A systematic review of the cost-effectiveness of interventions to increase cervical cancer screening among underserved women in Europe.

BACKGROUND: This study aimed to conduct a systematic review of the cost-effectiveness studies of interventions to increase cervical cancer screening uptake rates in underserved women in Europe. METHODS: A search of Embase, Medline, Global Health, PsychINFO, and NHS Economic Evaluation Database was conducted for studies published between January 2000 and September 2022. Studies were eligible if they analysed the cost-effectiveness of any interventions to improve participation in cervical cancer screening among underserved women of any age eligible to participate in cervical cancer screening in European countries, in any language. Study characteristics and cost-effectiveness results were summarised. Study quality was assessed using the Drummond Checklist, and methodological choices were further compared. RESULTS: The searches yielded 962 unique studies, with 17 of these (from twelve European countries) meeting the eligibility criteria for data extraction. All studies focused on underscreened women as an overarching group, with no identified studies focusing on specific subgroups of underserved women. Generally, self-HPV testing and reminder interventions were shown to be cost-effective to increase the uptake rates. There was also research showing that addressing access issues and adopting different screening modalities could be economically attractive in some settings, but the current evidence is insufficient due to the limited number of studies. CONCLUSION: This systematic review has revealed a gap in the literature on the cost-effectiveness of interventions to improve uptake rates of cervical cancer screening through tailored provision for specific groups of underserved women

Cost effectiveness of latent tuberculosis screening among asylum seekers in Stockholm

Introduction The burden of tuberculosis (TB) in Sweden is concentrated among migrants from high TB incidence countries. The incident cases in Sweden arise mainly through reactivation of a latent tuberculosis infection (LTBI) acquired in the home country or during transit. Progression from LTBI to active TB disease can be prevented through treatment with anti-tubercular medicines. LTBI screening is therefore offered for asylum seekers and refugees in Sweden as part of a voluntary health examination (HE). Little is known about their experiences of LTBI screening and treatment. In addition, there has been no previous evaluation of the cost-effectiveness of the current LTBI screening policy in Stockholm or Sweden. Aims The overarching aim of this thesis was to determine the cost-effectiveness of the current strategy of screening for LTBI among asylum seekers in Stockholm. This aim was achieved through the following specific objectives: 1) to assess the methodology of previously published economic models of LTBI screening and to develop an analytical framework, 2) to understand the experiences of asylum seekers with HE, 3) to quantify health-related quality of life (HRQoL) of LTBI patients and to explore the factors influencing it, 4) to quantify the HRQoL of TB patients, and 5) to assess the cost effectiveness of LTBI screening through an economic model. Methods A qualitative study was designed to explore the experiences of asylum seekers with HE; semi-structured interviews were conducted based on an interview guide. For the HRQoL studies, a HRQoL instrument, EQ-5D, and a mental health screening instrument, RHS-15, were used. For the LTBI patients, a mixed-method design was used, in which a crosssectional survey using the EQ-5D and RHS-15 instruments was combined with qualitative interviews of a subgroup. For the TB patients, a longitudinal study design was used in which a cohort filled the EQ-5D instrument at the beginning and the end of treatment. A literature review was performed to assess the methodology of published economic modelling studies of LTBI screening. Through this review a framework was developed guiding the development of an economic model (a Markov model) to assess the cost effectiveness of the current LTBI screening in Stockholm compared to a hypothetical scenario of no screening. The analysis adopted the societal perspective, and results were presented in term of incremental costeffectiveness ratios (ICERs); taking 500 000 SEK/QALY as a cost-effectiveness threshold. Results The HE was perceived as available by asylum seekers, with no serious physical or financial accessibility problems. They felt respected and trusted by the healthcare workers. However, information about the Swedish healthcare system was perceived to be incomplete and the HE was seen as non-responsive to their individual needs with main focus on infectious diseases. Among LTBI patients, 38% screened positive for mental health concerns using RHS-15, and 28% scored problems on mental health dimension of EQ-5D. These patients expressed fear of being contagious to others, an ambiguous threat of a vague diagnosis and future uncertainties about developing TB disease. However, LTBI patients had no overall HRQoL decrement. TB patients had a HRQoL utility score of 0,72 at the beginning of treatment, which improved significantly by the end of the treatment to 0,84. The cost effectiveness results showed that ICER is the lowest among the age group 13 to 19 at 303 881 SEK/QALY, which was the only ICER below the 500 000 SEK/QALY threshold. Discussion Asylum seekers had a generally positive attitude towards HE, including TB and LTBI screening, but also emphasized the need to broaden the focus on all health needs rather than solely focusing on infectious diseases. LTBI patients might have a compromised mental health partly linked to fear of TB disease. Therefore, it can be beneficial to address these concerns as part of LTBI management. TB patients had a compromised HRQoL and a decrement of 0,28 for TB patients is recommended to be used in economic evaluations. LTBI screening among asylum seekers in Stockholm is cost effective in the age group 13 to 19 while it is moderately cost-effective in the age groups 0 to 12 and 20 to 34 years. The latter is mainly due to the restrictive practices of offering treatment for persons over the age of 20 years. Conclusions Health examination is an acceptable, accessible health service. However, its quality can be improved by broadening the focus beyond infectious disease control. An LTBI diagnosis can be misunderstood as active TB and linked to stigma. The cost-effectiveness analysis showed that screening is cost effective only when preventive treatment is offered. Therefore, due to ethical and economic reasons, LTBI screening should only be performed for asylum seekers who are potentially eligible for LTBI treatment

