Cost-effectiveness of strategies to enhance mammography use

OBJECTIVE. To estimate the cost-effectiveness of three strategies to increase breast cancer screening with mammography (reminder postcard, reminder telephone call, and motivational telephone call). DESIGN. Cost accounting for each strategy followed by cost-effectiveness analysis. DATA SOURCE FOR EFFECTIVENESS. Randomized trial of three strategies conducted at Group Health Cooperative of Puget Sound (GHC). TARGET POPULATION. Women 50 to 79 years of age who were enrolled in GHC's breast cancer screening program who did not schedule screening mammography within 2 months after it was recommended by letter. PERSPECTIVE. Health plan. OUTCOME MEASURE. Marginal cost-effectiveness of each additional woman screened. RESULTS OF BASE-CASE ANALYSIS. Because of its high cost (about $26 per call) and intermediate effectiveness, the motivational call was the least cost-effective strategy. If it was assumed that 50$22 per woman screened versus $92 for the reminder call. Among women with no previous mammography, the marginal cost-effectiveness for the postcard was$70 versus $100 for the reminder call. RESULTS OF SENSITIVITY ANALYSIS. Among women with no previous mammography, the choice between the reminder postcard and the reminder call was sensitive to assumptions about the percentage of women expected to receive mammography in the absence of other promotional strategies. CONCLUSIONS. A simple reminder postcard is the most cost-effective way to increase mammography. Choices about how to promote mammography will ultimately depend on plan values and willingness to invest in promotional strategies that increase participation at higher unit costs. F or women 50 to 69 years of age, evidence clearly supports the effectiveness of mammography as a breast cancer screening tool. Randomized trials have demonstrated that mammographic screening in this age group can decrease breast cancer mortality rates by approximately 25% to 30% within 5 or 6 years. 1 Breast cancer mortality rates have decreased since 1990, perhaps in part because of widespread screening. 2-4 These benefits highlight the need to increase awareness and promotion of mammography. With the growth of managed care in the United States, the opportunity to use the health plan to promote mammography as a breast cancer screening tool has increased. However, health plans face the challenge of finding cost-effective ways to increase women's participation in screening programs. This paper is available at ecp.acponline.org. • • • Health benefits are sufficient incentive for health plans to find ways to increase participation, but the health care market also prompts plans to improve delivery of all preventive services. So-called "report cards," such as the Health Plan Employer Data Information Set (HEDIS) measures produced by the National Committee on Quality Assurance, include mammography participation in women 52 to 69 years of age as one of the elements on which managed health plans are evaluated. Many health insurance purchasers will not contract with plans that fail to meet HEDIS or other report card standards. Little research exists on the costs associated with alternative strategies for breast cancer screening recruitment. Most cost analyses have focused on the value of mammographic screening, and the results of these studies have contributed to widespread adoption of such screening for women 50 years of age and older. 5 The National Cancer Institute, the American Cancer Society, the U.S. Preventive Services Task Force, and other groups in the United States and other countries recommend screening mammography for women in this age group, in part because of demonstrated reductions in mortality rate. In this paper, we use the results of a recent randomized trial 8 to examine the cost-effectiveness of three strategies to encourage participation in mammographic screening (reminder postcard, reminder telephone call, and motivational telephone call). Methods Overview We report the estimated cost-effectiveness of alternative strategies to increase mammography use in women 50 to 79 years of age. Our data are based on a recent trial conducted at Group Health Cooperative of Puget Sound (GHC). Our goal was to provide health plans with information about the cost-effectiveness of a reminder postcard, reminder telephone call, and motivational telephone call in increasing enrollees' participation in screening programs. The outcome of interest, based on the anticipated needs of health plan decision makers, was the marginal or incremental cost per participant screened for each promotional strategy. Setting Our analysis is from the perspective of GHC, a mixedmodel HMO serving more than 500,000 enrollees in western Washington State. In terms of ethnicity and socioeconomic status, the GHC population is similar to the communities in which it provides care. 5 Although GHC has an ongoing breast cancer screening program, we did not consider the fixed costs associated with developing and maintaining this program in our analysis. Effectiveness: The Randomized Trial Effectiveness data for our analysis were based on a randomized trial 8 that evaluated alternative strategies to improve participation in GHC's breast cancer screening program. Participants were recruited for the trial from a random sample of 11,570 women aged 50 to 79 years who were due to receive mammography in GHC's breast cancer screening program. 214 Descriptive data on the women in each intervention group are given in Cost: Accounting Methods Overview Cost assignment for each strategy is based on the project team's report of resources used to deliver the intervention. Our cost model includes any office space or equipment from GHC's screening program that was used but not paid for by the trial. GHC allowed the research team to use some existing screening program resources (e.g., office space, telephones, computers) without charge. However, we estimated the overhead expenses needed for each intervention group by assuming that the health plan incurred all of the additional expenditures required to implement each promotional strategy. Dollar values for resources used in the trial were 1998 local market costs for personnel, office space, furnishings, and equipment. We do not use GHC's costs because they may reflect idiosyncrasies of GHC's pur- chasing or human resource policies. The cost model includes all personnel, hardware, and material necessary to implement and conduct the promotional strategies, except building and maintaining the screening program information system. Total costs for each fixed and variable resource used in each strategy were allocated on a per-participant basis. Average fixed cost elements necessary for each promotional strategy, such as office space, telephone lines, and computers, were allocated to all women randomly assigned to that strategy. Reminder Postcard Costs for the postcard group include development of the text used on the postcard as well as its design, production, and mailing. Production and mailing costs are based on bulk mailing charges, and we assume that all relevant personal information for eligible women was available from the existing health plan database. Costs included an analyst (to abstract screening program information on eligible women), equipment, and office space needed to complete these tasks. Reminder and Motivational Telephone Calls The most significant variable cost in both telephonebased strategies was time spent on the telephone. Callers in both telephone groups collected data on the length of the telephone calls, and costs were allocated on the basis of average cost per minute of contact time. Staff deliver

