A comparison of six approaches for measuring utility values among patients with locally advanced cervical cancer.

BACKGROUND: Several instruments are available to measure health utility values. However, limited studies have not yet comprehensively assessed the agreement among these instruments. This study therefore aimed to investigate the performance and agreement of six instruments for utility measures: EQ-5D-3L, EQ-5D-5L (cTTO model), EQ-5D-5L (DCE model), EQ-5D-5L (Hybrid model), TTO, and VAS, among locally advanced cervical cancer (LACC) patients in Thailand. METHODS: We compared utility scores derived from six approaches using Friedman's test. We also assessed the agreement of utility scores between each pairwise comparison by intraclass correlation coefficient (ICC) and Bland-Altman plot. RESULTS: The mean (SD) utility values derived from six approaches were as follows: 0.755 ± 0.248 (EQ-5D-3L), 0.801 ± 280 (TTO), 0.806 ± 0.156 (VAS), 0.871 ± 0.184 (cTTO model), 0.875 ± 0.168 (Hybrid model), and 0.900 ± 0.142 (DCE model). Significant differences across six approaches were found in Friedman's test. The ICC showed high agreement between EQ-5D-5L and EQ-5D-3L, and very high agreement between all three models of EQ-5D-5L. The Bland-Altman plots showed wide limit of agreement, except the pairwise comparison, between each model of the EQ-5D-5L. CONCLUSION: TTO, VAS, EQ-5D-3L and EQ-5D-5L could not be used interchangeably in LACC patients. The impact of using different instruments on economic evaluation findings warrants further investigation.

Cost-Effectiveness Analysis of Diagnostic Tests for Para-Aortic Lymph Node Detection in Locally Advanced Cervical Cancer.

PURPOSE: We aimed to determine the cost-effectiveness of diagnostic tests, ie, computed tomography (CT), magnetic resonance imaging (MRI), and fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) for para-aortic lymph node detection (PALND), in locally advanced cervical cancer (LACC) patients (stages IB3-IVA) with or without laparoscopic lymphadenectomy (LL) compared with no investigation (NoIx) based on provider and societal perspectives during 5 years. PATIENTS AND METHODS: Hybrid decision tree and Markov models were conducted to compare the cost and utility of six interventions including: 1) CT without LL, 2) CT with LL, 3) MRI without LL, 4) MRI with LL, 5) PET/CT without LL, and 6) PET/CT with LL compared with NoIx. All clinical parameters were obtained from published studies. Costs were presented in year 2019 values. Direct medical costs were retrieved from hospital database, while direct non-medical costs and utility were collected from interviewing 194 LACC patients during June to December 2019. One-way and probabilistic sensitivity analysis were used to investigate parameter uncertainties. RESULTS: Total costs of NoIx were $8026 and $11,444 from provider and societal perspectives, respectively, and quality-adjusted life year (QALY) was 3.70. NoIx was more effective and less costly. When six strategies were compared with NoIx, more additional costs were shown with $1835, $1735, $2022, $1987, $4002, and $4176 for CT without LL, CT with LL, MRI without LL, MRI with LL, PET/CT without LL, and PET/CT with LL, whereas QALYs were decreased with 0.07, 0.08, 0.07, 0.08, 0.05, and 0.07, respectively. Sensitivity analyses strengthened the benefit of NoIx. The most significant parameter was treatment outcomes of patients with PALN metastasis. CONCLUSION: NoIx or receiving basic clinical staging was a dominant option when compared with CT, MRI, and PET/CT for PALND before providing the treatment for LACC patients.

Cost of premature mortality attributable to smoking in the Middle East and North Africa.

BACKGROUND: Tobacco smoking is a leading cause of premature mortality, incurring substantial economic costs. AIMS: To estimate the rate and cost of premature mortality attributable to smoking in the 24 Middle East and North Africa (MENA) countries in 2015. METHODS: Smoking attributable fractions were estimated. Twenty-four smoking-related diseases were included in the analysis. For each country, the total number of deaths by disease, age, and gender among individuals aged ≥ 15 years were derived from a World Health Organization database. Human capital approach was used in calculating cost of premature mortality. RESULTS: Smoking was responsible for 465 285 deaths in MENA countries, resulting in 7 122 706 years of potential life lost, or an average of 15.23 years lost per smoking-related death. Of the total 465 285 smoking-related deaths, 412 415 (88.6%) occurred in men, accounting for 37% of all deaths from the diseases considered in this analysis among men. The total mortality cost attributable to smoking was estimated at US$ 29.7 billion in 2015 (0.76% of MENA's gross domestic product). Turkey was the country most affected by the tobacco epidemic, representing 41% of smoking-related mortality cost in the whole region, followed by Saudi Arabia (8.76%) and Egypt (7.88%). CONCLUSION: Smoking is an important preventable cause of premature mortality in MENA countries. Substantial decline in smoking-attributable deaths and significant economic cost saving can be achieved in this region through more effective tobacco control policies.

