06_Cost-Effectiveness Study of Hpv Vaccination in the Prevention of Cervical Cancer

7/29/2019 06_Cost-Effectiveness Study of Hpv Vaccination in the Prevention of Cervical Cancer

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COST-EFFECTIVENESS OF HPV VACCINATION IN

PREVENTION OF CERVICAL CANCER

IN MALAYSIA

Dr. Sharifa Ezat Wan Puteh

Department of Community Health

Faculty of MedicineUKMMC

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Researchers

Researchers

Prof Dato Syed Aljunid

Sharifa Ezat Wan Puteh

Fuad Ismail

Aniza Ismail

Seri Suniza Ahmad Zailani Hatta

Sharifah Noor Akmal

Nurismah Md Isa

Paul Ng

Murali Ganesalingam

Vicknesh Visvalingam Mymoon Alias

Majdah Mohd

Rushdan Mohd Noor

Institutions

UKMMC

Hospital Kuala Lumpur

Hospital Sultanah Bahiyah AlorStar Kedah

Hospital Kuantan, Pahang Hospital Kangar, Perlis

Hospital Seremban, NegeriSembilan

Ministry of Health Malaysia

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Cervical Cancer Serious health problem

9 mil. women develop disease each year world wide.

Developing countries with no preexisting screening orpoor coverage.

Much higher compared to developed countries with

established screening programs (UK 11.5/100000)

2nd most commonest cancer in Malaysia after breast

cancer.

Strong relationship with the Human Papilloma virus

(HPV) 16, 18.

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Cervical Cancer Incidence By Age, Peninsular Malaysia

(Per 100,000)

ETHNICITY % of Cervical

Cancer Cases

CHINESE 56.4

MALAYS 32.8

INDIANS 10.8

Total Nos. of Cases Per Year = 1,557(NCR 2003)

Incidence of CC by Age

010

20

30

40

50

60

70

80

Age 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70+

CR

2003 2006


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HPV Vaccine

Two types

1. Quadrivalent Vaccine

HPV Types 6, 11, 16, 18

Cervical, Vulva, Vagina Cancer and Genital Warts

2. Bivalent Vaccine

HPV Types 16,18

Cervical Cancer Only

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Objectives

SPECIFIC OBJECTIVES

To determine the cost of treatment and womens

quality of life according to age and disease progression.

To compare the CEA 3 programs i.e. Pap smear

program, HPV vaccination program and thecombined strategy (HPV vaccination with screeningprogram).

Robustness of the economic model using sensitivity analysis.


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STUDY HYPOTHESIS

Burden of Cervical Cancer is substantial to the Malaysian

economy.

Cost of treatment of cervical cancer patients will increasewith age and severity.

Combined strategy (HPV vaccination combined Pap

smear program) is the most cost-effective option.


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Cost-Effectiveness Model

Costs

Cost of Vaccination Program

Cost of Pap Smear Program

Cost of Managing Positive Pap Smear

Cost of Adverse Events of Vaccination

Outcomes

Quality Adjusted Life Years (QALYS)

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Cost-Effectiveness Ratio

(Cost/QALYs)

Negative: Cost Saving

Less than 1 GDP : Highly Cost Effective Between 1 to 3 GDP : Cost Effective

More than 3 GDP : Not Cost Effective

Per capita GDP 2006: RM 20,911 (WHO)

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METHODOLOGY

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Study Design

Economic Evaluation Design

Tools

1. Quality Of Life from SF-36 questionnaires. Physical composite summary scores (PCS)

Mental composite summary scores (MCS)

Quality Adjusted Life Years saved(QALYs)= QOL x lifeexpectancy (years) saved

2. Costing Data (patients & providers).

Duration: 2006-2008.

Respondents= 502 patients

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Costing Data

1. Expert group discussion, develop treatment algorithms, management costfor cervical cancers by severity pathways.

- Activity Based Costing.

2. Step down costing for the Providers Cost

Using case mix UKMMC cost per day admission and cost per day ofoutpatient.

Programs Cost-2 data and published literatures.

3. Micro costing questionnaire for Patients cost.

direct interview with respondents with cervical cancers. Modelling of vaccinated women, using QOL (secondary data Azman et

al 2004) and normal life expectancy of women (Statistics Dept 2006).

Patients sampled universally- inclusion and exclusion criteria.

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RESULTSSocio demographic dataand QOL

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Prevalence by Disease Stage

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Stage 4Stage 3Stage 2Stage 1ASCUSCIN 3CIN 2CIN 1

Disease by Stages

30

20

10

0

Percent

4.58%7.17%

28.29%30.88%

4.98%7.57%6.97%

9.56%


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Age and Ethnicity

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Mean age=53.0 (SD 11.23) years

OthersIndiansChineseMalay

Etnicity

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

Percent

1.79%

15.14%

37.25%

45.82%


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Respondents Income

Patients Income

Median RM 525 (IQR 300-1000)

/month.

Partners incomeMedian RM 500 (IQR 0-1150).

