Jane J Kim

Harvard Medical School, Boston, Massachusetts, United States

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Publications (69)419.87 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose: Standardized screening protocols for anal cancer do not yet exist despite the growing evidence that this human papillomavirus (HPV)-related cancer is preceded by premalignant stages, which if detected and removed, may prevent progression to cancer. Men who have sex with men (MSM) who are human immunodeficiency virus (HIV)-infected are among those at highest risk for anal cancer development. In order to inform policy recommendations in the United States, we estimated the health benefits and resource trade-offs associated with alternative primary anal cancer screening strategies for HIV-infected MSM. Method: We developed and calibrated a natural history microsimulation model that reflects the most recent understanding of anal carcinogenesis, accounting for interactions between HPV type-specific infections, CD4 lymphocyte strata, and anti-retroviral treatment (ART) status. Relevant strategies involved cytology-based screening, which varied by screening interval (i.e., every 1-3 years) and age at which men initiate screening (i.e., 30 vs. 40 years). Triage of abnormal results involved high-resolution anoscopy. Primary outcomes included discounted life expectancy (3% per year), cancer risk reduction and resource use (number of anoscopies performed). We calculated the incremental harm-benefit ratio (IHBR) in terms of the additional number of anoscopies required per year of life saved (YLS) for each strategy compared with the next most harmful strategy. Sensitivity analyses were conducted on test characteristics, and parameter uncertainty for progression to invasive cancer. Results: Compared with no screening, the least intensive strategy is projected to reduce cancer risk by 24%, while the most intensive strategy may reduce cancer risk by 66% among HIV-infected MSM. All strategies that initiated screening at age 40 were dominated by strategies that started at age 30. For those strategies on the harm-benefit frontier, triennial cytology-based screening required an additional 7.2 anoscopies per YLS compared with no screening, while the most intensive screening strategy (annual) required an additional 40.3 anoscopies per YLS, compared with biennial screening. The rank-order of strategies was preserved when we assumed a less sensitive anal cytology test. Conclusion: For HIV-infected MSM, the most efficient anal cancer screening strategies involve starting at age 30; however, the optimal screening interval is unclear, as more intensive strategies require explicit trade-offs between the harms and benefits, and depend on capacity constraints and society's willingness-to-pay for life-years and other health benefits.
    The 36th Annual Meeting of the Society for Medical Decision Making; 10/2014
  • Jane J Kim
    JNCI Journal of the National Cancer Institute 08/2014; 106(8). · 14.34 Impact Factor
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    ABSTRACT: Mathematical models of cervical cancer have been widely used to evaluate the comparative effectiveness and cost-effectiveness of preventive strategies. Major advances in the understanding of cervical carcinogenesis motivate the creation of a new disease paradigm in such models. To keep pace with the most recent evidence, we updated a previously developed microsimulation model of human papillomavirus (HPV) infection and cervical cancer to reflect 1) a shift towards health states based on HPV rather than poorly reproducible histological diagnoses and 2) HPV clearance and progression to precancer as a function of infection duration and genotype, as derived from the control arm of the Costa Rica Vaccine Trial (2004-2010). The model was calibrated leveraging empirical data from the New Mexico Surveillance, Epidemiology, and End Results Registry (1980-1999) and a state-of-the-art cervical cancer screening registry in New Mexico (2007-2009). The calibrated model had good correspondence with data on genotype- and age-specific HPV prevalence, genotype frequency in precancer and cancer, and age-specific cancer incidence. We present this model in response to a call for new natural history models of cervical cancer intended for decision analysis and economic evaluation at a time when global cervical cancer prevention policy continues to evolve and evidence of the long-term health effects of cervical interventions remains critical.