The Cost of Locally Advanced Cervical Cancer in Thailand: an Empirical Study for Economic Analysis.

OBJECTIVE: To evaluate cost of illness of locally advanced cervical cancer patients from societal perspective in three scenarios including completely cured without severe late side effects (S1), completely cured with late grade 3-4 gastrointestinal side effects (S2.1) or genitourinary side effects (S2.2), and disease recurrence and death (S3). METHODS:  The incidence-based approach was conducted. The cost was calculated for 5-year time horizon starting for the treatment initiation. Direct medical costs were extracted from hospital database. Cost of using two-dimensional technique and three-dimensional conformal radiation therapy were calculated separately. Direct non-medical costs and indirect costs in terms of productivity loss were based on actual expenses from the interview of 194 locally advanced cervical cancer patients from two tertiary hospitals in Bangkok, during June to December 2019. All costs were converted to US dollar in 2019 values. RESULTS: For 5 years, cost of illness per patient for using two-dimensional technique and three-dimensional conformal radiation therapy were US $8,391 and US $10,418 for S1, US $18,018 and US $20,045 for S2.1, US $17,908 and US $19,936 for S2.2, and US $61,076 and US $63,103 for S3, respectively. The economic burden for newly diagnosed locally advanced cervical cancer patients in Thailand in 2018 was approximately US $129 million and US $131 million for using two-dimensional technique and three-dimensional conformal radiation therapy, respectively. Cost from S3 accounted for 70% of all total cost. Premature death was the most important cost driver of cost of illness accounted for 64 % of the total cost estimates. CONCLUSIONS: Cost of illness of locally advanced cervical cancer patients produced significant economic burden from societal perspective. Disease recurrence and early death from cancer was the most influential cause of this burden.

A Comparison of EQ-5D-3L Index Scores Using Malaysian, Singaporean, Thai, and UK Value Sets in Indonesian Cervical Cancer Patients.

OBJECTIVES: To gain insight into the most suitable foreign value set among Malaysian, Singaporean, Thai, and UK value sets for calculating the EuroQol five-dimensional questionnaire index score (utility) among patients with cervical cancer in Indonesia. METHODS: Data from 87 patients with cervical cancer recruited from a referral hospital in Yogyakarta province, Indonesia, from an earlier study of health-related quality of life were used in this study. The differences among the utility scores derived from the four value sets were determined using the Friedman test. Performance of the psychometric properties of the four value sets versus visual analogue scale (VAS) was assessed. Intraclass correlation coefficients and Bland-Altman plots were used to test the agreement among the utility scores. Spearman ρ correlation coefficients were used to assess convergent validity between utility scores and patients' sociodemographic and clinical characteristics. With respect to known-group validity, the Kruskal-Wallis test was used to examine the differences in utility according to the stages of cancer. RESULTS: There was significant difference among utility scores derived from the four value sets, among which the Malaysian value set yielded higher utility than the other three value sets. Utility obtained from the Malaysian value set had more agreements with VAS than the other value sets versus VAS (intraclass correlation coefficients and Bland-Altman plot tests results). As for the validity, the four value sets showed equivalent psychometric properties as those that resulted from convergent and known-group validity tests. CONCLUSIONS: In the absence of an Indonesian value set, the Malaysian value set was more preferable to be used compared with the other value sets. Further studies on the development of an Indonesian value set need to be conducted.

The health-economic studies of HPV vaccination in Southeast Asian countries: a systematic review.

INTRODUCTION: The cervical cancer-related burden is an important problem in Southeast Asian (SEA) countries. However, only 3 out of 11 countries implement the comprehensive prevention program. Areas covered: This is a retrospective review from all relevant studies until 2015 from two main databases, MEDLINE/Pubmed and Embase in order to provide an evidence on the health economics of HPV vaccination in the region. Expert commentary: The implementation of HPV vaccination will generate substantial health and economic benefit in SEA countries since the number of cervical cancer cases in this region are generally high. Therefore, a clear recommendation on how HPV vaccination should be implemented in a country, for example on how many doses will be used, how much cost is required or is it a school based- or clinical based-delivery, is critically required.

Evaluation of Health-Related Quality of Life among Patients with Cervical Cancer in Indonesia.

