Beware of Kinked Frontiers: A Systematic Review of the Choice of Comparator Strategies in Cost-Effectiveness Analyses of Human Papillomavirus Testing in Cervical Screening

Abstract

Many of the CEAs reviewed appear to include insufficient comparator strategies. In particular, they omit strategies with relatively long screening intervals. Omitting relevant comparators matters particularly if it leads to the underestimation of ICERs for strategies around the cost-effectiveness threshold because these strategies are the most policy relevant from the CEA perspective. Consequently, such CEAs may not be providing the best possible policy guidance and lead to the mistaken adoption of cost-ineffective screening strategies.

Performance and Cost-Effectiveness of Computed Tomography Lung Cancer Screening Scenarios in a Population-Based Setting: A Microsimulation Modeling Analysis in Ontario, Canada

“…The results of this study suggest that scenario characteristics, especially smoking eligibility criteria and screening interval, influence the cost-effectiveness of a scenario and suggest that a large variety of scenarios should be considered. In addition, considering a wide variety of screening scenarios provides sufficient comparator scenarios to yield appropriate ICERs [ 18 ]. Previous studies often reported the ACERs of the investigated screening scenarios as the ICERs, which can give misleading cost-effectiveness estimates [ 17 ].…”

“…Furthermore, these studies considered limited numbers of screening scenarios, providing little information on the effects of screening eligibility criteria, and may have had insufficient numbers of comparator scenarios to yield correct ICERs [ 18 ]. The aim of this study was to investigate the benefits (such as lung cancer mortality reduction and the number of life-years gained), harms (such as the number of false-positive results and occurrence of overdiagnosis), and cost-effectiveness of many different lung cancer screening scenarios for the population of Ontario, overcoming some of the limitations of previous studies.…”

Generating evidence to inform health technology assessment of treatments for SLE: a systematic review of decision-analytic model-based economic evaluations

“…The incremental benefit of a health technology can be exaggerated by comparing it with a strategy that is not the next-best alternative; in turn, inappropriate comparators can result in overestimating relative cost-effectiveness. 47 Greater transparency at the scoping stage of future economic evaluations in SLE may be valuable to define the decision problem and select relevant comparators appropriately.…”

Using novel biomarkers to triage young adult women with minor cervical lesions: a cost‐effectiveness analysis

“…Ideally, all relevant strategies for a particular decision problem should be considered; identification of strategies thus requires in-depth understanding to the field and, often, consultations with experts. Omitting relevant strategies can lead to biased comparisons of strategies and incorrect identification of preferred strategies [109]. In addition, the analyst should define the target population of the analysis (i.e., to whom the intervention is intended).…”

“…The choice of competing strategies is an important component of CEA and essential for appropriate identification of cost-efficient and cost-effective strategies [109]. In line with recommendations for good modeling practice [128], the analyses in Papers I-IV triage for HPV-positive/cytology-negative women, which has been suggested as a relevant triage method for HPV-based screening elsewhere [168,173].…”