The European Journal of Health Economics

Decision thresholds with genetic testing

A genetic test is a test for the presence or absence of a genetic mutation. A positive test outcome that reveals a mutation associated with increased risk for a disease may lead a patient to seek preventive treatment provided that the penetrance (probability of developing the disease given the mutation) is sufficiently high. We derive the test threshold and the test-treatment threshold, which confine the mutation probability interval for the use of the genetic test. Test and treatment costs as well as a low penetrance rate of the mutation narrow this interval. We illustrate the model with parameters of the test for BRCA1 and BRCA2 genes as well as of preventive treatment options for breast cancer.

Interprofessional team-based primary care practice and preventive cancer screening: evidence from Family Health Teams in Ontario, Canada

Health care reforms introduced interprofessional team-based primary care to optimize access to health care and preventive services. In this context, preventive cancer screening represents an important measure as it is essential for the early detection of cancer and treatment. We investigated the effects of Family Health Teams (FHTs), an interprofessional team-based primary care practice setting, on cancer screening rates in Ontario, Canada. By utilizing comprehensive health administrative data from April 1st 2011 to March 31st 2023, we determined the effect of FHT on screening rates for breast, cervical, and colorectal cancer while controlling for relevant physician and patient characteristics. Our analytical framework employs fractional probit models, including the Mundlak procedure, and generalized estimating equations to assess the impact of practicing in FHTs on cancer screening rates, while accounting for unobserved physician heterogeneity. Our results indicate that compared to non-FHTs, physicians practicing in FHTs have higher breast (2.4%), cervical (2%), and colon (0.8%) cancer screening rates per physician per year. The effectiveness of FHTs in promoting cancer screenings is particularly pronounced in smaller practices and among populations in rural and economically deprived areas. Our findings highlight the role of teams in enhancing preventive health care services potentially through task shifting mechanisms and suggest that such models may offer a pathway to improving access to preventive health care, especially in marginalized populations. Our research contributes to the literature by providing empirical evidence on the benefits of interprofessional team-based primary care in improving cancer screening.

A systematic review of the cost-effectiveness of interventions to increase cervical cancer screening among underserved women in Europe

Abstract Background This study aimed to conduct a systematic review of the cost-effectiveness studies of interventions to increase cervical cancer screening uptake rates in underserved women in Europe. Methods A search of Embase, Medline, Global Health, PsychINFO, and NHS Economic Evaluation Database was conducted for studies published between January 2000 and September 2022. Studies were eligible if they analysed the cost-effectiveness of any interventions to improve participation in cervical cancer screening among underserved women of any age eligible to participate in cervical cancer screening in European countries, in any language. Study characteristics and cost-effectiveness results were summarised. Study quality was assessed using the Drummond Checklist, and methodological choices were further compared. Results The searches yielded 962 unique studies, with 17 of these (from twelve European countries) meeting the eligibility criteria for data extraction. All studies focused on underscreened women as an overarching group, with no identified studies focusing on specific subgroups of underserved women. Generally, self-HPV testing and reminder interventions were shown to be cost-effective to increase the uptake rates. There was also research showing that addressing access issues and adopting different screening modalities could be economically attractive in some settings, but the current evidence is insufficient due to the limited number of studies. Conclusion This systematic review has revealed a gap in the literature on the cost-effectiveness of interventions to improve uptake rates of cervical cancer screening through tailored provision for specific groups of underserved women.

Cost–utility analysis of risk-reducing strategies to prevent breast and ovarian cancer in BRCA-mutation carriers in Switzerland

Abstract Objective We aimed to identify the most cost-effective of all prophylactic measures available in Switzerland for women not yet affected by breast and ovarian cancer who tested positive for a BRCA1/2 mutation. Methods Prophylactic bilateral mastectomy (PBM), salpingo-oophorectomy (PBSO), combined PBM&PBSO and chemoprevention (CP) initiated at age 40 years were compared with intensified surveillance (IS). A Markov model with a life-long time horizon was developed from the perspective of the Swiss healthcare system using mainly literature-derived data to evaluate costs, quality-adjusted life years (QALYs) and survival. Costs and QALYs were discounted by 3% per year. Robustness of the results was tested with deterministic and probabilistic sensitivity analyses. Results All prophylactic measures were found to be cost-saving with an increase in QALYs and life years (LYs) compared to IS. PBM&PBSO were found to be most cost-effective and dominated all other strategies in women with a BRCA1 or BRCA2 mutation. Lifetime costs averaged to 141,293 EUR and 14.5 QALYs per woman with a BRCA1 mutation under IS, versus 76,639 EUR and 19.2 QALYs for PBM&PBSO. Corresponding results for IS per woman with a BRCA2 mutation were 102,245 EUR and 15.5 QALYs, versus 60,770 EUR and 19.9 QALYs for PBM&PBSO. The results were found to be robust in sensitivity analysis; no change in the dominant strategy for either BRCA-mutation was observed. Conclusion All more invasive strategies were found to increase life expectancy and quality of life of women with a BRCA1 or BRCA2 mutation and were cost-saving for the Swiss healthcare system compared to IS.