    American journal of epidemiology. 07/2014;
  • The Journal of infectious diseases. 07/2014;
  • Emily A Burger, Jane J Kim
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    ABSTRACT: Failures in cervical cancer screening include non-participation, under-screening, and loss-to-follow up of abnormal results. We estimated the long-term health benefits from and maximum investments in interventions targeted to improving compliance to guidelines while remaining cost-effective. We employed a mathematical model empirically calibrated to simulate the natural history of cervical cancer in Norway. A baseline scenario reflecting current practice using cytology-based screening was compared to scenarios that target different sources of non-compliance: 1) failure to follow-up women with abnormal results, 2) screening less frequently than recommended (i.e., under-screening), and 3) absence of screening. A secondary analysis included human papillomavirus (HPV)-based screening as the primary test. Model outcomes included reductions in lifetime cancer risk and incremental net monetary benefit (INMB) resulting from improvements with compliance. Compared to the status quo, improving all sources of non-compliance leads to important health gains and produced positive INMBs across a range of developed-country willingness-to-pay thresholds. For example, a 2% increase in compliance could reduce lifetime cancer risk by 1-3%, depending on the targeted source of non-compliance and primary screening method. Assuming a willingness-to-pay threshold of $83,000 per year of life saved and cytology-based screening, interventions that increase follow-up of abnormal results yielded the highest INMB per 2% increase in coverage ($19 ($10-21)). With HPV-based screening, recruiting non-screeners resulted in the largest INMB ($23 ($18-32)). Considerable funds could be allocated towards policies that improve compliance with screening under the current cytology-based program or towards adoption of primary HPV-based screening while remaining cost-effective. © 2014 Wiley Periodicals, Inc.
    International Journal of Cancer 03/2014; · 6.20 Impact Factor
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    Sorapop Kiatpongsan, Jane J Kim
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    ABSTRACT: Current prophylactic vaccines against human papillomavirus (HPV) target two of the most oncogenic types, HPV-16 and -18, which contribute to roughly 70% of cervical cancers worldwide. Second-generation HPV vaccines include a 9-valent vaccine, which targets five additional oncogenic HPV types (i.e., 31, 33, 45, 52, and 58) that contribute to another 15-30% of cervical cancer cases. The objective of this study was to determine a range of vaccine costs for which the 9-valent vaccine would be cost-effective in comparison to the current vaccines in two less developed countries (i.e., Kenya and Uganda).
    PLoS ONE 01/2014; 9(9):e106836. · 3.53 Impact Factor
  • Journal of comparative effectiveness research. 01/2014; 3(1):1-3.
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    ABSTRACT: Increasingly, countries have introduced female vaccination against human papillomavirus (HPV), causally linked to several cancers and genital warts, but few have recommended vaccination of boys. Declining vaccine prices and strong evidence of vaccine impact on reducing HPV-related conditions in both women and men prompt countries to reevaluate whether HPV vaccination of boys is warranted. A previously-published dynamic model of HPV transmission was empirically calibrated to Norway. Reductions in the incidence of HPV, including both direct and indirect benefits, were applied to a natural history model of cervical cancer, and to incidence-based models for other non-cervical HPV-related diseases. We calculated the health outcomes and costs of the different HPV-related conditions under a gender-neutral vaccination program compared to a female-only program. Vaccine price had a decisive impact on results. For example, assuming 71% coverage, high vaccine efficacy and a reasonable vaccine tender price of $75 per dose, we found vaccinating both girls and boys fell below a commonly cited cost-effectiveness threshold in Norway ($83,000/quality-adjusted life year (QALY) gained) when including vaccine benefit for all HPV-related diseases. However, at the current market price, including boys would not be considered 'good value for money.' For settings with a lower cost-effectiveness threshold ($30,000/QALY), it would not be considered cost-effective to expand the current program to include boys, unless the vaccine price was less than $36/dose. Increasing vaccination coverage to 90% among girls was more effective and less costly than the benefits achieved by vaccinating both genders with 71% coverage. At the anticipated tender price, expanding the HPV vaccination program to boys may be cost-effective and may warrant a change in the current female-only vaccination policy in Norway. However, increasing coverage in girls is uniformly more effective and cost-effective than expanding vaccination coverage to boys and should be considered a priority.
