Reproducibility of colposcopy quality indicators-A survey among members of the European Federation for Colposcopy.

INTRODUCTION: Colposcopy is an important part of the diagnostic work-up of women with an abnormal cervical screening test as it is used to guide the collection of biopsies. Although quality assurance has been used in the evaluation of screening programs, not much is known about quality indicators for the diagnostics and treatment of screen-positive women. Therefore, the European Federation for Colposcopy developed quality indicators aiming to support colposcopy practice across Europe. We performed a survey of colposcopy cases to determine if the quality indicators are understandable, relevant, and reproducible. MATERIAL AND METHODS: We conducted a survey among all members of the European Federation for Colposcopy Quality and Standards Group from November 2022 to March 2023. Members were asked to collect information on a total of 17 quality indicators for 50 women who had been newly referred for colposcopy due to an abnormal screening test between January 1, 2020 to December 31, 2021. Results were reported descriptively. RESULTS: We included data on 609 cases from 12 members across Europe. The majority of the quality indicators were either achieved or within reach of the agreed standard, often due to few countries with outlying data. One quality indicator had very low performance, although stratified results indicated that two countries had different clinical management of the patient type thereby skewing the results. In addition, discrepancies between the number of cases included in each quality indicator raised concerns regarding potential misunderstanding of the quality indicator and its objective. CONCLUSIONS: Quality indicators on colposcopy must be understandable to those collecting data, highlighting the importance of validating quality indicators before data collection.

Incidence of cervical intraepithelial neoplasia in Estonia.

OBJECTIVE: This study aimed to assess the incidence of cervical intraepithelial neoplasia (CIN) by grade (CIN 1, CIN 2, CIN 3) and age in Estonia (a country with less developed cervical cancer screening program and high cervical cancer incidence). MATERIALS AND METHODS: This descriptive study uses data from a health insurance fund covering the whole country to estimate the incidence of CIN by grade. CIN case definition was based on specific diagnostic procedures (biopsy, pathological diagnosis, and colposcopy) and/or treatment procedures (excision, local destructive therapy, conization, and hysterectomy) with the CIN-specific diagnosis code (International Statistical Classification of Diseases, 10 Revision) reported on health care claims. Age-specific incidence rates were calculated together with the 95% CIs. Main outcome measure includes CIN grade-specific incidence rate per 1,000 women. RESULTS: The estimates for CIN incidence per 1,000 women range from 0.68 to 2.83 for CIN 1, 0.63 to 1.24 for CIN 2, and 0.13 to 0.53 for CIN 3 for narrow (biopsy/pathological diagnosis based) and broad (any CIN-specific diagnostic procedure/treatment based) case definition criteria, respectively. CONCLUSIONS: Our estimates for cervical dysplasia disease frequency and age distribution are in line with those from other developed countries. Administrative health care resources (such as health insurance fund data) are a valuable source for health research.

Cost-effectiveness of HPV vaccination in the context of high cervical cancer incidence and low screening coverage.

BACKGROUND: Estonia has high cervical cancer incidence and low screening coverage. We modelled the impact of population-based bivalent, quadrivalent or nonavalent HPV vaccination alongside cervical cancer screening. METHODS: A Markov cohort model of the natural history of HPV infection was used to assess the cost-effectiveness of vaccinating a cohort of 12-year-old girls with bivalent, quadrivalent or nonavalent vaccine in two doses in a national, school-based vaccination programme. The model followed the natural progression of HPV infection into subsequent genital warts (GW); premalignant lesions (CIN1-3); cervical, oropharyngeal, vulvar, vaginal and anal cancer. Vaccine coverage was assumed to be 70%. A time horizon of 88years (up to 100years of age) was used to capture all lifetime vaccination costs and benefits. Costs and utilities were discounted using an annual discount rate of 5%. RESULTS: Vaccination of 12-year-old girls alongside screening compared to screening alone had an incremental cost-effectiveness ratio (ICER) of €14,007 (bivalent), €14,067 (quadrivalent) and €11,633 (nonavalent) per quality-adjusted life-year (QALY) in the base-case scenario and ranged between €5367-21,711, €5142-21,800 and €4563-18,142, respectively, in sensitivity analysis. The results were most sensitive to changes in discount rate, vaccination regimen, vaccine prices and cervical cancer screening coverage. CONCLUSION: Vaccination of 12-year-old girls alongside current cervical cancer screening can be considered a cost-effective intervention in Estonia. Adding HPV vaccination to the national immunisation schedule is expected to prevent a considerable number of HPV infections, genital warts, premalignant lesions, HPV related cancers and deaths. Although in our model ICERs varied slightly depending on the vaccine used, they generally fell within the same range. Cost-effectiveness of HPV vaccination was found to be most dependent on vaccine cost and duration of vaccine immunity, but not on the type of vaccine used.