Kine Pedersen

Cost-effective management of women with minor cervical lesions: Revisiting the application of HPV DNA testing

BACKGROUND Lack of consensus in management guidelines for women with minor cervical lesions, coupled with novel screening approaches, such as human papillomavirus (HPV) genotyping, necessitate revisiting prevention policies. We evaluated the cost-effectiveness and resource trade-offs of alternative triage strategies to inform cervical cancer prevention in Norway. METHODS We used a decision-analytic model to compare the lifetime health and economic consequences associated with ten novel candidate approaches to triage women with minor cervical lesions. Candidate strategies varied by: 1) the triage test(s): HPV testing in combination with cytology, HPV testing alone with or without genotyping for HPV-16 and -18, and immediate colposcopy, and 2) the length of time between index and triage testing (i.e., 6, 12 or 18months). Model outcomes included quality-adjusted life-years (QALYs), lifetime societal costs, and resource use (e.g., colposcopy referrals). RESULTS The current Norwegian guidelines were less effective and more costly than candidate strategies. Given a commonly-cited willingness-to-pay threshold in Norway of

Using novel biomarkers to triage young adult women with minor cervical lesions: a cost‐effectiveness analysis

100,000 per QALY gained, the preferred strategy involved HPV genotyping with immediate colposcopy referral for HPV-16 or -18 positive and repeat HPV testing at 12months for non-HPV-16 or -18 positive (

Choosing wisely: a model-based analysis evaluating the trade-offs in cancer benefit and diagnostic referrals among alternative HPV testing strategies in Norway

78,010 per QALY gained). Differences in health benefits among candidate strategies were small, while resource use varied substantially. More effective strategies required a moderate increase in colposcopy referrals (e.g., a 9% increase for the preferred strategy) compared with current levels. CONCLUSION New applications of HPV testing may improve management of women with minor cervical lesions, yet are accompanied by a trade-off of increased follow-up procedures.

Did hospitals respond to changes in weights of Diagnosis Related Groups in Norway between 2006 and 2013

To evaluate the short‐term consequences and cost‐effectiveness associated with the use of novel biomarkers to triage young adult women with minor cervical cytological lesions.

Using Decision-Analytic Modeling to Isolate Interventions That Are Feasible, Efficient and Optimal: An Application from the Norwegian Cervical Cancer Screening Program.

Background:Forthcoming cervical cancer screening strategies involving human papillomavirus (HPV) testing for women not vaccinated against HPV infections may increase colposcopy referral rates. We quantified health and resource trade-offs associated with alternative HPV-based algorithms to inform decision-makers when choosing between candidate algorithms.Methods:We used a mathematical simulation model of HPV-induced cervical carcinogenesis in Norway. We compared the current cytology-based strategy to alternative strategies that varied by the switching age to primary HPV testing (ages 25–34 years), the routine screening frequency (every 3–10 years), and management of HPV-positive, cytology-negative women. Model outcomes included reductions in lifetime cervical cancer risk, relative colposcopy rates, and colposcopy rates per cervical cancer prevented.Results:The age of switching to primary HPV testing and the screening frequency had the largest impacts on cancer risk reductions, which ranged from 90.9% to 96.3% compared to no screening. In contrast, increasing the follow-up intensity of HPV-positive, cytology-negative women provided only minor improvements in cancer benefits, but generally required considerably higher rates of colposcopy referrals compared to current levels, resulting in less efficient cervical cancer prevention.Conclusions:We found that in order to maximise cancer benefits HPV-based screening among unvaccinated women should not be delayed: rather, policy makers should utilise the triage mechanism to control colposcopy referrals.

An overview of cervical cancer epidemiology and prevention in Scandinavia

It has been argued that activity based payment systems make hospitals focus on the diagnostic groups that are most beneficial given costs and reimbursement rates. This article tests this hypothesis by exploring the relationship between changes in the reimbursement rates and changes in the number of registered treatment episodes for all diagnosis-related groups in Norway between 2006 and 2013. The number of treatment episodes can be affected by many factors and in order to isolate the effect of changes in the reimbursement system, we exclude DRGs affected by policy reforms and administrative changes. The results show that hospitals increased the number of admissions in a specific DRG four times more when the reimbursement was increased, relative to the change for DRGs with reduced rates. The direction of the result was consistent across time periods and sub-groups such as surgical vs. medical, and inpatient vs. outpatient DRGs. The effect was smaller, but remained significant after eliminating DRGs that were most likely to be affected by upcoding. Activities that the hospital had little control over, such as the number of births, had small effects, while activity levels in more discretionary categories, for instance mental diseases, were more affected. This demonstrates that contrary to the wishes of policy makers the economic incentives affect hospital reporting and priority setting behavior.

