RESUMO
The number of overdose-related fatalities continues to reach historic levels across Canada, despite ongoing efforts by authorities. To reduce mortality, a clinical trajectory ranging from preventative measures to crisis intervention, skill training to treatment, and risk assessment to risk management needs to be supported. The web-based Risk Assessment and Management Platform (RAMP) was developed to realize this concept and to empower people who use drugs through an integrated tool that allows them to better understand and manage their risk of overdose. This paper outlines the architecture and development of RAMP, which is built on the WordPress platform. WordPress components are mapped onto a 3-tier architecture that consists of presentation, application, and database layers. The architecture facilitates the development of a modular software that includes several features that are independent in functionality but interact with each other in an integrated platform. The relatively low coupling and high coherence of the features may reduce the cost of maintenance and increase flexibility of future developments. RAMP's architecture comprises a user interface, conceptual framework, and backend layers. The RAMP front end effectively uses some of the WordPress' features such as HTML5, CSS, and JavaScript to create a mobile, friendly, and scalable user interface. The RAMP backend uses several standard and custom WordPress plug-ins to support risk assessment and monitoring, with the goal of mitigating the impacts and eliminating risks together. A rule-based decision support system has been hard-coded to suggest relevant modules and goals to complement each user's lifestyle and goals based on their risk assessment. Finally, the backend uses the MySQL database management system and communicates with the RAMP framework layer via the data access layer to facilitate a timely and secure handling of information. Overall, RAMP is a modular system developed to identify and manage the risk of opioid overdose in the population of people who use drugs. Its modular design uses the WordPress architecture to efficiently communicate between layers and provide a base for external plug-ins. There is potential for the current system to adopt and address other related fields such as suicide, anxiety, and trauma. Broader implementation will support this concept and lead to the next level of functionality.
RESUMO
As Norway considers revising triage approaches following their first adolescent cohort with human papillomavirus (HPV) vaccination entering the cervical cancer screening program, we analyzed the health impact and cost-effectiveness of alternative primary HPV triage approaches for women initiating cervical cancer screening in 2023. We used a multimodeling approach that captured HPV transmission and cervical carcinogenesis to evaluate the health benefits, harms and cost-effectiveness of alternative extended genotyping and age-based triage strategies under five-yearly primary HPV testing (including the status-quo screening strategy in Norway) for women born in 1998 (ie, age 25 in 2023). We examined 35 strategies that varied alternative groupings of high-risk HPV genotypes ("high-risk" genotypes; "medium-risk" genotypes or "intermediate-risk" genotypes), number and types of HPV included in each group, management of HPV-positive women to direct colposcopy or active surveillance, wait time for re-testing and age at which the HPV triage algorithm switched from less to more intensive strategies. Given the range of benchmarks for severity-specific cost-effectiveness thresholds in Norway, we found that the preferred strategy for vaccinated women aged 25 years in 2023 involved an age-based switch from a less to more intensive follow-up algorithm at age 30 or 35 years with HPV-16/18 genotypes in the "high-risk" group. The two potentially cost-effective strategies could reduce the number of colposcopies compared to current guidelines and simultaneously improve health benefits. Using age to guide primary HPV triage, paired with selective HPV genotype and follow-up time for re-testing, could improve both the cervical cancer program effectiveness and efficiency.
Assuntos
Infecções por Papillomavirus , Neoplasias do Colo do Útero , Adolescente , Gravidez , Feminino , Humanos , Adulto , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/prevenção & controle , Papillomavirus Humano , Análise Custo-Benefício , Papillomavirus Humano 16/genética , Infecções por Papillomavirus/diagnóstico , Infecções por Papillomavirus/prevenção & controle , Infecções por Papillomavirus/epidemiologia , Triagem , Detecção Precoce de Câncer , Papillomavirus Humano 18/genética , Colposcopia , NoruegaRESUMO
ABSTRACT: This Research Letter summarizes all updates to the 2019 Guidelines through September 2023, including: endorsement of the 2021 Opportunistic Infections guidelines for HIV+ or immunosuppressed patients; clarification of use of human papillomavirus testing alone for patients undergoing observation for cervical intraepithelial neoplasia 2; revision of unsatisfactory cytology management; clarification that 2012 guidelines should be followed for patients aged 25 years and older screened with cytology only; management of patients for whom colposcopy was recommended but not completed; clarification that after treatment for cervical intraepithelial neoplasia 2+, 3 negative human papillomavirus tests or cotests at 6, 18, and 30 months are recommended before the patient can return to a 3-year testing interval; and clarification of postcolposcopy management of minimally abnormal results.