Clarithromycin and endoscopic sinus surgery for adults with chronic rhinosinusitis with and without nasal polyps: study protocol for the MACRO randomised controlled trial.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common source of ill health; 11% of UK adults reported CRS symptoms in a worldwide population study. Guidelines are conflicting regarding whether antibiotics should be included in primary medical management, reflecting the lack of evidence in systematic reviews. Insufficient evidence to inform the role of surgery contributes to a fivefold variation in UK intervention rates. The objective of this trial is to establish the comparative effectiveness of endoscopic sinus surgery (ESS) or a prolonged course of antibiotics (clarithromycin) in adult patients with CRS in terms of symptomatic improvement and costs to the National Health Service compared with standard medical care (intranasal medication) at 6 months. METHODS/DESIGN: A three-arm parallel-group trial will be conducted with patients who remain symptomatic after receiving appropriate medical therapy (either in primary or secondary care). They will be randomised to receive: (1) intranasal medication plus ESS, (2) intranasal medication plus clarithromycin (250 mg) or (3) intranasal medication plus a placebo. Intranasal medication (current standard medical care) is defined as a spray or drops of intranasal corticosteroids and saline irrigations. The primary outcome measure is the SNOT-22 questionnaire, which assesses disease-specific health-related quality of life. The study sample size is 600. Principal analyses will be according to the randomised groups irrespective of compliance. The trial will be conducted in at least 16 secondary or tertiary care centres with an internal pilot at six sites for 6 months. DISCUSSION: The potential cardiovascular side effects of macrolide antibiotics have been recently highlighted. The effectiveness of antibiotics will be established through this trial, which may help to reduce unnecessary usage and potential morbidity. If ESS is shown to be clinically effective and cost-effective, the trial may encourage earlier intervention. In contrast, if it is shown to be ineffective, then there should be a significant reduction in surgery rates. The trial results will feed into the other components of the MACRO research programme to establish best practice for the management of adults with CRS and design the ideal patient pathway across primary and secondary care. TRIAL REGISTRATION: ISRCTN36962030 . Registered on 17 October 2018

