Chaiken Sarina R, Bruegl Amanda S, Caughey Aaron B, Emerson Jenna, Munro Elizabeth G
Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon.
Obstet Gynecol. 2023 Apr 1;141(4):756-763. doi: 10.1097/AOG.0000000000005106. Epub 2023 Mar 9.
To examine the cost effectiveness of human papillomavirus (HPV) vaccination after excisional procedure compared with no vaccination.
We constructed a decision-analytic model (TreeAge Pro 2021) to compare outcomes between patients who underwent an excisional procedure followed by nonavalent HPV vaccination to those who underwent an excisional procedure without vaccination. Our theoretical cohort contained 250,000 patients, the approximate number undergoing excisional procedures annually in the United States. Our outcomes were costs, quality-adjusted life-years (QALYs), recurrence events, number of surveillance Pap tests with co-testing, number of colposcopies, and second excisional procedures. Probabilities of recurrence were based on a recently published meta-analysis. All values were derived from the literature, and QALYs were discounted at a rate of 3%. Outcomes were applied for 4 years after the initial excisional procedure. Our cost-effectiveness threshold was $100,000 per QALY. Sensitivity analyses were performed to evaluate the robustness of the model.
In our theoretical cohort of patients who underwent an excisional procedure, the HPV vaccination strategy was associated with 17,281 fewer recurrences of cervical intraepithelial neoplasia (CIN) (8,360 fewer cases of CIN 1 and 8,921 fewer cases of CIN 2 or 3), 26,203 fewer Pap tests (1,025,368 vs 1,051,570), 17,281 fewer colposcopies (20,588 vs 37,869), and 8,921 fewer second excisional procedures (4,779 vs 13,701). The vaccination strategy was associated with a higher cost of $135 million. Vaccination was a cost-effective strategy, with an incremental cost-effectiveness ratio of $29,181 per QALY, compared with no vaccination. In our sensitivity analyses, the HPV vaccination strategy remained cost effective until the cost of the three-dose HPV vaccine series reached $1,899 or the baseline (nonvaccinated) probability of recurrence was less than 4.8%.
In our model, HPV vaccination for patients with a prior excisional procedure led to improved outcomes and was cost effective. Our study suggests that clinicians should consider offering the three-dose HPV vaccine series to patients who have undergone an excisional procedure to decrease the risk of CIN recurrence and its sequelae.
研究与不接种疫苗相比，切除术后接种人乳头瘤病毒（HPV）疫苗的成本效益。
我们构建了一个决策分析模型（TreeAge Pro 2021），比较接受切除术后接种九价HPV疫苗的患者与接受切除术后未接种疫苗的患者的结局。我们的理论队列包含250,000名患者，约为美国每年接受切除术的患者数量。我们的结局指标包括成本、质量调整生命年（QALY）、复发事件、联合检测的宫颈涂片检查次数、阴道镜检查次数和二次切除手术次数。复发概率基于最近发表的一项荟萃分析。所有数值均来自文献，QALY按3%的贴现率贴现。结局指标应用于初次切除术后4年。我们的成本效益阈值为每QALY 100,000美元。进行敏感性分析以评估模型的稳健性。
在我们接受切除术的理论队列患者中，HPV疫苗接种策略与宫颈上皮内瘤变（CIN）复发减少17,281例相关（CIN 1减少8,360例，CIN 2或3减少8,921例），宫颈涂片检查减少26,203次（1,025,368次对1,051,570次），阴道镜检查减少17,281次（20,588次对37,869次），二次切除手术减少8,921次（4,779次对13,701次）。疫苗接种策略的成本更高，为1.35亿美元。与不接种疫苗相比，接种疫苗是一种具有成本效益的策略，增量成本效益比为每QALY 29,181美元。在我们的敏感性分析中，HPV疫苗接种策略在三剂HPV疫苗系列成本达到1,899美元或基线（未接种疫苗）复发概率低于4.8%之前一直具有成本效益。
在我们的模型中，对既往接受过切除术的患者接种HPV疫苗可改善结局且具有成本效益。我们的研究表明，临床医生应考虑为接受过切除术的患者提供三剂HPV疫苗系列，以降低CIN复发及其后遗症的风险。