Assuntos
Infecções por Papillomavirus , Displasia do Colo do Útero , Neoplasias do Colo do Útero , Feminino , Gravidez , Humanos , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/terapia , Consenso , Gestão de Riscos , Colposcopia , Esfregaço Vaginal , Infecções por Papillomavirus/complicações , Infecções por Papillomavirus/diagnóstico , PapillomaviridaeRESUMO
Population models of cancer reflect the overall US population by drawing on numerous existing data resources for parameter inputs and calibration targets. Models require data inputs that are appropriately representative, collected in a harmonized manner, have minimal missing or inaccurate values, and reflect adequate sample sizes. Data resource priorities for population modeling to support cancer health equity include increasing the availability of data that 1) arise from uninsured and underinsured individuals and those traditionally not included in health-care delivery studies, 2) reflect relevant exposures for groups historically and intentionally excluded across the full cancer control continuum, 3) disaggregate categories (race, ethnicity, socioeconomic status, gender, sexual orientation, etc.) and their intersections that conceal important variation in health outcomes, 4) identify specific populations of interest in clinical databases whose health outcomes have been understudied, 5) enhance health records through expanded data elements and linkage with other data types (eg, patient surveys, provider and/or facility level information, neighborhood data), 6) decrease missing and misclassified data from historically underrecognized populations, and 7) capture potential measures or effects of systemic racism and corresponding intervenable targets for change.
Assuntos
Equidade em Saúde , Neoplasias , Humanos , Masculino , Feminino , Atenção à Saúde , Classe Social , Etnicidade , Neoplasias/diagnóstico , Neoplasias/epidemiologia , Neoplasias/terapiaRESUMO
BACKGROUND: Self-identified Black women in the United States have higher cervical cancer incidence and mortality than the general population, but these differences have not been clearly attributed across described cancer care inequities. METHODS: A previously established microsimulation model of cervical cancer was adapted to reflect demographic, screening, and survival data for Black US women and compared with a model reflecting data for all US women. Each model input with stratified data (all-cause mortality, hysterectomy rates, screening frequency, screening modality, follow-up, and cancer survival) was sequentially replaced with Black-race specific data to arrive at a fully specified model reflecting Black women. At each step, we estimated the relative contribution of inputs to observed disparities. RESULTS: Estimated (hysterectomy-adjusted) cervical cancer incidence was 8.6 per 100â000 in the all-race model vs 10.8 per 100â000 in the Black-race model (relative risk [RR] = 1.24, range = 1.23-1.27). Estimated all-race cervical cancer mortality was 2.9 per 100â000 vs 5.5 per 100â000 in the Black-race model (RR = 1.92, range = 1.85-2.00). We found the largest contributors of incidence disparities were follow-up from positive screening results (47.3% of the total disparity) and screening frequency (32.7%). For mortality disparities, the largest contributor was cancer survival differences (70.1%) followed by screening follow-up (12.7%). CONCLUSION: To reduce disparities in cervical cancer incidence and mortality, it is important to understand and address differences in care access and quality across the continuum of care. Focusing on the practices and policies that drive differences in treatment and follow-up from cervical abnormalities may have the highest impact.
