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Episode 13 looks at the NICE Draft Guidance Evaluating FibroScan use in Community and Primary Care settings. This conversation focuses on the real impact of a decision not to compensate at this time, with most discussion centering in some form around the idea that a positive NAFLD screen leads to what Chris Estes of the Center for Disease Analysis Foundation describes as a "Cascade of Care." 

Jörn Schattenberg leads this conversation by asking whether we can use an entry test or some other method to enrich the test and thereby speed development of the data necessary to answer the question. Chris Estes points out that the right analysis will require assessment of the entire care cascade, with all its tests and care for people who test positive. Roger Green asks Chris whether such data exists in another setting where we can extrapolate to this situation, to which Chris notes that the FibroScan studies are fairly early and done only in tertiary care centers. Louise Campbell asks Chris whether any post-COVID modeling has been done given that the downstream burdens COVID is placing on the healthcare system due to diseases being diagnosed later in course of disease. Chris refers to some viral hepatitis analysis that suggests that while analysts initially assumed a two-year lag in care due to COVID, the actual impacts on care and costs appear to last far longer. The rest of the discussion bounces back and forth between the question how to apply data that lead to clear inferences but is not directly applicable to this case and the lack of the continuum of data necessary to make clean comparisons. At the end, Louise Campbell suggests that a decision not to compensate will way most heavily on economically burdened and rural patients. Roger Green asks whether this becomes one more health burden on people who already have not received enough care and Chris Estes describes this combination of inability to travel and incur costs of care with COVID, the dramatic increases in opioid addiction in this population, and well-noted increases in drinking and obesity to create a "perfect storm" of risk factors.