Advancing the evaluation of cervical cancer screening: development and application of a longitudinal adherence metric

BACKGROUND Decision makers often need to simultaneously consider multiple criteria or outcomes when deciding whether to adopt new health interventions. OBJECTIVES Using decision analysis within the context of cervical cancer screening in Norway, we aimed to aid decision makers in identifying a subset of relevant strategies that are simultaneously efficient, feasible, and optimal. METHODS We developed an age-stratified probabilistic decision tree model following a cohort of women attending primary screening through one screening round. We enumerated detected precancers (i.e., cervical intraepithelial neoplasia of grade 2 or more severe (CIN2+)), colposcopies performed, and monetary costs associated with 10 alternative triage algorithms for women with abnormal cytology results. As efficiency metrics, we calculated incremental cost-effectiveness, and harm-benefit, ratios, defined as the additional costs, or the additional number of colposcopies, per additional CIN2+ detected. We estimated capacity requirements and uncertainty surrounding which strategy is optimal according to the decision rule, involving willingness to pay (monetary or resources consumed per added benefit). RESULTS For ages 25 to 33 years, we eliminated four strategies that did not fall on either efficiency frontier, while one strategy was efficient with respect to both efficiency metrics. Compared with current practice in Norway, two strategies detected more precancers at lower monetary costs, but some required more colposcopies. Similar results were found for women aged 34 to 69 years. CONCLUSIONS Improving the effectiveness and efficiency of cervical cancer screening may necessitate additional resources. Although efficient and feasible, both society and individuals must specify their willingness to accept the additional resources and perceived harms required to increase effectiveness before a strategy can be considered optimal.

Kostnader ved Masseundersøkelsen mot livmorhalskreft

New technologies such as human papillomavirus (HPV) testing and vaccination necessitate comprehensive policy analyses to optimize cervical cancer prevention. To inform future Scandinavian‐specific policy analyses, we aimed to provide an overview of cervical cancer epidemiology and existing prevention efforts in Denmark, Norway and Sweden. We compiled and summarized data on current prevention strategies, population demography and epidemiology (for example, age‐specific HPV prevalence and cervical cancer incidence over time) for each Scandinavian country by reviewing published literature and official guidelines, performing registry‐based analyses using primary data and having discussions with experts in each country. In Scandinavia, opportunistic screening occurred as early as the 1950s and by 1996, all countries had implemented nationwide organized cytology‐based screening. Prior to implementation of widespread screening and during 1960–66, cervical cancer incidence was considerably higher in Denmark than in Norway and Sweden. Decades of cytology‐based screening later (i.e. 2010–2014), cervical cancer incidence has been considerably reduced and has converged across the countries since the 1960s, although it still remains lowest in Sweden. Generally, Scandinavian countries face similar cervical cancer burdens and utilize similar prevention approaches; however, important differences remain. Future policy analyses will need to evaluate whether these differences warrant differential prevention policies or whether efforts can be streamlined across Scandinavia.

Adapting cervical cancer screening for women vaccinated against human papillomavirus infections: The value of stratifying guidelines

Background Attendance to routine cancer screening at repeated intervals is essential for reducing morbidity and mortality of targeted cancers, yet currently defined quality-assurance metrics evaluate coverage within a defined period of time (e.g. 3.5 years). Methods We developed a longitudinal adherence metric that captures attendance to cancer screening at repeated intervals, and applied the metric to population-based data from the Cancer Registry of Norway that captures two decades of organised cervical cancer screening, including all screening tests and cervical cancer diagnoses for women living in Norway at any time during years 1992-2013 and eligible for at least two screening rounds (1 round = 3.5 years, N = 1 391 812). For each woman, we calculated the proportion of eligible screening rounds with at least one registered cytology test, and categorised women into one of five longitudinal adherence categories: never-screeners, severe under-screeners, moderate under-screeners, guidelines-based screeners and over-screeners. For each category, we evaluated cancer outcomes such as cancer stage at diagnosis. Results Only 46% of screen-eligible women were consistently screened at least once every 3.5 years, and the majority of these were over-screened. In contrast, 29% were moderately under-screened, 17% were severely under-screened and 8% had never attended screening. Screening behaviour was associated with cancer outcomes; e.g., the proportion of cancers diagnosed at Stage I increased from 21% among never-screeners to 70% among over-screeners. Conclusion The longitudinal adherence metric evaluates screening performance as a succession of screening episodes, reflecting both guidelines and the fundamental principles of screening, and may be a valuable addition to existing performance indicators.