Assuntos
Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Neoplasias do Colo do Útero , Feminino , Humanos , Carcinogênese , Incidência , Estados Unidos/epidemiologia , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/epidemiologia , Brancos , Negro ou Afro-AmericanoRESUMO
BACKGROUND: To eliminate cervical cancer as a public health problem, the World Health Organization had recommended routine vaccination of adolescent girls with two doses of the human papillomavirus (HPV) vaccine before sexual initiation. However, many countries have yet to implement HPV vaccination because of financial or logistical barriers to delivering two doses outside the infant immunisation programme. METHODS: Using three independent HPV transmission models, we estimated the long-term health benefits and cost-effectiveness of one-dose versus two-dose HPV vaccination, in 188 countries, under scenarios in which one dose of the vaccine gives either a shorter duration of full protection (20 or 30 years) or lifelong protection but lower vaccine efficacy (e.g. 80%) compared to two doses. We simulated routine vaccination with the 9-valent HPV vaccine in 10-year-old girls at 80% coverage for the years 2021-2120, with a 1-year catch-up campaign up to age 14 at 80% coverage in the first year of the programme. RESULTS: Over the years 2021-2120, one-dose vaccination at 80% coverage was projected to avert 115.2 million (range of medians: 85.1-130.4) and 146.8 million (114.1-161.6) cervical cancers assuming one dose of the vaccine confers 20 and 30 years of protection, respectively. Should one dose of the vaccine provide lifelong protection at 80% vaccine efficacy, 147.8 million (140.6-169.7) cervical cancer cases could be prevented. If protection wanes after 20 years, 65 to 889 additional girls would need to be vaccinated with the second dose to prevent one cervical cancer, depending on the epidemiological profiles of the country. Across all income groups, the threshold cost for the second dose was low: from 1.59 (0.14-3.82) USD in low-income countries to 44.83 (3.75-85.64) USD in high-income countries, assuming one dose confers 30-year protection. CONCLUSIONS: Results were consistent across the three independent models and suggest that one-dose vaccination has similar health benefits to a two-dose programme while simplifying vaccine delivery, reducing costs, and alleviating vaccine supply constraints. The second dose may become cost-effective if there is a shorter duration of protection from one dose, cheaper vaccine and vaccination delivery strategies, and high burden of cervical cancer.
Assuntos
Infecções por Papillomavirus , Vacinas contra Papillomavirus , Neoplasias do Colo do Útero , Adolescente , Feminino , Lactente , Humanos , Criança , Análise Custo-Benefício , Papillomavirus Humano , Infecções por Papillomavirus/epidemiologia , Infecções por Papillomavirus/prevenção & controle , Neoplasias do Colo do Útero/epidemiologia , Neoplasias do Colo do Útero/prevenção & controle , VacinaçãoRESUMO
INTRODUCTION: Cystoid macular edema (CME) is the most common cause of central vision loss in eyes with branch retinal vein occlusion (BRVO eyes). In recent literature, choroidal vascularity index (CVI) has been proposed to be an enhanced depth imaging optical coherence tomography (EDI-OCT) metric that may help characterize choroidal vascular changes in the setting of retinal ischemia, and potentially prognose visual outcomes and treatment patterns for patients with BRVO-related CME. This study sought to further characterize choroidal vascular changes in BRVO by comparing the CVI, subfoveal choroidal thickness (SFCT), and central subfield thickness (CST) in BRVO eyes with CME compared to unaffected fellow eyes. METHODS: This was a retrospective cohort study. Subjects included treatment-naïve BRVO eyes with CME diagnosed within 3 months of onset of symptoms and unaffected fellow eyes. EDI-OCT images were collected at baseline and at the 12-month follow-up visit. CVI, SFCT, and CST were measured. Demographics, treatment patterns, and best-corrected visual acuity (VA) were abstracted. Median CVI, SFCT, CST, and VA were compared between the two cohorts. Longitudinal relationships between these variables were analyzed. RESULTS: A total of 52 treatment-naïve eyes with BRVO and CME and 48 unaffected fellow eyes were identified. Baseline CVI was lower in eyes with BRVO than in fellow eyes (64.7% vs. 66.4%, P = 0.003). At 12 months, there was no difference in CVI between BRVO eyes and fellow eyes (65.7% vs 65.8%, P = 0.536). In BRVO eyes, there was a strong correlation between reduced CST and improved VA over the 12-month study period (r = 0.671, P < 0.001). CONCLUSION: There are differences in CVI in treatment-naïve BRVO eyes with CME at presentation compared to fellow eyes, but these differences resolve over time. Anatomic changes in macular thickness in BRVO eyes with CME may be correlated with VA outcomes.