    PLoS ONE 01/2014; 9(3):e89974. · 3.53 Impact Factor
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    ABSTRACT: We studied the cost-effectiveness of cervical cancer prevention strategies in the Central and Eastern Europe and Central Asia (CEECA) region. The cost-effectiveness of human papillomavirus (HPV)16/18 vaccination of 12 year-old girls was calculated for 28 countries, under the assumption that vaccination prevents 70% of all cervical cancer cases and that cervical cancer and all-cause mortality rates are stable without vaccination. At three-dose vaccination costs of I$ 100 per vaccinated girl (currency 2005 international dollars), HPV16/18 vaccination was very cost-effective in 25 out of 28 countries using the country's gross domestic product (GDP) per capita as cost-effectiveness threshold (criterion by World Health Organization). A three-dose vaccination cost of I$ 100 is within the current range of vaccine costs in European immunization programs, and therefore our results indicate that HPV vaccination may be good value for money. To evaluate the cost-effectiveness of cervical cancer screening combined with vaccination, we calibrated a published simulation model to HPV genotype data collected in Slovenia, Poland, and Georgia. The screening interval was varied at 3, 6, and 10 years starting at age 25 or 30 and ending at age 60. In Slovenia and Poland, combined vaccination and 10-yearly HPV (DNA) screening (vaccination coverage 70%, screening coverage per round 70%) was very cost-effective when the cost of three-dose vaccination was I$ 100 per vaccinated girl. More intensive screening was very cost-effective when the screening coverage per round was 30% or 50%. In Georgia, 10-yearly Pap screening was very cost-effective in unvaccinated women. Vaccination combined with 10-yearly HPV screening was likely to be cost-effective if the three-dose vaccination cost was I$ 50 per vaccinated girl. To conclude, cervical cancer prevention strategies utilizing both HPV16/18 vaccination and HPV screening are very cost-effective in countries with sufficient resources. In low-resource settings, low vaccine pricing is essential for strategies of combined vaccination and screening to be cost-effective. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Central and Eastern Europe and Central Asia Region" Vaccine Volume 31, Supplement 7, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.
    Vaccine 12/2013; 31S7:H71-H79. · 3.77 Impact Factor
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    ABSTRACT: To date, no studies have evaluated the cost-effectiveness of human papillomavirus (HPV) vaccination in countries in the Extended Middle East and North Africa (EMENA) region. We synthesized population and epidemiologic data for 20 EMENA countries using a model-based approach to estimate averted cervical cancer cases and deaths, disability-adjusted life years (DALYs) and cost-effectiveness ratios (I$ [international dollars] per DALY averted) associated with HPV vaccination of pre-adolescent girls. We utilized additional epidemiologic data from Algeria, Lebanon, and Turkey to evaluate select cervical cancer screening strategies either alone or in combination with vaccination. Results showed that pre-adolescent vaccination of five consecutive birth cohorts at 70% coverage has the potential to prevent over 180,000 cervical cancer cases. Cases averted varied by country, largely due to differences in cancer burden and population size; 69% of cases averted occurred in the three GAVI-eligible countries in EMENA. Despite the low cervical cancer incidence in EMENA, we found that HPV vaccination was cost-effective using a threshold of each country's gross domestic product per capita (a common metric for evaluating cost-effectiveness) in all but five countries at a cost per vaccinated girl of I$25 ($5 per dose). However, cost-effectiveness diminished with increasing vaccine cost; at a cost of I$200 per vaccinated girl, HPV vaccination was cost-effective in only five countries. When the cost per vaccinated girl exceeded I$50 in Lebanon and Turkey and I$150 in Algeria, screening alone was most attractive. We identified opportunities to improve upon current national screening guidelines, involving less frequent screening every 3-5 years. While pre-adolescent HPV vaccination promises to be a cost-effective strategy in most EMENA countries at low costs, decision makers will need to consider many other factors, such as affordability, acceptability, feasibility, and competing health priorities, when making decisions about cervical cancer prevention. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Extended Middle East and North Africa Region" Vaccine Volume 31, Supplement 6, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.
