Mickle, K.; Lasser, K. E.; Hoch, J. S.; Cipriano, L. E.; Dreitlein, W. B.; Pearson, S. D., 2019, "The effectiveness and value of patisiran and inotersen for hereditary transthyretin amyloidosis: A summary from the Institute for Clinical and Economic Review’s midwest comparative effectiveness public advisory council", Journal of Managed Care and Specialty Pharmacy, January 25(1): 10 - 15.
  Abstract: DISCLOSURES: Funding for this summary was contributed by the Laura and John Arnold Foundation, Blue Shield of California, and California Health Care Foundation to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER’s annual policy summit is supported by dues from Aetna, AHIP, Anthem, Blue Shield of California, CVS Caremark, Express Scripts, Harvard Pilgrim Health Care, Cambia Health Solutions, United Healthcare, Kaiser Permanente, Premera Blue Cross, AstraZeneca, Genentech, GlaxoSmithKline, Johnson & Johnson, Merck, National Pharmaceutical Council, Prime Therapeutics, Sanofi, Spark Therapeutics, Health Care Service Corporation, Editas, Alnylam, Regeneron, Mallinkrodt, Biogen, HealthPartners, and Novartis. Mickle, Dreitlein, and Pearson are ICER employees. Lasser, Cipriano, and Hoch have nothing to disclose. Hereditary transthyretin amyloidosis (hATTR) is a rare, autosomal dominant disease caused by the misfolding of the liver protein transthyretin (TTR). Patients ultimately develop TTR depositions across multiple body systems and organs leading most prominently to progressive polyneuropathy or cardiac dysfunction, with many patients experiencing both. Polyneuropathy associated with hATTR significantly impairs motor, autonomic, and sensory nerve function. Initial neuropathic pain is followed by progressive motor weakness, ultimately leading to the inability to walk. Gastrointestinal impairment due to autonomic neuropathy is also disabling, and it can progress to later-stage wasting and cachexia.2 TTR deposition in cardiac tissue can result in thickening of ventricular walls, diastolic dysfunction, arrhythmia, and heart failure. Approximately 10,000 people worldwide have been diagnosed with hATTR-related neuropathy, of which 3,000-3,500 patients are in the United States. The incidence of cardiomyopathy due to hATTR is largely unknown because of varying estimates of the proportion of patients who develop clinical disease (7%-80%), although prevalence is known to increase with advancing age. The median age at onset of symptoms is 68.1 years, and the median survival time from diagnosis is 5-15 years; survival is shorter for individuals with cardiac involvement (2.5-4 years). Standard treatment for hATTR includes diflunisal and liver transplantation, but neither approach reverses the damage caused by TTR deposits, and both treatments are restricted to relatively healthy patients due to safety and mortality risks. The Institute for Clinical and Economic Review (ICER) recently conducted a review of 2 new first-in-class drugs for hATTR: patisiran (Onpattro, Alnylam Pharmaceuticals) and inotersen (Tegsedi, Akcea Therapeutics). Both drugs aim to reduce TTR by targeting the RNA that produces the misfolded protein, either by enhancing RNA degradation (inotersen) or by reducing its production (patisiran). The U.S. Food and Drug Administration (FDA) approved patisiran on August 10, 2018; when ICER concluded its assessment in September 2018, inotersen was still undergoing FDA review. Here, we present a summary of the systematic literature review, cost-effectiveness analyses, and policy discussion with key stakeholders regarding the overall value of these RNA-targeted therapies. The full report is published on ICER’s website at www.icer-review.org.

  Link(s) to publication:

  http://dx.doi.org/10.18553/jmcp.2019.25.1.010

• Cipriano, L. E.; Weber, T. A., 2018, "Population-level intervention and information collection in dynamic healthcare policy", Health Care Management Science, December 21(4): 604 - 631.
  Abstract: © 2017 The Author(s) We develop a general framework for optimal health policy design in a dynamic setting. We consider a hypothetical medical intervention for a cohort of patients where one parameter varies across cohorts with imperfectly observable linear dynamics. We seek to identify the optimal time to change the current health intervention policy and the optimal time to collect decision-relevant information. We formulate this problem as a discrete-time, infinite-horizon Markov decision process and we establish structural properties in terms of first and second-order monotonicity. We demonstrate that it is generally optimal to delay information acquisition until an effect on decisions is sufficiently likely. We apply this framework to the evaluation of hepatitis C virus (HCV) screening in the general population determining which birth cohorts to screen for HCV and when to collect information about HCV prevalence.

  Link(s) to publication:

  http://dx.doi.org/10.1007/s10729-017-9415-5

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