Bruce Kelly H, Moriarty James P, Borah Bijan J, Dholakia Ruchita, Lohman Mary E, Brewer Jerry D, Vidal Nahid Y, Bakkum-Gamez Jamie N, Cliby William A
Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
Gynecol Oncol Rep. 2024 Feb 22;52:101339. doi: 10.1016/j.gore.2024.101339. eCollection 2024 Apr.
To determine the cost of two surgical treatment approaches for vulvar Paget's disease and model the cost-effectiveness considering differences in recurrence and reoperation over time.
We assessed cost-effectiveness between excision guided by Mohs micrographic surgery (MMS-E) and traditional wide local excision (WLE). We examined billing data from patients with vulvar Paget's disease who underwent MMS-E (cases, n = 24, 2018-2022) or WLE (controls, n = 64, 1990-2020). We created typical treatment bundles incorporating physician-administered services and facility costs standardized to Medicare reimbursements in 2022 United States Dollars (USD). The primary measure of effectiveness was disease-free years of life. A secondary analysis estimated quality-adjusted life years (QALY). A Markov model simulated treatment pathways over a 10-year time horizon. Transition probabilities were based on institutional recurrence rates (3-year RR 6.7 % for MMS-E vs 34.1 % for WLE). We used a willingness-to-pay threshold of 100,000 USD per QALY.
The cost of a single surgical episode was 34,664 USD for MMS-E and 14,969 USD for WLE. In the setting of lower recurrence rates with MMS-E, the incremental cost was 12,789 USD per disease-free year gained. A secondary analysis incorporating QALY showed an incremental cost of 72,820 USD per QALY.
MMS-E appears to be a cost-effective treatment for vulvar Paget's disease compared to historic standard of care. Our ability to estimate quality of life gained by avoiding disease recurrence was limited by scant data for this rare condition; thus, future studies incorporating health utility values are needed to facilitate a more comprehensive analysis.
确定外阴佩吉特病两种手术治疗方法的成本，并考虑随时间推移复发和再次手术的差异，对成本效益进行建模。
我们评估了莫氏显微外科手术引导下的切除术（MMS-E）和传统广泛局部切除术（WLE）之间的成本效益。我们检查了接受MMS-E（病例组，n = 24，2018 - 2022年）或WLE（对照组，n = 64，1990 - 2020年）的外阴佩吉特病患者的计费数据。我们创建了典型治疗套餐，纳入了医生提供的服务和以2022年美元（USD）的医疗保险报销为标准的设施成本。有效性的主要衡量指标是无病生存年数。二次分析估计了质量调整生命年（QALY）。马尔可夫模型模拟了10年时间范围内的治疗路径。转移概率基于机构复发率（MMS-E的3年复发率为6.7%，而WLE为34.1%）。我们使用的支付意愿阈值为每QALY 100,000美元。
单次手术的成本，MMS-E为34,664美元，WLE为14,969美元。在MMS-E复发率较低的情况下，每获得一个无病生存年的增量成本为12,789美元。纳入QALY的二次分析显示，每QALY的增量成本为72,820美元。
与历史护理标准相比，MMS-E似乎是治疗外阴佩吉特病的一种具有成本效益的方法。我们通过避免疾病复发来估计所获得生活质量的能力受到这种罕见疾病数据匮乏的限制；因此，未来需要纳入健康效用值的研究，以促进更全面的分析。