Brief interventions for at-risk drinking: Patient outcomes and cost-effectiveness in managed care organizations

Aims: Evaluate effectiveness and costs of brief interventions for patients screening positive for at-risk drinking in managed health care organizations (MCOs). Methods: A pre-post, quasi-experimental, multi-site evaluation conducted at 15 clinic sites within five MCO settings. At-risk drinkers (N = 1329) received either: (i) brief intervention delivered by licensed practitioners; or (ii) brief intervention delivered by mid-level professional specialists (nurses); or (iii) usual care (comparison condition). Clinics were randomly assigned to three study conditions. Data were collected on the cost of screening and brief intervention. Follow-up interviews were conducted at 3 and 12 months. Results: Participants in all three study conditions were drinking significantly less at 3-month follow-up, but the decline was significantly greater in the two intervention groups than in the control group. There were no significant differences between the two intervention conditions. Of the patients in the intervention conditions 60% reduced their alcohol consumption by =1 drink per week, compared with 53% of those in the control condition. No differences were found on a measure of the quality of life. Differential reductions in weekly alcohol consumption between intervention and control groups were significant at 12-month follow-up. Average incremental costs of the interventions were $4.16 USD per patient using licensed practitioners and$2.82 USD using mid-level specialists. Conclusion: Alcohol screening and brief intervention when implemented in managed care organizations produces modest, statistically significant reductions in at-risk drinking. Interventions delivered to a common protocol by mid-level specialists are as effective as those delivered by licensed practitioners at about two-thirds the cost

Development conceptual of pharmacoeconomic model of technology for early diagnosis and pharmacotherapy of pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a rare, progressive disease with a poor prognosis in the absence of timely diagnosis and appropriate therapy. Despite significant advances in the treatment of PAH, many patients remain undiagnosed years after the onset of the disease. Evaluation of the implementation of early diagnostic technologies for PAH is increasingly being used to develop economic evidence for health care at the early stages of diagnosis. The development of models of early diagnosis technology for LAH is highly relevant and can be used in the development and management of new medical technologies, as well as to reduce the perceived risks during the implementation of screening programs for LAH diagnosis. The objective of the paper: Conceptual development of a pharmacoeconomic model of the technology of early diagnosis and pharmacotherapy of PAH. Our pharmacoeconomic analysis is based on the «cost–effectiveness» model, which reflects the effectiveness and associated costs of implementing diagnostic screening for early detection of patients with PAH. The analysis of input data of the existing health care system was conducted using systematic review, documentary, informational and graphical research methods. The presented pharmacoeconomic model describes not only the structure of the incidence of PAH in the studied risk group or at the level of the entire population, but also takes into account the pharmacoeconomic evaluation of the complex technology of timely medical care for patients with PAH based on diagnostic screening. A pharmacoeconomic model of the technology of early diagnosis and pharmacotherapy of pulmonary arterial hypertension was developed, which covered a horizon of 10 years and was conducted from the point of view of the existing health care system, showed that for patients with delayed diagnosis of PAH, the modeling determined the average life expectancy at the level of 4.13 years and 2.08 QALYs. It has been determined that a diagnostic screening strategy for PAH would be cost–effective compared to no screening at different thresholds of diagnostic cost. However, other factors such as public awareness and acceptance of the screening programme and availability of human resources should be considered