Our study evaluated a novel ocular optical coherence tomography imaging metric, the choroidal vascularity index, in eyes that developed cystoid macular edema, a condition which can significantly impair acuity of central vision, after being diagnosed with branch retinal vein occlusion. In each patient, we compared the choroidal vascularity index in eyes that developed treatment-naïve, newly diagnosed branch retinal vein occlusion with cystoid macular edema to the non-diseased fellow eye. We made comparisons at the time of diagnosis (baseline) and at the 12-month follow up, and analyzed changes over time. We found that at the baseline visit, branch retinal vein occlusion eyes with cystoid macular edema had a significantly lower choroidal vascularity index than their unaffected fellow eyes, but that the differences between eyes resolved by the 12-month follow-up visit. Our findings suggest that choroidal vascularity may be compromised in the acute phase of branch retinal vein occlusion, but that this phenomenon resolves over time. Future research should further evaluate whether imaging characteristics of choroidal vascularity may be associated with changes in anatomic and visual outcomes in retinal diseases.
RESUMO
OBJECTIVES: Model-based cost-effectiveness analyses can inform decisions about screening guidelines by quantifying consequences of alternative algorithms. Although actual screening adherence is imperfect, incorporating nonadherence into analyses that aim to determine optimal screening may affect the policy recommendations. We evaluated the impact of nonadherence assumptions on the optimal cervical cancer screening in Norway. METHODS: We used a microsimulation model of cervical carcinogenesis to project the long-term health and economic outcomes under alternative screening algorithms and adherence patterns. We compared 18 algorithms involving primary human papillomavirus testing (5-yearly) that varied follow-up management of different human papillomavirus results. We considered 12 adherence scenarios: perfect adherence, 8 high- and low-coverage "random-complier" scenarios, and 3 "systematic-complier" scenarios that reflect conditional screening behavior over a lifetime. We calculated incremental cost-effectiveness ratios and considered a strategy with the highest incremental cost-effectiveness ratio < 55 000 US dollars/quality-adjusted life-year as "optimal." RESULTS: Under perfect adherence, the least intensive screening strategy was optimal; in contrast, assuming any nonadherence resulted in a more intensive optimal strategy. Accounting for lower adherence resulted in both lower costs and health benefits, which allowed for a more intensive strategy to be considered optimal, but more harms for women who screen according to guidelines (ie, up to 41% more colposcopies when comparing the optimal strategy in the lowest-adherence scenario with the optimal strategy under perfect adherence). CONCLUSIONS: Assuming nonadherence in analyses designed to inform national guidelines may lead to a relatively more intensive recommendation. Designing guidelines for those who do not adhere to them may lead to over-screening of those who do.
Assuntos
Neoplasias do Colo do Útero , Feminino , Humanos , Colposcopia , Análise Custo-Benefício , Detecção Precoce de Câncer , Programas de Rastreamento , Anos de Vida Ajustados por Qualidade de Vida , Neoplasias do Colo do Útero/diagnósticoRESUMO
BACKGROUND: The DONATE HCV trial demonstrated the safety and efficacy of transplanting hearts from hepatitis C viremic (HCV+) donors. In this report, we examine the cost-effectiveness and impact of universal HCV+ heart donor eligibility in the United States on transplant waitlist time and life expectancy. METHODS: We developed a microsimulation model to compare 2 waitlist strategies for heart transplant candidates in 2018: (1) status quo (SQ) and (2) SQ plus HCV+ donors (SQ + HCV). From the DONATE HCV trial and published national datasets, we modeled mean age (53 years), male sex (75%), probabilities of waitlist mortality (0.01-0.10/month) and transplant (0.03-0.21/month) stratified by medical urgency, and posttransplant mortality (0.003-0.052/month). We assumed a 23% increase in transplant volume with SQ + HCV compared with SQ. Costs (2018 United States dollar) included waitlist care ($2200-190 000/month), transplant ($213 400), 4-wk HCV treatment ($26 000), and posttransplant care ($2500-11 300/month). We projected waitlist time, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs [$/QALY, discounted 3%/year]; threshold ≤$100 000/QALY). RESULTS: Compared with SQ, SQ + HCV decreased waitlist time from 8.7 to 6.7 months, increased undiscounted life expectancy from 8.9 to 9.2 QALYs, and increased discounted lifetime costs from $671 400/person to $690 000/person. Four-week HCV treatment comprised 0.5% of lifetime costs. The ICER of SQ + HCV compared with SQ was $74 100/QALY and remained ≤$100 000/QALY with up to 30% increases in transplant and posttransplant costs. CONCLUSIONS: Transplanting hearts from HCV-infected donors could decrease waitlist times, increase life expectancy, and be cost-effective. These findings were robust within the context of current high HCV treatment costs.