    Vaccine 12/2013; 31S6:G65-G77. · 3.77 Impact Factor
  • Vaccine 12/2013; 31S6:G78-G79. · 3.77 Impact Factor
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    ABSTRACT: Using population and epidemiologic data for 48 countries in sub-Saharan Africa, we used a model-based approach to estimate cervical cancer cases and deaths averted, disability-adjusted life years (DALYs) averted and incremental cost-effectiveness ratios (I$ (international dollar) per DALY averted) for human papillomavirus (HPV) vaccination of pre-adolescent girls. Additional epidemiologic data from Uganda and South Africa informed estimates of cancer risk reduction and cost-effectiveness ratios associated with pre-adolescent female vaccination followed by screening of women over age 30. Assuming 70% vaccination coverage, over 670,000 cervical cancer cases would be prevented among women in five consecutive birth cohorts vaccinated as young adolescents; over 90% of cases averted were projected to occur in countries eligible for GAVI Alliance support. There were large variations in health benefits across countries attributable to differential cancer rates, population size, and population age structure. More than half of DALYs averted in sub-Saharan Africa were in Nigeria, Tanzania, Uganda, the Democratic Republic of the Congo, Ethiopia, and Mozambique. When the cost per vaccinated girl was I$5 ($0.55 per dose), HPV vaccination was cost-saving in 38 sub-Saharan African countries, and cost I$300 per DALY averted or less in the remaining countries. At this vaccine price, pre-adolescent HPV vaccination followed by screening three times per lifetime in adulthood cost I$300 per year of life saved (YLS) in Uganda (per capita GDP I$1,140) and I$1,000 per YLS in South Africa (per capita GDP I$9,480). In nearly all countries assessed, HPV vaccination of pre-adolescent girls could be very cost-effective if the cost per vaccinated girl is less than I$25-I$50, reflecting a vaccine price being offered to the GAVI Alliance. In-country decision makers will need to consider many other factors, such as affordability, acceptability, feasibility, and competing health priorities, when making decisions about cervical cancer prevention. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Sub-Saharan Africa Region" Vaccine Volume 31, Supplement 5, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.
    Vaccine 12/2013; 31S5:F60-F72. · 3.77 Impact Factor
  • Vaccine 12/2013; 31S5:F73-F74. · 3.77 Impact Factor
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    ABSTRACT: Infection with human papillomavirus (HPV) is recognized as one of the major causes of infection-related cancer worldwide, as well as the causal factor in other diseases. Strong evidence for a causal etiology with HPV has been stated by the International Agency for Research on Cancer for cancers of the cervix uteri, penis, vulva, vagina, anus and oropharynx (including base of the tongue and tonsils). Of the estimated 12.7 million new cancers occurring in 2008 worldwide, 4.8% were attributable to HPV infection, with substantially higher incidence and mortality rates seen in developing versus developed countries. In recent years, we have gained tremendous knowledge about HPVs and their interactions with host cells, tissues and the immune system; have validated and implemented strategies for safe and efficacious prophylactic vaccination against HPV infections; have developed increasingly sensitive and specific molecular diagnostic tools for HPV detection for use in cervical cancer screening; and have substantially increased global awareness of HPV and its many associated diseases in women, men, and children. While these achievements exemplify the success of biomedical research in generating important public health interventions, they also generate new and daunting challenges: costs of HPV prevention and medical care, the implementation of what is technically possible, socio-political resistance to prevention opportunities, and the very wide ranges of national economic capabilities and health care systems. Gains and challenges faced in the quest for comprehensive control of HPV infection and HPV-related cancers and other disease are summarized in this review. The information presented may be viewed in terms of a reframed paradigm of prevention of cervical cancer and other HPV-related diseases that will include strategic combinations of at least four major components: 1) routine introduction of HPV vaccines to women in all countries, 2) extension and simplification of existing screening programs using HPV-based technology, 3) extension of adapted screening programs to developing populations, and 4) consideration of the broader spectrum of cancers and other diseases preventable by HPV vaccination in women, as well as in men. Despite the huge advances already achieved, there must be ongoing efforts including international advocacy to achieve widespread—optimally universal—implementation of HPV prevention strategies in both developed and developing countries. This article summarizes information from the chapters presented in a special ICO Monograph ‘Comprehensive Control of HPV Infections and Related Diseases’ Vaccine Volume 30, Supplement 5, 2012. Additional details on each subtopic and full information regarding the supporting literature references may be found in the original chapters.