Evaluation of a Diabetic Point of Care Education in Primary Care

BACKGROUND: Diabetes education is the cornerstone of managing diabetes. The education can be delivered in group or individual sessions. Given that group classes are not always well received, a brief five-minute point of care education was developed and incorporated into patients’ routine diabetic appointment. The effectiveness of the method is yet to be determined. PURPOSE: The purpose of this Doctor of Nursing Practice (DNP) project was to evaluate the effectiveness and acceptability of a recently implemented diabetes point of care education as compared to patients’ usual care in an urban primary care clinic. METHODS: An outcome evaluation using a retrospective chart audit was conducted. Data analyses included changes in A1C between the groups. A nine-point DPC education questionnaire survey and provider interview were administered to assess satisfaction with the program. RESULTS: A total of 80 patients comprised each group with no statistically significant demographic differences at the baseline. No significant changes in A1C between the groups were found after three DPC visits 3 months apart. Approximately 67% of DPC patients were satisfied with the educational format. Open responses from both patients and providers regarding the program revealed three common themes: (a) the need for motivation, (b) simpler instructions, and (c) individualizing the material. The participants also cited lack of resources, complexity of disease management, and physical impediments as barriers to diabetic education. CONCLUSION: Although no changes in A1C were noted between the groups, patient satisfaction rates were high for point of care education. Based on their responses, initial knowledge level and screening for diabetes distress are recommended for an individualized educational plan. Furthermore, patients’ readiness and motivation must be considered, with more time allotted for the LDE during or after the provider visit. Patients were clearly interested in receiving education tailored to their needs

The credibility of health economic models for health policy decision-making: the case of population screening for abdominal aortic aneurysm

<i>Objectives</i>: To review health economic models of population screening for abdominal aortic aneurysm (AAA) among elderly males and assess their credibility for informing decision-making. <i>Methods</i>: A literature review identified health economic models of ultrasound screening for AAA. For each model focussing on population screening in elderly males, model structure and input parameter values were critically appraised using published good practice guidelines for decision analytic models. <i>Results</i>: Twelve models published between 1989 and 2003 were identified. Converting costs to a common currency and base year, substantial variability in cost-effectiveness results were revealed. Appraisals carried out for the nine models focusing on population screening showed differences in their complexity, with the simpler models generating results most favourable to screening. Eight of the nine models incorporated two or more simplifying structural assumptions favouring screening; uncertainty surrounding these assumptions was not investigated by any model. Quality assessments on a small number of parameters revealed input values varied between models, methods used to identify and incorporate input data were often not described, and few sensitivity analyses were reported. <i>Conclusions</i>: Large variation exists in the cost-effectiveness results generated by AAA screening models. The substantial number of factors potentially contributing to such disparities means that reconciliation of model results is impossible. In addition, poor reporting of methods makes it difficult to identify the most plausible and thus most useful model of those developed

The cost-utility of telemedicine to screen for diabetic retinopathy in India.

PURPOSE: To assess the cost-effectiveness of a telemedicine diabetic retinopathy (DR) screening program in rural Southern India that conducts 1-off screening camps (i.e., screening offered once) in villages and to assess the incremental cost-effectiveness ratios of different screening intervals. DESIGN: A cost-utility analysis using a Markov model. PARTICIPANTS: A hypothetical cohort of 1000 rural diabetic patients aged 40 years who had not been previously screened for DR and who were followed over a 25-year period in Chennai, India. METHODS: We interviewed 249 people with diabetes using the time trade-off method to estimate utility values associated with DR. Patient and provider costs of telemedicine screening and hospital-based DR treatment were estimated through interviews with 100 diabetic patients, sampled when attending screening in rural camps (n = 50) or treatment at the base hospital in Chennai (n = 50), and with program and hospital managers. The sensitivity and specificity of the DR screening test were assessed in comparison with diagnosis using a gold standard method for 346 diabetic patients. Other model parameters were derived from the literature. A Markov model was developed in TreeAge Pro 2009 (TreeAge Software Inc, Williamstown, MA) using these data. MAIN OUTCOME MEASURES: Cost per quality-adjusted life-year (QALY) gained from the current teleophthalmology program of 1-off screening in comparison with no screening program and the cost-utility of this program at different screening intervals. RESULTS: By using the World Health Organization threshold of cost-effectiveness, the current rural teleophthalmology program was cost-effective ($1320 per QALY) compared with no screening from a health provider perspective. Screening intervals of up to a frequency of screening every 2 years also were cost-effective, but annual screening was not (>$3183 per QALY). From a societal perspective, telescreening up to a frequency of once every 5 years was cost-effective, but not more frequently. CONCLUSIONS: From a health provider perspective, a 1-off DR telescreening program is cost-effective compared with no screening in this rural Indian setting. Increasing the frequency of screening up to 2 years also is cost-effective. The results are dependent on the administrative costs of establishing and maintaining screening at regular intervals and on achieving sufficient coverage

