Economic Evaluation And Strategy Optimization Of Cervical Cancer Screening And Vaccination Based On Markov Decision Model

【Purpose】 In this study,the existing cervical cancer screening technology and human papillomavirus vaccines of various valence types in China were combined with different kinds of intervention strategies,and the health economics evaluation of different strategies was carried out by constructing decision tree-Markov model to find out the intervention strategies with economy.At the same time,with the support of the field survey data of a province in southern China,the empirical study of economic evaluation was conducted,so as to provide a reference for the development of cervical cancer screening strategy and the allocation of health resources in different regions in the future.【 Methods 】 The important parameters needed for the construction of the decision tree-Markov model were obtained through literature analysis and key person interview.Then,Tree Age Pro software was used to build the health economics evaluation model for the intervention strategy of cervical cancer in China.Half cycle correction and univariate sensitivity analysis were used to reduce the error of the model and improve the stability of the model.Sixteen screening strategies were evaluated by using cost-effectiveness ratio,cost-utility ratio and cost-benefit ratio in economic evaluation methods.Based on the cost accounting survey of screening institutions in a southern province in 2019,the total input cost of cervical cancer screening program in the province was calculated.The economic burden of disease was calculated based on the historical data of cervical cancer inpatients in a third-grade hospital in this province from 2008 to 2018,and the health benefits generated by the implementation of the screening program were calculated.And economic evaluation of screening items was carried out by using the cost-benefit ratio and other indicators.【Results】(1)Research on the direct medical economic burden of hospitalized patients with cervical cancer:From 2008 to 2018,the average medical expenses per person of hospitalized patients with cervical cancer was 17333.23 yuan,the average hospitalization days per person was 16, and the average age of patients was 48 years old.Overall,the direct medical economic burden of hospitalized patients with cervical cancer in this hospital increased by nearly5000 yuan in the past 11 years.Diagnostic expenses accounted for the largest proportion of the total hospitalization medical expenses(26.14%),followed by drug expenses(23.05%),treatment expenses(22.39%),comprehensive medical services expenses(14.61%),consumables expenses(13.79%)and other expenses(0.01%).The results of one-way ANOVA showed that there were significant differences in medical expenses of hospitalized patients with cervical cancer in different age,hospitalization day,treatment results and hospitalization times.(2)Economic evaluation of cervical cancer intervention strategies in China:The results of the analysis showed that among the 16 simulated intervention strategies,2-valent vaccine vaccination,4-valent vaccine vaccination,9-valent vaccine vaccination,2-valent vaccine combined with LBC screening,4-valent vaccine combined with LBC screening,9-valent vaccine combined with LBC screening,4-valent vaccine combined with HPV screening,9-valent vaccine combined with HPV screening,HPV screening,VIA/VILI screening combined with 9-valent vaccine have cost-effective advantage.The lowest average cost-effectiveness ratio was the HPV screening(C/E=61.43),and the highest was2-valent vaccination(C/E=674.50).The lowest incremental cost-effectiveness ratio was4-valent vaccination combined with HPV screening(ICER=1066.51),and the highest incremental cost-effectiveness ratio was HPV screening(ICER=63406.35).The results of benefit cost ratio analysis showed that the highest ratio was LBC screening combined with9-valent vaccination(B/C=36850),and the lowest was VIA/VILI screening(B/C=2239).Discount rate,vaccine coverage rate and sensitivity of screening technology are the main factors influencing the evaluation model of intervention strategy.(3)Economic evaluation and strategy optimization of cervical cancer screening program in a southern province in 2019:A total of 295877 people were screened in this province in 2019,the total investment cost was 39682060.1 yuan,and the total benefit was 112652170.5 yuan.The cost-effectiveness analysis showed that the cost of each case of precancerous lesion(low/high)was 22144.01 yuan,and the cost of each case of cervical cancer was 778079.61 yuan.Overall,the benefit cost ratio of cervical cancer screening project in 2019 was 1.84:1.The optimization of screening strategy based on Markov model in this province showed that the combination of 2-valent HPV vaccine and current screening(HPV-LBC)was the optimal intervention strategy,with a C/E and B/C of 153.48 and 2.99,respectively.【Conclusions】(1)From 2008 to 2018,the medical expenses of cervical cancer inpatients in this hospital showed an increasing trend,but the average length of stay decreased,mainly due to the continuous progress of cervical cancer diagnosis and treatment technology,which not only raised the price of medical services,but also reduced the average length of stay.Benefited from the implementation of drug price zero-addition,after 2015,the proportion of drug cost in the medical expenses of patients began to gradually decline,and the treatment cost began to become the highest proportion of the cost,which is the embodiment of the value of cervical cancer diagnosis and treatment services.The direct medical economic burden of patients in different age,length of stay,treatment results and the number of hospitalizations are significantly different.(2)Considering the lack of balanced allocation of medical and health resources,if the screening effect is taken as the outcome index,HPV screening(the lowest cost-effectiveness ratio),LBC screening,VIA/VILI screening and nonintervention strategies are recommended in order for the areas with limited resources or poor economy.The results showed that there was no significant difference in cost-effectiveness ratio between different screening techniques.For economically developed areas or areas with abundant health resources,HPV screening combined with 9-valent vaccine,HPV screening combined with 4-valent vaccine,LBC screening combined with 9-valent vaccine,HPV screening combined with 2-valent vaccine,LBC screening combined with 4-valent vaccine,VIA/VILI screening combined with 9-valent vaccine,LBC screening combined with2-valent vaccine,VIA/VILI screening combined with 4-valent vaccine,VIA/VILI screening combined with 2-valent vaccine,9-valent vaccine,4-valent vaccine and 2-valent vaccine(the cost-effectiveness ratio was the highest)are recommended in order.If the screening benefit is taken as the outcome index,the best intervention strategy was cytological screening(LBC)combined with 9-valent vaccine,and the least recommended strategy was VIA/VILI screening.The results of univariate sensitivity analysis showed that the discount rate had the greatest influence on the model,followed by vaccine coverage and screening sensitivity.In general,the sensitivity factors in the model are relatively few,that is,the stability of the model is good.(3)The total benefit of the cervical cancer screening project in 2019 was greater than the total cost(B/C=1.84:1),which realizes the reasonable allocation and optimal utilization of limited health resources in the early screening project.The analysis results of cost-effectiveness ratio showed that the higher the detection level is,the higher the cost of input is.The results of benefit cost ratio indicated that the lower the detection level is,the lower the benefit of each unit cost is.Based on the analysis of the optimization of the intervention strategies in the province,the combination of the two-valent vaccine with the current screening program is the most cost-effective strategy and has the highest benefit-to-cost ratio among the four strategies evaluated.Therefore,it is recommended that the province should include primary prevention(vaccine)in the cervical cancer screening program in the future to further improve the screening effect/benefit.