    Vaccine 12/2013; 31:G1–G31. · 3.77 Impact Factor
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    ABSTRACT: Purpose: To examine tradeoffs between cervical cancer screening test performance (sensitivity, specificity) and programmatic considerations (population coverage, follow-up of screen-positive women) in low-resource settings. Method: Using an individual-based Monte Carlo simulation model of the natural history of human papillomavirus (HPV) and cervical cancer calibrated to epidemiologic data from Uganda, we assumed screening occurred once in a woman's lifetime at age 35 with two-visit HPV DNA testing or one-visit visual inspection with acetic acid (VIA). Model outcomes included reduction in lifetime risk of cancer and incremental cost-effectiveness ratios (ICERs). For each screening modality, we performed one- and two-way sensitivity analyses to assess the tradeoffs between 1) test sensitivity and specificity; 2) test sensitivity and screening coverage; and 3) screening coverage and follow-up rates of screen-positive women. Sensitivity, specificity and coverage were varied 30-100% and loss-to-follow-up rates were varied from 15-60% per clinical contact. To assess the tradeoff between test sensitivity and loss-to-follow-up given uncertainty, we compared HPV DNA testing with 80-100% sensitivity to VIA with 40-60% sensitivity, as loss-to-follow-up varied from 15-60%. Result: For both screening modalities, improving test sensitivity had greater potential to reduce the ICER of onetime screening relative to comparable improvements in test specificity, due to the potential for increased benefits relative to costs incurred. While there were similar reductions in cancer risk for comparable changes in coverage and sensitivity, the costs associated with increasing coverage were proportional to benefits, yielding stable ICERs; as sensitivity increased from 30-100%, ICERs decreased by 65% (HPV testing). A comparison of HPV DNA testing and VIA found that when loss-to-follow-up per clinical contact was low (i.e., 15%), HPV testing yielded greater cancer risk reductions than VIA at all assumed levels of sensitivity. When loss-to-follow-up rates reached 60% per visit, a perfectly sensitive HPV test yielded similar cancer risk reductions as the least sensitive VIA program considered. The rank ordering of strategies changed dramatically as sensitivity and loss-to-follow-up varied. Conclusion: Available screening modalities pose tradeoffs between test performance, coverage, and follow-up. Where screening is limited, test sensitivity and follow-up of screen-positive women are critical determinants of the relative effectiveness and cost-effectiveness of prevention programs.
    The 35th Annual Meeting of the Society for Medical Decision Making; 10/2013
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    ABSTRACT: Purpose: School-based vaccination of 12-year-old girls against human papillomavirus (HPV) was introduced in Norway in 2009, free of charge. Since the vaccine is ideally targeted to young individuals prior to HPV exposure, catch-up vaccination for girls over age 12 was not publicly funded. Our objective was to estimate the cost-effectiveness of a one-year female catch-up program (starting in 2014) up to age 26. Method: We calibrated a previously published dynamic model of HPV transmission to fit observed HPV prevalence and cervical cancer incidence in Norway. Under various scenarios of catch-up vaccination in females, we projected reductions in HPV incidence over multiple birth cohorts, including both direct and indirect benefits, and applied these reductions to a microsimulation model of cervical cancer and incidence-based models for non-cervical HPV-related diseases. We adopted a societal perspective and assumed that vaccination of females age >19 years would incur higher delivery costs (i.e., through their family physician). Scenarios reflecting 50% coverage of women up to age 20, 22, 24 or 26 were compared to a baseline strategy assuming that these cohorts were not vaccinated. Sensitivity analyses were conducted on vaccine cost (market vs. tender price) and differential uptake among targeted women. Result: The marginal benefit of the vaccine decreased as the upper bound of the catch-up age increased. For example, at 50% coverage, the cohort of girls aged 18-years-old in 2014 gained an absolute 21% in cumulative reduction in HPV-16 incidence, compared to no catch-up campaign, while for the cohort of girls aged 26-years-old, this gain was only 10%. Cost-effectiveness followed a similar trend. At the current market price of the vaccine, catch-up can only be extended to age 22 while still remaining below Norway’s willingness-to-pay threshold (≈$83,000/QALY), compared with vaccinating 12-year-old girls only. However, the tender price of the vaccination (not publicly available) is believed to be less than 50% of the market price, in which case a catch-up program to age 26 falls below the threshold. Results remained stable for a catch-up campaign achieving only 30% coverage. Conclusion: At current market price, a one-year catch-up program up to age 22 is likely to be cost effective; however, at the assumed tender price, HPV vaccination may be extended to age 26 while remaining cost-effective.