Assuntos
Hepatite C Crônica , Hepatite C , Humanos , Masculino , Estados Unidos , Pessoa de Meia-Idade , Antivirais/uso terapêutico , Análise Custo-Benefício , Hepatite C/diagnóstico , Hepatite C/tratamento farmacológico , Hepacivirus , Doadores de Tecidos , Anos de Vida Ajustados por Qualidade de Vida , Hepatite C Crônica/tratamento farmacológicoRESUMO
BACKGROUND: Interventions targeting the same disease but at different points along the disease continuum (e.g., screening and vaccination to prevent cervical cancer [CC]) are often evaluated in isolation, which can affect cost-effectiveness profiles and policy conclusions. We evaluated nonavalent human papillomavirus (HPV) vaccine (9vHPV) compared with bivalent HPV vaccine (2vHPV) alongside deintensified screening intervals for a vaccinated birth cohort to inform a single optimal integrated CC prevention policy. METHODS: Using a multimodeling approach, we evaluated the health and economic impacts of alternative CC screening strategies for a Norwegian birth cohort eligible for HPV vaccination in 2021 assuming they received 1) 2vHPV or 2) 9vHPV. We conducted 1) a restricted analysis that evaluated the optimal HPV vaccine under current screening guidelines; and 2) a comprehensive analysis including alternative screening and vaccination strategy combinations. We calculated incremental cost-effectiveness ratios (ICERs) and evaluated them according to different cost-effectiveness thresholds. RESULTS: Assuming a cost-effectiveness threshold of $40,000 per quality-adjusted life year (QALY) gained, we found that, while holding screening intensity fixed, switching the routine vaccination program in Norway from 2vHPV to 9vHPV would not be considered cost-effective (ICER of $132,700 per QALY gained). However, when allowing for varying intensities of CC screening, we found that switching to 9vHPV would be cost-effective compared with 2vHPV under an alternative threshold of $55,000 per QALY gained, if coupled with reductions in the number of lifetime screens. CONCLUSIONS: Our analysis highlights the importance of evaluating the full potential policy landscape for country-level decision makers considering policy adoption, including nonindependent primary and secondary prevention efforts, to draw appropriate conclusions and avoid sub-optimal outcomes. HIGHLIGHTS: Without evaluating the full potential policy landscape, including primary and secondary prevention efforts, country-level decision makers may not be able to draw appropriate policy conclusions, resulting in suboptimal outcomes.An applied example from cervical cancer prevention in Norway compared a restricted analysis of current screening guidelines to a comprehensive analysis including alternative screening and vaccination strategy combinations.We found that a switch from bivalent to nonavalent human papillomavirus vaccine would be considered cost-effective in Norway if coupled with reductions in the number of lifetime screens compared with the current screening strategy.A comprehensive analysis that considers how different types of interventions along the disease continuum affect each other will be critical for decision makers interpreting cost-effectiveness analysis results.