16

RM 3000

and above

RM 2500-

2999

RM 2000-

2499

RM 1500-

1999

RM 1000-

1499

RM 500-

999

Income

RM0-499

Patients' Income

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

Percent

1.99%0.4%2.59%

2.79%

9.96%

20.32%

61.95%

RM 3000 and

above

RM 2500-

2999

RM 2000-

2499

RM 1500-

1999

RM 1000-

1499

RM 500-999Partners

Income RM0-

499

Range of Partners Income

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

Percent

6.18%

1.79%6.37%7.17%

11.35%

18.53%

48.61%

Household Income/ month: RM 800 (IQR 400-1525).


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Healthcare Expenditure

(Percentage Spent on Health)

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50-59%40-49%30-39%20-29%10-19%% spent onhealth care


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Preinvasive

Diseases

Stage 1A1 Stage 1A2 Stage 1B-2A Stage 2B-4A Stage 4B Total

33.98

27.72

24.23

26.5925.59

26.25

28.36

20.54

14.25

10.98

13.5112.65

11.48

15.18

Life Expectancy by Disease Severity

Life Expectancy Vaccinated Women Life Expectancy Cervical Cancers

Difference p


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QUALITY OF LIFE

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0102030405060708090

PhysicalFun

ctioning

(PF)

Rolelimitation-p

hysical

(REP)

BodilyPain(BP)

Generalhealth(GH)

Vitality(VT)

SocialFunctio

ning(SF)

Rolelim

itation-

emotional(REE)

MentalHea

lth(MH)

QOL between Cervical Cancers & Normal Women

Cervical Cancers

Normal Women

Population

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QOL by Disease Severity

21

0.00

10.00

20.0030.00

40.00

50.00

60.00

PCS

MCS

PCS difference significant p


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QOL by Age

22

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

45.00

50.00

Lessthan25

y

ears

old

2

5-34years

35-44years

45-54years

55-64years

65years

and

above

Total

PCS

MCS

PCS difference significant p


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Clinical Pathways Cost

Less than

25 years

old

25-34

years

35-44

years

45-54

years

55-64

years

65 years

and above

Total

1,7433,260

17,333

20,741

25,222 25,561

21,250

Cost/Case/Year by Age

Mean cost difference significant p


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Comparison of Costs by Activities

ActivitiesUK (

Million) %

Malaysia

(RM Million) %

Cost of Screening 104.3 56.2 22.0 9

Cost of Managing

Pre-invasiveDisease

34.5 18.6 1.4 1

Cost of managing

new invasive

cancer cases

33.3 17.9 167 68

Cost of managingexisting cases 13.5 7.3 55 22

Total 185.6 100 245.4 100

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Brown RE, Breugelmans JG, Theodoratou D, Benard S. Costs of Detection and Treatment of Cervical Cancer, Cervical Dysplasia

and Genital Warts in the UK. Current Medical Research and Options. 2006; 22 (4):663.Sharifa Ezat et al. 2008.Economic Burden of Cervical Cancer in Malaysia. Medical Journal of Indonesia. 17(4):272-280.


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COSTING and CEA

Three program strategies-

1. Pap smear2. HPV Vaccinations

3. Combined (Vaccination & Pap smear)

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Parameters in CE Model

Quadrivalent Vaccine Sensitivity Analysis Cost/dose

RM 300-RM 400

No booster required i.e. Vaccine

efficacy sustained

Side effects not serious

Pap smear population coverage

40, 70 and 80%

Mandatory Vaccinations

Administered at 15 years old

Plus catch up period from 9-26 years

old.

Coverage 70% only.

Cost and outcomes were

discounted 3% for 10 years.

Incidence Cx Cancer based on

19.7/100,000 female

population (year 2003).

Female population based on

Msia population statistics year

2006.

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Scenarios for Cost Effectiveness

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Scenario Pap Smear

Coverage

Price of

Vaccine/dose

Base Case 40% RM 300

Best Case 70% RM 300

Worst Case 40% RM 400


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CEA of Three Programs

Cost (RM)/

QALYs

Pap Smear

Only

HPV

Vaccination

only

Combined

Base Case 1,215 35,347 11,290

Best Case 1,100 35,347 7,713

Worst Case 1,215 46,530 14,590


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Incremental Cost Effectiveness Ratio (ICER)

Strategy Cost (RM) Effectivenes(QALYs)

Incremental Incremen-tal

Effectiveness

(QALYs)

ICER(per

QALYs

avoided)

RM

Cost (RM)

Pap smearprogram

40%

coverage

91,930,890 109,850 _ _ _

Pap smear

program

70%Coverage

211,462,910 192,237 77,999,691 82,387 947

Combined

Strategy

Best Case

1,837,478,053 238,240 1,626,015,143 46,002

35,347


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Budget Impact Assessment

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

Cost per year Cost per 5 years Cost per 10

years

Cost per 20

years

Cost per 50

years

Millions

RM (Cost) Projected Cost if Reduced Incidence


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Conclusions Loss of life to years is substantial in cervical cancer patients.

Cost gets higher with increase severity and age.

QOL lowest at

older age group

higher severity of disease.

Physical functions more affected than Mental functions.

Combined strategy is Highly Cost Effective

HPV Vaccine Alone is still cost-effective at all level of Sensitivity in preventingCervical Cancers in Malaysia

More cost effective at higher Pap smear coverage and if vaccine cost is

cheaper.

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THANK YOU

[email protected][email protected]

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06_Cost-Effectiveness Study of Hpv Vaccination in the Prevention of Cervical Cancer

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