    The 35th Annual Meeting of the Society for Medical Decision Making; 10/2013
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    ABSTRACT: Purpose: Increasingly, countries have introduced vaccination against human papillomavirus (HPV), causally linked to several cancers and genital warts, targeted to young girls, but few have recommended routine vaccination of boys. Declining vaccine prices and the growing evidence of vaccine impact on reducing HPV-related conditions in both women and men prompts countries, such as Norway, to decide whether HPV vaccination of boys is warranted. Method: A previously-published dynamic model of HPV transmission was updated to integrate recent evidence of gender- and type-specific natural history of HPV infections and empirically calibrated to observed HPV prevalence and cervical cancer incidence in Norway. Reductions in the incidence of HPV, which include both the direct and indirect benefits of vaccination, were applied to a microsimulation model of the natural history of cervical cancer in the presence of status quo screening, and to incidence-based models for other non-cervical HPV-related diseases among both men and women. We adopted a societal perspective and compared the incremental costs and benefits (discounted 4% annually) of a scenario reflecting the current 3-dose coverage level of pre-adolescent girls (75%) with and without similar coverage in boys in a school-based delivery program. Multiple good-fitting parameter sets from the dynamic model were used to explore the impact of parameter uncertainty on reductions in HPV incidence. Sensitivity analyses were conducted on vaccine cost and properties, and differential uptake among boys. Result: Assuming 75% vaccine coverage, high, lifelong vaccine efficacy, and the current market price of the vaccine (plus administration and supplies), we found that expanding the vaccination program to include boys generally exceeded the commonly cited willingness-to-pay threshold in Norway (i.e., $83,000/QALY), compared with vaccination of 12-year-old girls alone, even when including vaccine benefits to all HPV-related conditions. However, the current tender price is estimated at half the market price (not-publicly available); under this assumption, vaccinating both girls and boys exceeded $100,000/QALY when only cervical cancer endpoints were considered but fell below Norway’s willingness-to-pay threshold when including all HPV-related conditions. Results remained stable when male uptake was 50%. Conclusion: At Norway’s current market price, expanding the HPV vaccination program to boys is unlikely to be cost effective; however, at the assumed tender price, vaccinating boys becomes more attractive and may warrant a change in the current female-only vaccination policy.
    The 35th Annual Meeting of the Society for Medical Decision Making; 10/2013
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  • JAMA Internal Medicine 02/2013; 173(3):241-2. · 13.25 Impact Factor
  • Djøra I Soeteman, Jane J Kim
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    ABSTRACT: This article reviews the current evidence on the cost-effectiveness of psychotherapy for personality disorders (PDs). Although the evidence is still scarce, several well-designed cost-effectiveness studies provide insight into the question - how cost effective is it to reimburse therapies for PDs? This article further argues that the implementation costs and effects should be an integral part of cost-effectiveness analyses to enhance the dissemination of treatment recommendations. Moreover, cost-effectiveness analyses are important in working towards a more patient-centered approach in psychotherapy research that could potentially help accelerate the implementation and adoption of cost-effective care for PDs.
    Expert Review of Pharmacoeconomics & Outcomes Research 02/2013; 13(1):73-81. · 1.67 Impact Factor

Publication Stats

1k Citations
419.87 Total Impact Points

Institutions

  • 2006–2014
    • Harvard Medical School
      Boston, Massachusetts, United States
    • Duke University Medical Center
      • Department of Obstetrics and Gynecology
      Durham, NC, United States
    • Imperial College London
      • Department of Infectious Disease Epidemiology
      London, ENG, United Kingdom
  • 2004–2013
    • Harvard University
      • • Center for Health Decision Science
      • • Department of Health Policy and Management
      Boston, MA, United States
  • 2012
    • Chulalongkorn University
      Krung Thep, Bangkok, Thailand
    • University of Sydney
      Sydney, New South Wales, Australia
  • 2010–2011
    • De Viersprong National Institute of Personality Disorders
      Amsterdamo, North Holland, Netherlands
    • Catalan Institute of Oncology
      • Infections and Cancer Unit
      Badalona, Catalonia, Spain
    • Erasmus MC
      • Department of Medical Psychology and Psychotherapy
      Rotterdam, South Holland, Netherlands
  • 2007
    • The University of Western Ontario
      • Department of Obstetrics and Gynaecology
      London, Ontario, Canada