Assuntos
Infecções por Papillomavirus , Vacinas contra Papillomavirus , Neoplasias do Colo do Útero , Análise Custo-Benefício , Feminino , Humanos , Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus/uso terapêutico , Políticas , Anos de Vida Ajustados por Qualidade de Vida , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/prevenção & controle , VacinaçãoRESUMO
OBJECTIVE: Programs for early intervention in psychosis have shown clinical efficacy. The authors aimed to evaluate the cost-effectiveness of early intervention programs compared with standard care for the treatment of first-episode psychosis in the United States. METHODS: A decision-analytic model integrating published data on clinical efficacy, costs, and health utilities was developed to evaluate early intervention versus standard care over the lifetime of patients after their first psychotic episode. Model input data were derived from meta-analyses, clinical trials, and U.S. national data. The main outcomes included hospitalizations, employment rate, quality-adjusted life years (QALYs), lifetime health care costs, and incremental cost-effectiveness ratios (ICERs). RESULTS: Compared with patients receiving standard care, patients in the early intervention strategy had 3.2 fewer hospitalizations and 2.7 more years of employment over the course of their remaining life expectancy. From a health care perspective, early intervention had an ICER of approximately $51,600 per QALY. From a societal perspective, early intervention saved costs (i.e., yielded greater health benefits and had lower costs compared with standard care). Results were sensitive to the effect of early intervention on suicide, cost of standard care, cost of early intervention, and the effect (relative risk) of early intervention on employment. A scenario analysis that excluded the effect (i.e., hazard ratio) of early intervention on suicide yielded an ICER of approximately $197,000 per QALY. CONCLUSIONS: These results suggest that it is economically beneficial to fund early intervention in psychosis programs in the United States. The findings indicate that early intervention in psychosis saves costs (from the societal perspective) and is cost-effective (health care sector perspective).
Assuntos
Custos de Cuidados de Saúde , Transtornos Psicóticos , Análise Custo-Benefício , Humanos , Transtornos Psicóticos/terapia , Anos de Vida Ajustados por Qualidade de Vida , Resultado do Tratamento , Estados UnidosRESUMO
Introduction. Delayed implementation of evidence-driven interventions has consequences that can be formally evaluated. In Norway, programs to prevent cervical cancer (CC)-screening and treatment of precancerous lesions and prophylactic vaccination against human papillomavirus (HPV) infection-have been implemented, but each encountered delays in policy implementation. To examine the effect of these delays, we project the outcomes that would have been achieved with timely implementation of two policy changes compared with the de facto delays in implementation (in Norway). Methods. We used a multimodeling approach that combined HPV transmission and cervical carcinogenesis to estimate the health outcomes and timeline for CC elimination associated with the implementation of two CC prevention policy decisions: a multicohort vaccination program of women up to age 26 years with bivalent vaccine in 2009 compared with actual "delayed" implementation in 2016, and a switch from cytology to primary HPV-based testing in 2015 compared with "delayed" rollout in 2020. Results. Timely implementation of two policy changes compared with current Norwegian prevention policy timeline could have averted approximately 970 additional cases (range of top 10 sets: 830-1060) and accelerated the CC elimination timeline by around 4 years (from 2039 to 2035). Conclusions. If delaying implementation of effective and cost-effective interventions is being considered, the decision-making process should include quantitative analyses on the effects of delays.
RESUMO
BACKGROUND: The guidelines for managing abnormal cervical cancer screening tests changed from a results-based approach in 2012 to a risk-based approach in 2019. OBJECTIVE: We estimated the cost-effectiveness of the 2019 management guidelines and the changes in resource utilization moving from 2012 to 2019 guidelines. STUDY DESIGN: We utilized a previously published model of cervical cancer natural history and screening to estimate and compare the lifetime costs and the number of screens, colposcopies, precancer treatments, cancer cases, and cancer deaths associated with the 2012 vs 2019 management guidelines. We assessed these guidelines under the scenarios of observed screening practice and perfect screening adherence to 3-year cytology starting at age 21, with a switch to either 3-year or 5-year cytology plus human papillomavirus cotesting at age 30. In addition, we estimated the lifetime costs and life years to determine the cost-effectiveness of shifting to the 2019 management guidelines. RESULTS: Under the assumptions of both observed screening practice and perfect screening adherence with a strategy of 3-year cytology at ages 21 to 29 and switching to 3-year cotesting at age 30, the management of the screening tests according to the 2019 guidelines was less costly and more effective than the 2012 guidelines. For 3-year cytology screening at ages 21 to 29 and switching to 5-year cotesting at age 30, the 2019 guidelines were more cost-effective at a willingness-to-pay threshold of $100,000 per life year gained. Across all scenarios, the 2019 management guidelines were associated with fewer colposcopies and cancer deaths. CONCLUSION: Our model-based analysis suggests that the 2019 guidelines are more effective overall and also more cost-effective than the 2012 guidelines, supporting the principle of "equal management of equal risks."
