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Med Decis Making. 2018 Nov;38(8):930-941. doi: 10.1177/0272989X18807438.

Simple Inclusion of Complex Diagnostic Algorithms in Infectious Disease Models for Economic Evaluation.

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School of Health and Related Research, University of Sheffield, Sheffield, UK (PJD).
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (JJP, DWD).
Division of Asthma Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (LBM).



Cost-effectiveness models for infectious disease interventions often require transmission models that capture the indirect benefits from averted subsequent infections. Compartmental models based on ordinary differential equations are commonly used in this context. Decision trees are frequently used in cost-effectiveness modeling and are well suited to describing diagnostic algorithms. However, complex decision trees are laborious to specify as compartmental models and cumbersome to adapt, limiting the detail of algorithms typically included in transmission models.


We consider an approximation replacing a decision tree with a single holding state for systems where the time scale of the diagnostic algorithm is shorter than time scales associated with disease progression or transmission. We describe recursive algorithms for calculating the outcomes and mean costs and delays associated with decision trees, as well as design strategies for computational implementation. We assess the performance of the approximation in a simple model of transmission/diagnosis and its role in simplifying a model of tuberculosis diagnostics.


When diagnostic delays were short relative to recovery rates, our approximation provided a good account of infection dynamics and the cumulative costs of diagnosis and treatment. Proportional errors were below 5% so long as the longest delay in our 2-step algorithm was under 20% of the recovery time scale. Specifying new diagnostic algorithms in our tuberculosis model was reduced from several tens to just a few lines of code.


For conditions characterized by a diagnostic process that is neither instantaneous nor protracted (relative to transmission dynamics), this novel approach retains the advantages of decision trees while embedding them in more complex models of disease transmission. Concise specification and code reuse increase transparency and reduce potential for error.


computational techniques; cost-effectiveness; decision trees; diagnostic algorithms; infectious diseases; transmission models

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