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Cost-effectiveness of human papillomavirus vaccination
Submit responseThe article by Kim et al. offers an important contribution to our understanding of the cost implications of HPV control strategies in women over 30(1). It also offers lessons in the uses and potential misuses of cost-effectiveness estimates. The article adopted a societal perspective that many internists would be ill-advised to apply in their clinical practice. For this reason, some of the conclusions drawn by the article could be inapplicable to clinical decision-making. Our role as physicians is to advise our patients how to achieve health outcomes that they value given resource constraints. Physicians cannot ignore cost effectiveness, but given a patient centered perspective it would be a disservice to simply accept and apply the pronouncement that , "HPV vaccine does not represent good value for resources expended."
The paper used nothing more than informal heuristics to propel an assumption that society should not spend more than $100,000 per QALY. It is unlikely that this particular value applies to any particular individual consulting their physician about whether to receive an HPV vaccine. If we assume that individual patients' willingness to pay thresholds are normally distributed around $100,000 per QALY, then half of patients would happily pay out of their pocket for a vaccine that generated a $100,000 QALY and half would not. Our job as internists is to know our patients well enough to enable them to make decisions that are right for them. willingness to pay thresholds are normally distributed around $100,000 per QALY, then half of patients would happily pay out of their pocket for a vaccine that generated a $100,000 QALY and half would not. Our job as internists is to know our patients well enough to enable them to make decisions that are right for them.
There are decisions in health policy that naturally demand a societal decision. These decisions are typically about publicly shared resources, like permissible levels of air pollutants, or appropriate speed limits, where all must share in a common decision. Vaccination decisions can be individually titrated, and there is no compelling reason to deny technology and information about it to those willing to pay for their own vaccine.
There is an unfortunate precedent for mistaking the individual and societal perspective. An influential study in 1995 concluded that the polysaccharide meningococcal vaccine's ability to save lives at $1 million per life saved was not cost-effective(2). As a result, of it being declared "not cost-effective," physicians generally did not even discuss the presence of this vaccine to college-bound teens who were at heightened risk. A generation of youth missed an opportunity. Earlier this decade several states passed laws mandating counseling about the presence of a vaccine (3), it emerged that with physician guidance many patients reached an independent judgment that the benefits of meningococcal vaccine represented good value for their own out of pocket spending.
There is no compelling reason for the US population to be subjected to a one-size fits all decision on whether women over 30 can be protected from HPV with a vaccine. Instead, the results of this paper, can contribute to liberating discussions between doctors and patients on the value of health and how much money to devote to its pursuit.
References
1. Kim JJ, Ortendahl J, Goldie SJ. Cost-effectiveness of human papillomavirus vaccination and cervical cancer screening in women older than 30 years in the United States. Ann Intern Med. 2009;151(8):538-45.
2. Jackson LA, Schuchat A, Gorsky RD, Wenger JD. Should college students be vaccinated against meningococcal disease? A cost-benefit analysis. Am J Public Health. 1995;85(6):843-5.
3. Baltimore RS, Jenson HB. Meningococcal vaccine: new recommendations for immunization of college freshmen. Curr Opin Pediatr. 2001;13(1):47-50.
Conflict of Interest:
None declared