Assuntos
Detecção Precoce de Câncer/economia , Infecções por Papillomavirus/diagnóstico , Displasia do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/diagnóstico , Adulto , Idoso , Colo do Útero/patologia , Colo do Útero/virologia , Análise Custo-Benefício , Feminino , Humanos , Pessoa de Meia-Idade , Infecções por Papillomavirus/economia , Infecções por Papillomavirus/patologia , Guias de Prática Clínica como Assunto , Neoplasias do Colo do Útero/economia , Neoplasias do Colo do Útero/patologia , Esfregaço Vaginal/economia , Adulto Jovem , Displasia do Colo do Útero/economia , Displasia do Colo do Útero/patologiaRESUMO
Several countries have implemented primary human papillomavirus (HPV) testing for cervical cancer screening. HPV testing enables home-based, self-collected sampling (self-sampling), which provides similar diagnostic accuracy as clinician-collected samples. We evaluated the impact and cost-effectiveness of switching an entire organized screening program to primary HPV self-sampling among cohorts of HPV vaccinated and unvaccinated Norwegian women. We conducted a model-based analysis to project long-term health and economic outcomes for birth cohorts with different HPV vaccine exposure, that is, preadolescent vaccination (2000- and 2008-cohorts), multiage cohort vaccination (1991-cohort) or no vaccination (1985-cohort). We compared the cost-effectiveness of switching current guidelines with clinician-collected HPV testing to HPV self-sampling for these cohorts and considered an additional 44 strategies involving either HPV self-sampling or clinician-collected HPV testing at different screening frequencies for the 2000- and 2008-cohorts. Given Norwegian benchmarks for cost-effectiveness, we considered a strategy with an additional cost per quality-adjusted life-year below $55 000 as cost-effective. HPV self-sampling strategies considerably reduced screening costs (ie, by 24%-40% across cohorts and alternative strategies) and were more cost-effective than clinician-collected HPV testing. For cohorts offered preadolescent vaccination, cost-effective strategies involved HPV self-sampling three times (2000-cohort) and twice (2008-cohort) per lifetime. In conclusion, we found that switching from clinician-collected to self-collected HPV testing in cervical screening may be cost-effective among both highly vaccinated and unvaccinated cohorts of Norwegian women.
Assuntos
Detecção Precoce de Câncer/economia , Papillomaviridae/isolamento & purificação , Vacinas contra Papillomavirus/imunologia , Neoplasias do Colo do Útero/diagnóstico , Vacinação , Adulto , Idoso , Análise Custo-Benefício , Feminino , Humanos , Pessoa de Meia-Idade , Qualidade de Vida , Manejo de Espécimes , IncertezaRESUMO
The context of comparing two different groups of subjects that are measured repeatedly over time is considered. Our specific focus is on highly variable count data which have a nonnegligible frequency of zeros and have time trends that are difficult to characterize. These challenges are often present when analyzing bacteria or gene expression data sets. Traditional longitudinal data analysis methods, including generalized estimating equations, can be challenged by the features present in these types of data sets. We propose a Bayesian methodology that effectively confronts these challenges. A key feature of the methodology is the use of Gaussian processes to flexibly model the time trends. Inference procedures based on both sharp and interval null hypotheses are discussed, including for the important hypotheses that test for group differences at individual time points. The proposed methodology is illustrated with next-generation sequencing (NGS) data sets corresponding to two different experimental conditions. In particular, the method is applied to a case study containing bacteria counts of mice with chronic and nonchronic wounds to identify potential wound-healing probiotics. The methodology can be applied to similar NGS data sets comparing two groups of subjects.