Economic evaluation of screening for open angle glaucoma

Objectives: The aim of this study was to assess the cost-effectiveness of screening for open-angle glaucoma (OAG) in the United Kingdom, given that OAG is an important cause of blindness worldwide. Methods: A Markov model was developed to estimate lifetime costs and benefits of a cohort of patients facing, alternatively, screening or current opportunistic case finding strategies. Strategies, varying in how screening would be organized (e.g., invitation for assessment by a glaucoma-trained optometrist [GO] or for simple test assessment by a technician) were developed, and allowed for the progression of OAG and treatment effects. Data inputs were obtained from systematic reviews. Deterministic and probabilistic sensitivity analyses were performed. Results: Screening was more likely to be cost-effective as prevalence increased, for 40 year olds compared with 60 or 75 year olds, when the re-screening interval was greater (10 years), and for the technician strategy compared with the GO strategy. For each age cohort and at prevalence levels of ≤1 percent, the likelihood that either screening strategy would be more cost-effective than current practice was small. For those 40 years of age, “technician screening” compared with current practice has an incremental cost-effectiveness ratio (ICER) that society might be willing to pay when prevalence is 6 percent to 10 percent and at over 10 percent for 60 year olds. In the United Kingdom, the age specific prevalence of OAG is much lower. Screening by GO, at any age or prevalence level, was not associated with an ICER < £30,000. Conclusions: Population screening for OAG is unlikely to be cost-effective but could be for specific subgroups at higher risk.This study was developed from a health technology assessment on the clinical and cost-effectiveness of screening for open-angle glaucoma (OAG), funded by the National Institute for Health Research Health Technology Assessment Programme (project no. 04/08/02).Peer reviewedAuthor versio

Systematic review and meta-analysis of the growth and rupture rates of small abdominal aortic aneurysms: implications for surveillance intervals and their cost-effectiveness.

BACKGROUND: Small abdominal aortic aneurysms (AAAs; 3.0-5.4 cm in diameter) are usually asymptomatic and managed by regular ultrasound surveillance until they grow to a diameter threshold (commonly 5.5 cm) at which surgical intervention is considered. The choice of appropriate surveillance intervals is governed by the growth and rupture rates of small AAAs, as well as their relative cost-effectiveness. OBJECTIVES: The aim of this series of studies was to inform the evidence base for small AAA surveillance strategies. This was achieved by literature review, collation and analysis of individual patient data, a focus group and health economic modelling. DATA SOURCES: We undertook systematic literature reviews of growth rates and rupture rates of small AAAs. The databases MEDLINE, EMBASE on OvidSP, Cochrane Central Register of Controlled Trials 2009 Issue 4, ClinicalTrials.gov, and controlled-trials.com were searched from inception up until the end of 2009. We also obtained individual data on 15,475 patients from 18 surveillance studies. REVIEW METHODS: Systematic reviews of publications identified 15 studies providing small AAA growth rates, and 14 studies with small AAA rupture rates, up to December 2009 (later updated to September 2012). We developed statistical methods to analyse individual surveillance data, including the effects of patient characteristics, to inform the choice of surveillance intervals and provide inputs for health economic modelling. We updated an existing health economic model of AAA screening to address the cost-effectiveness of different surveillance intervals. RESULTS: In the literature reviews, the mean growth rate was 2.3 mm/year and the reported rupture rates varied between 0 and 1.6 ruptures per 100 person-years. Growth rates increased markedly with aneurysm diameter, but insufficient detail was available to guide surveillance intervals. Based on individual surveillance data, for each 0.5-cm increase in AAA diameter, growth rates increased by about 0.5 mm/year and rupture rates doubled. To control the risk of exceeding 5.5 cm to below 10% in men, on average a 7-year surveillance interval is sufficient for a 3.0-cm aneurysm, whereas an 8-month interval is necessary for a 5.0-cm aneurysm. To control the risk of rupture to below 1%, the corresponding estimated surveillance intervals are 9 years and 17 months. Average growth rates were higher in smokers (by 0.35 mm/year) and lower in patients with diabetes (by 0.51 mm/year). Rupture rates were almost fourfold higher in women than men, doubled in current smokers and increased with higher blood pressure. Increasing the surveillance interval from 1 to 2 years for the smallest aneurysms (3.0-4.4 cm) decreased costs and led to a positive net benefit. For the larger aneurysms (4.5-5.4 cm), increasing surveillance intervals from 3 to 6 months led to equivalent cost-effectiveness. LIMITATIONS: There were no clear reasons why the growth rates varied substantially between studies. Uniform diagnostic criteria for rupture were not available. The long-term cost-effectiveness results may be susceptible to the modelling assumptions made. CONCLUSIONS: Surveillance intervals of several years are clinically acceptable for men with AAAs in the range 3.0-4.0 cm. Intervals of around 1 year are suitable for 4.0-4.9-cm AAAs, whereas intervals of 6 months would be acceptable for 5.0-5.4-cm AAAs. These intervals are longer than those currently employed in the UK AAA screening programmes. Lengthening surveillance intervals for the smallest aneurysms was also shown to be cost-effective. Future work should focus on optimising surveillance intervals for women, studying whether or not the threshold for surgery should depend on patient characteristics, evaluating the usefulness of surveillance for those with aortic diameters of 2.5-2.9 cm, and developing interventions that may reduce the growth or rupture rates of small AAAs. FUNDING: The National Institute for Health Research Health Technology Assessment programme