BACKGROUND: Evaluation of health-related quality of life (HRQOL) in cervical cancer patients is important in order to design the interventions for improving patient outcomes. Reports of HRQOL among cervical cancer patients in Indonesia are limited. Moreover, measurement using EQ-5D-3L is to our best knowledge has hitherto not been performed. This study aimed to examine the HRQOL of cervical cancer patients in Indonesia using EQ- 5D-3L. MATERIALS AND METHODS: A cross-sectional study was conducted by interviewing cervical cancer patients using the EQ-5D-3L questionnaire. Percentages of patients who reported having problems in each dimension of EQ-5D as well as EQ-5D index score (utility) were calculated. RESULTS: Our findings indicated that the most frequent reported problems were pain/discomfort (67.8%) followed by anxiety/depression (57.5%). The mean of EQ-5D VAS was 75.8 (SD=17.0). The mean (SD) utility scores were 0.85 (0.19), 0.76 (0.20), 0.71 (0.21), and 0.77 (0.13) for cervical cancer patients in stage I, II, III, and IV, respectively. CONCLUSIONS: Cervical cancer significantly affects patient HRQOL. Efforts should be made to improve the quality of life of cervical cancer patients especially in terms of pain /discomfort and anxiety/depression reduction.

Cost of Illness of Chronic Hepatitis B Infection in Vietnam.

OBJECTIVES: To estimate the total financial burden of chronic hepatitis B virus (HBV) infection for Vietnam by quantifying the direct medical, the direct nonmedical, and indirect costs among patients with various stages of chronic HBV infection. METHODS: Direct medical cost data were retrieved retrospectively from medical histories of inpatients and outpatients in 2008 from a large referral hospital in Hanoi, Vietnam. Direct nonmedical and indirect costs data were obtained from face-to-face interviews of outpatients from the same hospital. The treatment cost per patient per chronic HBV infection stage was multiplied by the total estimated patients in Vietnam to get the total cost of illness for the nation. RESULTS: Nationally, the total cost attributable to chronic HBV infection and its complications in 2008 was estimated to be approximately US $4.4 billion, with the direct medical cost accounting for about 70% of that estimate. The cost of antivirals was the major cost driver in treating chronic HBV infection. The per-patient total annual direct medical cost increased with the severity of the disease, with the estimated costs for chronic HBV infection and hepatocellular carcinoma as US $450.35 and US $1883.05, respectively. When compared with the 2008 per-capita gross domestic product of ∼US $1024, the financial burden of treating chronic HBV infection is very high in Vietnam. CONCLUSIONS: This study confirmed that chronic HBV infection poses a significant financial burden for the average patient and that lacking treatment would become a social issue in Vietnam. Although HBV vaccination has been universally implemented, more health care investment and the greater availability of affordable medications are still needed to attain equity in proper treatment for patients with HBV infection.

Economic evaluation of policy options for prevention and control of cervical cancer in Thailand.

BACKGROUND: The Thai healthcare setting has seen patients with cervical cancer experience an increasing burden of morbidity and mortality, a stagnation in the performance of cervical screening programmes and the introduction of a vaccine for the prevention of human papillomavirus (HPV) infection. OBJECTIVE: This study aims to identify the optimum mix of interventions that are cost effective, from societal and healthcare provider perspectives, for the prevention and control of cervical cancer. METHODS: A computer-based Markov model of the natural history of cervical cancer was used to simulate an age-stratified cohort of women in Thailand. The strategy comparators, including both control and prevention programmes, were (i) conventional cytology screening (Pap smears); (ii) screening by visual inspection with acetic acid (VIA); and (iii) HPV-16, -18 vaccination. Input parameters (e.g. age-specific incidence of HPV infection, progression and regression of the infection, test performance of screening methods and efficacy of vaccine) were synthesized from a systematic review and meta-analysis. Costs (year 2007 values) and outcomes were evaluated separately, and compared for each combination. The screening strategies were started from the age of 30-40 years and repeated at 5- and 10-year intervals. In addition, HPV vaccines were introduced at age 15-60 years. RESULTS: All of the screening strategies showed certain benefits due to a decreased number of women developing cervical cancer versus 'no intervention'. Moreover, the most cost-effective strategy from the societal perspective was the combination of VIA and sequential Pap smear (i.e., VIA every 5 years for women aged 30-45 years, followed by Pap smear every 5 years for women aged 50-60 years). This strategy was dominant, with a QALY gain of 0.01 and a total cost saving of Baht (Bt) 800, compared with doing nothing. From the societal perspective, universal HPV vaccination for girls aged 15 years without screening resulted in a QALY gain of 0.06 at an additional cost of Bt 8,800, based on the cost of Bt 15,000 for a full immunization schedule. The incremental cost-effectiveness ratio, comparing HPV vaccinations for girls aged 15 years with the current national policy of Pap smears for women aged 35-60 years every 5 years, was approximately Bt 18,1000 per QALY gained. This figure was relatively high for the Thai setting. CONCLUSIONS: The results suggest that controlling cervical cancer by increasing the numbers of women accepting the VIA and Pap smear screening as routine and by improving the performance of the existing screening programmes is the most cost-effective policy option in Thailand.