Clinical effectiveness and cost-effectiveness of interventions for the treatment
of anogenital warts: systematic review and economic evaluation
#MMPMID27034016
Thurgar E
; Barton S
; Karner C
; Edwards SJ
Health Technol Assess
2016[Mar]; 20
(24
): v-vi, 1-486
PMID27034016
show ga
BACKGROUND: Typically occurring on the external genitalia, anogenital warts
(AGWs) are benign epithelial skin lesions caused by human papillomavirus
infection. AGWs are usually painless but can be unsightly and physically
uncomfortable, and affected people might experience psychological distress. The
evidence base on the clinical effectiveness and cost-effectiveness of treatments
for AGWs is limited. OBJECTIVES: To systematically review the evidence on the
clinical effectiveness of medical and surgical treatments for AGWs and to develop
an economic model to estimate the cost-effectiveness of the treatments. DATA
SOURCES: Electronic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed
Citations, EMBASE, The Cochrane Library databases and Web of Science) were
searched from inception (or January 2000 for Web of Science) to September 2014.
Bibliographies of relevant systematic reviews were hand-searched to identify
potentially relevant studies. The World Health Organization International
Clinical Trials Registry Platform and ClinicalTrials.gov were searched for
ongoing and planned studies. REVIEW METHODS: A systematic review of the clinical
effectiveness literature was carried out according to standard methods and a
mixed-treatment comparison (MTC) undertaken. The model implemented for each
outcome was that with the lowest deviance information criterion. A de novo
economic model was developed to assess cost-effectiveness from the perspective of
the UK NHS. The model structure was informed through a systematic review of the
economic literature and in consultation with clinical experts. Effectiveness data
were obtained from the MTC. Costs were obtained from the literature and standard
UK sources. RESULTS: Of 4232 titles and abstracts screened for inclusion in the
review of clinical effectiveness, 60 randomised controlled trials (RCTs)
evaluating 19 interventions were included. Analysis by MTC indicated that
ablative techniques were typically more effective than topical interventions at
completely clearing AGWs at the end of treatment. Podophyllotoxin 0.5% solution
(Condyline(®), Takeda Pharmaceutical Company Ltd; Warticon(®) solution, Stiefel
Laboratories Ltd) was found to be the most effective topical treatment evaluated.
Networks for other outcomes included fewer treatments, which restrict conclusions
on the comparative effectiveness of interventions. In total, 84 treatment
strategies were assessed using the economic model. Podophyllotoxin 0.5% solution
first line followed by carbon dioxide (CO2) laser therapy second line if AGWs did
not clear was most likely to be considered a cost-effective use of resources at a
willingness to pay of £20,000-30,000 per additional quality-adjusted life-year
gained. The result was robust to most sensitivity analyses conducted.
LIMITATIONS: Limited reporting in identified studies of baseline characteristics
for the enrolled population generates uncertainty around the comparability of the
study populations and therefore the generalisability of the results to clinical
practice. Subgroup analyses were planned based on type, number and size of AGWs,
all of which are factors thought to influence treatment effect. Lack of data on
clinical effectiveness based on these characteristics precluded analysis of the
differential effects of treatments in the subgroups of interest. Despite
identification of 60 studies, most comparisons in the MTC are informed by only
one RCT. Additionally, lack of head-to-head RCTs comparing key treatments,
together with minimal reporting of results in some studies, precluded
comprehensive analysis of all treatments for AGWs. CONCLUSIONS: The results
generated by the MTC are in agreement with consensus opinion that ablative
techniques are clinically more effective at completely clearing AGWs after
treatment. However, the evidence base informing the MTC is limited. A
head-to-head RCT that evaluates the comparative effectiveness of interventions
used in clinical practice would help to discern the potential advantages and
disadvantages of the individual treatments. The results of the economic analysis
suggest that podophyllotoxin 0.5% solution is likely to represent a
cost-effective first-line treatment option. More expensive effective treatments,
such as CO2 laser therapy or surgery, may represent cost-effective second-line
treatment options. No treatment and podophyllin are unlikely to be considered
cost-effective treatment options. There is uncertainty around the
cost-effectiveness of treatment with imiquimod, trichloroacetic acid and
cryotherapy. STUDY REGISTRATION: This study is registered as PROSPERO
CRD42013005457. FUNDING: The National Institute for Health Research Health
Technology Assessment programme.
|Condylomata Acuminata/*therapy
[MESH]
|Cost-Benefit Analysis
[MESH]
|Humans
[MESH]
|Laser Therapy/*economics/methods
[MESH]
|Papillomaviridae/isolation & purification
[MESH]
|Podophyllotoxin/economics/*therapeutic use
[MESH]
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