Human papillomavirus in Italy: retrospective cohort analysis and preliminary vaccination effect from real-world data

Abstract Introduction The objective of this study was to estimate the lifetime risk of hospitalization associated with all major human papillomavirus (HPV)-related diseases in Italy. Moreover, a preliminary vaccination effect was also performed. Methods A retrospective, nonrandomized, observational study was developed based on patients hospitalized between 2006 and 2018 in Italy. All hospitalizations were identified through administrative archives, according to the International Classification of Diseases (ICD-9 CM). Information related to the hospital discharges of all accredited public and private hospitals, both for ordinary and day care regimes, was taken into account. We included hospitalizations related to resident patients presenting one of the ICD-9-CM codes as primary or secondary diagnosis: genital warts (GW); ‘cervical intraepithelial neoplasia (CIN)’ (067.32–067.33); ‘condyloma acuminatum’ (078.11); ‘anal cancers’ (AC) (154.2–154.8); oropharyngeal cancers (OC): ‘oropharyngeal cancer’(146.0–146.9) and ‘head, face and neck cancers’ (171.0); genital cancers (GC): ‘penis cancer’ (187.1–187.9) and ‘cervical cancer’ (180.0–180.9). Data were stratified by birth year and divided into two groups: (a) cohort born before 1996 (not vaccinable) and (b) cohort born after 1997 (vaccinable—first cohort that could be vaccinated at the beginning of immunization schedule in girls since 2008 in Italy). Disease-specific hospitalization risks for both groups were estimated by sex, year and age. Results Epidemiological data demonstrate that the peak hospitalization risk occurred at 24–26 years of age for GW (both male and female); 33–41 and 47–54 years for AC males and females, respectively; 53–59 and 52–58 years for OC males and females, respectively; and 54–60 and 39–46 years for GC males and females, respectively. Focusing on GW and GC, vaccinable females demonstrate a significant reduction in hospitalization risks (− 54% on average) compared to nonvaccinable females until 21 years of age (maximum follow-up available for girls born after 1997). Comparing the same birth cohort of males, no differences in hospitalization risk were found. Conclusions These results support the importance of primary prevention strategies in Italy and suggest that increased VCRs and time of observation (genital cancers for which vaccination is highly effective, have a latency of some decades) will provide useful information for decision-makers.

Hospital resource utilisation from HPV-related diseases in England: a real-world cost analysis

Abstract Background and objective HPV (human papillomavirus) is the virus most often responsible for sexually transmitted infections. The burden of HPV-related diseases on hospital resources represents a major public health problem. The objective of this study was to quantify the lifetime economic burden of HPV-related diseases based on hospital resources from the perspective of National Health Service (NHS) in England. Methods Patients’ data were extracted, anonymised and aggregated by NHS digital from Hospital Episode Statistics (HES) database of patients admitted in 2015 and followed for three years. Data on hospitalizations were identified according to the International Classification of Diseases (ICD-10 CM). Health Resource Group (HRG) tariffs and National Reference Costs were used to estimate the hospitalization costs of anal, cervical, genital, oropharyngeal cancers as well as anogenital warts and cervical dysplasia. Results A total of 19,296 hospitalized patients were included in the estimation model, (39% was male and 61% female. At admission, the average age was 60 and 50 years old, respectively). Life-time costs per patients diagnosed with oropharyngeal cancer were £16,911 (£17,142 for male and £16,334 for female), penile cancer £12,539, vaginal cancer £12,676, anal cancer £13.773 (£12,590 for male, £14,525 for female). Cervical cancer accounted for £12,721, whereas cervical dysplasia for £3932. Resource used for hospitalized patients with anogenital warts was equal to £872 (£884 and £856 for men and women, respectively). On average, outpatient accounted for 39% of the total lifetime costs. Conclusion The results of this study highlight that a substantial amount of resources is utilized for the treatment of HPV-related diseases at hospital level in England. These measures have the potential to inform policy decisions to ensure an optimal use of the NHS resources.