Roland P Y, Naumann R W, Alvarez R D, Kilgore L C, Partridge E E
Department of Obstetrics and Gynecology, University of Alabama at Birmingham 35233-7333, USA.
Gynecol Oncol. 1995 Oct;59(1):75-80. doi: 10.1006/gyno.1995.1270.
The purpose of this study was to investigate contemporary methods of evaluating and treating abnormal Pap smears, in terms of their potential for excessive treatment and financial impact on health care delivery systems.
Clinical algorithms for the evaluation and treatment of abnormal Pap smears were constructed, taking into consideration different philosophies on the need for colposcopic biopsy, the role of cryotherapy, and LLETZ. The algorithms employed (1) colposcopy of all patients with cryotherapy of mild dysplasia and LLETZ of moderate to severe dysplasia; (2) colposcopy with observation of mild dysplasia, treatment of moderate dysplasia by cryotherapy, and severe dysplasia by LLETZ; (3) colposcopy of LGSIL Paps before treatment and immediate LLETZ of HGSIL; and (4) immediate LLETZ of LGSIL and HGSIL Paps. Each algorithm was theoretically applied to a cohort of colposcopy clinic patients based upon referral Pap smear, with excessive treatment and costs calculated. The cohort's repeat Pap smear, colposcopic biopsy, and candidacy for cryotherapy were included in the analysis. The decision to use repeat Pap smear in treatment planning, submit only diagnostic LLETZ pathology, and select immediate LLETZ candidates by HGSIL/severe dysplasia Pap smear was considered. Financial impact was calculated using nationwide fiftieth-percentile reimbursement costs for procedures and related pathology.
Colposcopy provided little opportunity for excessive treatment. In contrast, 49.3% of cases subjected to immediate LLETZ would theoretically not have required treatment, if initially evaluated by colposcopy. The use of the subset of HGSIL cases encompassing severe dysplasia only identified patients suitable for immediate LLETZ, with an excessive treatment rate of only 2.8%. Traditional colposcopy (algorithm 2) would have been least expensive at $718 per patient. Algorithms 1 and 3 were intermediate at $785 and $754 per patient, respectively. Immediate LLETZ of all abnormal Paps (algorithm 4) would have been most costly at $838 per patient.
The abandonment of colposcopy and reliance on immediate LLETZ for evaluation and treatment of cervical lesions would have been expensive and had significant potential for excessive treatment. Traditional colposcopic evaluation, coupled with observation of mild dysplasia, appeared to be the most cost-effective means of treating cervical dysplasia and had a low potential for excessive treatment.
本研究旨在探讨评估和治疗异常巴氏涂片的当代方法，考量其过度治疗的可能性以及对医疗保健提供系统的财务影响。
构建了用于评估和治疗异常巴氏涂片的临床算法，考虑了关于阴道镜活检必要性、冷冻疗法的作用以及大环状电切除术（LLETZ）的不同理念。这些算法采用：（1）对所有患者进行阴道镜检查，轻度发育异常者采用冷冻疗法，中度至重度发育异常者采用大环状电切除术；（2）阴道镜检查，观察轻度发育异常，中度发育异常采用冷冻疗法，重度发育异常采用大环状电切除术；（3）对低度鳞状上皮内病变（LGSIL）巴氏涂片在治疗前进行阴道镜检查，对高度鳞状上皮内病变（HGSIL）立即采用大环状电切除术；（4）对LGSIL和HGSIL巴氏涂片立即采用大环状电切除术。每种算法理论上应用于一组基于转诊巴氏涂片的阴道镜诊所患者，计算过度治疗和成本。分析纳入该队列的重复巴氏涂片、阴道镜活检以及冷冻治疗的适用性。考虑了在治疗计划中使用重复巴氏涂片、仅提交诊断性大环状电切除术病理报告以及通过HGSIL /重度发育异常巴氏涂片选择立即进行大环状电切除术的候选者的决策。使用全国第50百分位数的程序和相关病理报销成本计算财务影响。
阴道镜检查几乎没有过度治疗的机会。相比之下，如果最初通过阴道镜检查评估，理论上49.3%接受立即大环状电切除术的病例本不需要治疗。仅使用包含重度发育异常的HGSIL病例子集来识别适合立即进行大环状电切除术的患者，过度治疗率仅为2.8%。传统阴道镜检查（算法2）每位患者成本最低，为718美元。算法1和3居中，每位患者分别为785美元和754美元。对所有异常巴氏涂片立即采用大环状电切除术（算法4）成本最高，每位患者为838美元。
放弃阴道镜检查而依赖立即大环状电切除术来评估和治疗宫颈病变会成本高昂且有显著的过度治疗可能性。传统阴道镜检查评估，结合观察轻度发育异常，似乎是治疗宫颈发育异常最具成本效益的方法，且过度治疗可能性低。
