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Impact | Screening for health

Volume 20, Number 5
May 2014

Lauren Cipriano identifies the optimal time to start and stop a health program, and when to collect more information.

cipriano-impact-14.jpgHepatitis C is an infectious disease that attacks the liver, often leading to liver failure or cancer. In the past, hepatitis C treatments were often ineffective and could last as long as 48 weeks, with potentially debilitating side-effects. Fortunately, more effective drugs have recently been approved.

Ivey professor Lauren Cipriano applies management science and operations research to health policy issues. She recently completed a series of studies that looked at the treatment and screening of hepatitis C.

Her first study, published in Annals of Internal Medicine, analysed the cost-effectiveness of the new hepatitis C drugs. Though extremely expensive, these drugs have the potential to shorten treatment and are more likely to result in cure. “The question we looked at is whether these costly new treatments will avert enough severe liver disease, liver cancers, and liver transplants to be good value for money in the long run,” says Cipriano.

This question has significant implications for health funders with important budgetary considerations. Cipriano and her research team found that the new treatments were good value for the money in patients with advanced disease. They also identified an important role for genetic testing to identify individuals with less advanced disease who would benefit the most from the new, expensive drugs.

People infected with hepatitis C often have no symptoms for many years, even decades, and so many people do not know they have it. Of the five million Americans with the disease, baby boomers make up about two thirds of those who are infected. In the second of Cipriano’s studies, published in the journal PLOS ONE, she and her research team focused on the cost-effectiveness of hepatitis C screening programs. “The absence of effective treatments prevented general population screening from being worthwhile in the past,” she says. “Now there are better treatment options available and the best time to treat people is before they develop symptoms and potentially irreversible liver damage.”

Cipriano and her co-authors found that screening was cost effective for baby boomers. In the paper, they recommended once-in-a-lifetime screening for all Americans who were between the ages of 40 and 65 in 2010. This study was cited by the U.S. Preventive Service Task Force in its recommendation to screen people in this age group at their next routine physical.

Hepatitis C prevalence drops sharply among younger populations. Cipriano’s most recent study seeks to identify the youngest group of individuals for whom screening is still cost effective. She found that the screening policy adopted by the U.S. Preventive Service Task Force does not go far enough. Her study recommends routine screening at age 50, at least until those born in 1976 turn 50 (12 years from now). At that time, more information should be collected about hepatitis C prevalence and the program re-evaluated.

Cipriano’s study uses a unique mathematical framework to simultaneously identify the optimal time to start or stop a program and the optimal time to collect more information. Though a twelve-year gap between policy evaluations might seem lengthy, Cipriano says that it depends on how rapidly the environment is changing. “In the case of hepatitis C, prevalence is not changing that rapidly, so 12 years is appropriate. In a more dynamic setting, policy re-examination should come much sooner.”

The mathematical framework used in the study was developed with Thomas Weber of École Polytechnique Fédérale de Lausanne. This framework can be extended to answer more general questions for policy makers, like how to ensure that the mix of public health services is optimal for a changing population. “Health factors in the population, such as obesity, diabetes, cancer, and smoking, are changing over time, and that changes the optimal mix of health interventions,” says Cipriano. “How do we decide which policies to adopt in this changing environment? The answer to this question is intricately linked to decisions about when to collect more information and re-evaluate policy decisions.”

These are important questions for business as well as public policy. Companies waste money by re-evaluating programs too often or too infrequently. Five years is often deemed an appropriate re-evaluation interval because it coincides with budget cycles.

Managers or policy makers usually ask the question: do we want more information about this today? Cipriano’s framework asks the question: when do we want more information? “The critical insight from our study is that the timing of decision re-evaluation is as important as the decision itself.”


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