Assuntos
Sequenciamento de Nucleotídeos em Larga Escala , Animais , Teorema de Bayes , Humanos , Cadeias de Markov , Camundongos , Método de Monte Carlo , Distribuição NormalRESUMO
BACKGROUND: Rheumatic mitral valve disease (RMVD) is a major cause of acquired valvular disease in India. We compared the cost-effectiveness of surgical treatment strategies for young adults with severe RMVD from an Indian public payer perspective. METHODS: We developed a Markov model to reflect the burden of RMVD among a hypothetical cohort of 20-year-olds in India and to estimate quality-adjusted life years (QALYs) and lifetime costs associated with three strategies: (1) Repair; (2) Mechanical valve replacement (MVR-M); and (3) Bioprosthetic valve replacement (MVR-B), compared to a baseline strategy involving a mix of surgeries approximating the standard of care in India (32% Repair, 33% MVR-M, 35% MVR-B). Data on disease burden, intervention effects, and direct medical costs (2018 US$) were obtained from the literature. Deterministic and probabilistic sensitivity analyses were conducted to assess model uncertainty. RESULTS: Repair ($2530, 9.7 QALYs) was less costly and more effective than the standard of care ($2990, 8.7 QALYs) and MVR-M ($3220, 6.2 QALYs). The incremental cost-effective ratio for MVR-B ($3190, 10.1 QALYs) compared to Repair was $1590 per QALY, which may be cost-effective at a threshold of India's per-capita gross domestic product (GDP: $2005). The optimal choice between Repair or MVR-B was sensitive to variations in surgery costs, background mortality, and risks for reoperation. CONCLUSIONS: Our model-based analysis suggests that Repair is the optimal strategy and MVR-M should not be recommended for this subpopulation. MVR-B may be cost-effective in contexts where quality of Repair is not assured, newer generation bioprostheses are used, or the costs of the bioprosthetic valve decrease.
Assuntos
Doenças das Valvas Cardíacas , Implante de Prótese de Valva Cardíaca , Análise Custo-Benefício , Doenças das Valvas Cardíacas/epidemiologia , Doenças das Valvas Cardíacas/cirurgia , Humanos , Índia/epidemiologia , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
High out-of-pocket (OOP) medical expenses for cervical cancer (CC) can lead to catastrophic health expenditures (CHEs) and medical impoverishment in many low-resource settings. There are 32 million women at risk for CC in Ethiopia, where CC screening is extremely limited. An evaluation of the population health and financial risk protection benefits, and their distributional consequences across socioeconomic groups, from human papillomavirus (HPV) vaccination will be critical to support CC prevention efforts in this setting. We used a static cohort model that captures the main features of HPV vaccines and population demographics to project health and economic outcomes associated with routine HPV vaccination in Ethiopia. Health outcomes included the number of CC cases, and costs included vaccination and operational costs in 2015 US dollars over the years 2019-2118 and CC treatment costs over the lifetimes of cohorts eligible for vaccination in Ethiopia. We estimated the household OOP medical expenditures averted (assuming 68% of direct medical expenditures were financed OOP) and cases of CHE averted. A case of CHE was defined as 40% of household consumption expenditures, and the cases of CHE averted depended on wealth quintile, disease incidence, healthcare use and OOP payments. Our analysis shows that, assuming 100% vaccine efficacy against HPV-16/18 and 50% vaccination coverage, routine HPV vaccination could avert up to 970 000 cases of CC between 2019 and 2118, which translates to â¼932 000 lives saved. Additionally, routine HPV vaccination could avert 33 900 cases of CHE. Approximately one-third of health benefits would accrue to the poorest wealth quintile, whereas 50% of financial risk protection benefits would accrue to this quintile. HPV vaccination can reduce disparities in CC incidence, mortality and household health expenditures. This understanding and our findings can help policymakers in decisions regarding targeted CC control efforts and investment in a routine HPV vaccination programme following an initial catch-up programme.