10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer

BACKGROUND The comparative effectiveness of treatments for prostate cancer that is detected by prostatespecific antigen (PSA) testing remains uncertain. METHODS We compared active monitoring, radical prostatectomy, and external-beam radiotherapy for the treatment of clinically localized prostate cancer. Between 1999 and 2009, a total of 82,429 men 50 to 69 years of age received a PSA test; 2664 received a diagnosis of localized prostate cancer, and 1643 agreed to undergo randomization to active monitoring (545 men), surgery (553), or radiotherapy (545). The primary outcome was prostate-cancer mortality at a median of 10 years of follow-up. Secondary outcomes included the rates of disease progression, metastases, and all-cause deaths. RESULTS There were 17 prostate-cancer-specific deaths overall: 8 in the active-monitoring group (1.5 deaths per 1000 person-years; 95% confidence interval [CI], 0.7 to 3.0), 5 in the surgery group (0.9 per 1000 person-years; 95% CI, 0.4 to 2.2), and 4 in the radiotherapy group (0.7 per 1000 person-years; 95% CI, 0.3 to 2.0); the difference among the groups was not significant (P = 0.48 for the overall comparison). In addition, no significant difference was seen among the groups in the number of deaths from any cause (169 deaths overall; P = 0.87 for the comparison among the three groups). Metastases developed in more men in the active-monitoring group (33 men; 6.3 events per 1000 person-years; 95% CI, 4.5 to 8.8) than in the surgery group (13 men; 2.4 per 1000 person-years; 95% CI, 1.4 to 4.2) or the radiotherapy group (16 men; 3.0 per 1000 person-years; 95% CI, 1.9 to 4.9) (P = 0.004 for the overall comparison). Higher rates of disease progression were seen in the active-monitoring group (112 men; 22.9 events per 1000 person-years; 95% CI, 19.0 to 27.5) than in the surgery group (46 men; 8.9 events per 1000 person-years; 95% CI, 6.7 to 11.9) or the radiotherapy group (46 men; 9.0 events per 1000 person-years; 95% CI, 6.7 to 12.0) (P<0.001 for the overall comparison). CONCLUSIONS At a median of 10 years, prostate-cancer-specific mortality was low irrespective of the treatment assigned, with no significant difference among treatments. Surgery and radiotherapy were associated with lower incidences of disease progression and metastases than was active monitoring. (Funded by the National Institute for Health Research; ProtecT Current Controlled Trials number, ISRCTN20141297; ClinicalTrials.gov number, NCT02044172.) a bs tr ac

Ozonation attenuates the steroidogenic disruptive effects of sediment free oil sands process water in the H295R cell line

There is concern regarding oil sands process water (OSPW) produced by the oil sands industry in Alberta, Canada. Little is known about the potential for OSPW, and naphthenic acids (NAs), which are the primary persistent and toxic constituents of OSPW, to affect endocrine systems. Although ozonation significantly reduces concentrations of NAs and OSPW toxicity, it was hypothesized that oxidation of OSPW might produce hydroxylated products with steroidogenic activity. Therefore, untreated and ozone treated OSPW were examined for effects on sex steroid production using the H295R Steroidogenesis Assay. Untreated OSPW significantly decreased testosterone (T) and increased 17 beta-estradiol (E2) concentrations at OSPW dilutions greater or equal to 10-fold. This effect was mainly due to decreased U metabolism. Analysis of CYP19A (aromatase) mRNA abundance and enzyme activity suggested that induction of this enzyme activity may have also contributed to these effects. Reduction of parent NA concentrations by 24% or 85% decreased the effect of OSPW on E2 production. Although T production remained significantly reduced in cells exposed to ozone treated OSPW, the effect was diminished. Aromatase mRNA abundance and enzyme activity were significantly greater in cells exposed to ozone treated OSPW. however the magnitude was less than in cells exposed to untreated OSPW. No change of U metabolism was observed in cells exposed to ozone treated OSPW, which may account for recovery of E2 levels. The results indicate that OSPW exposure can decrease E2 and T production, but zonation is an effective treatment to reduce NA concentrations in OSPW without increasing affects on steroidogenesis. (C) 2010 Elsevier Ltd. All rights reserved.Alberta Water Research Institute [C4288]; National Science and Engineering Research Council of Canada [326415-07]; Western Economic Diversification Canada [6578, 6807]; Canada Foundation for Infrastructur

A review of the epidemiology, pathophysiology, and efficacy of anti-diabetic drugs used in the treatment of nonalcoholic fatty liver disease

In recent years, epidemiological studies have consistently demonstrated that the coexistence of nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus (T2DM) is strongly associated with increased mortality and morbidity related to hepatic- and extrahepatic causes. Indeed, compared with the general population, patients with T2DM are more likely to be diagnosed with more severe forms of NAFLD (i.e., nonalcoholic steatohepatitis (NASH) with liver fibrosis). There is an ongoing debate whether NALFD is a consequence of diabetes or whether NAFLD is simply a component and manifestation of the metabolic syndrome, since liver fat (steatosis) and even more advanced stages of liver fibrosis can occur in the absence of diabetes. Nevertheless, insulin resistance is a key component of the mechanism of NAFLD development; furthermore, therapies that lower blood glucose concentrations also appear to be effective in the treatment of NAFLD. Here, we will discuss the pathophysiological and epidemiological associations between NAFLD and T2DM. We will also review currently available anti-diabetic agents with their regard to their efficacy of NAFLD/NASH treatment

No differences in rotational thromboelastometry measurements between portal and peripheral circulation in cirrhotic patients undergoing TIPS

Background: In patients with liver cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) is considered a standardized treatment of refractory ascites or variceal bleeding. TIPS thrombosis (TT) and/or portal vein thrombosis (PVT) are possible complications during/after TIPS placement. Previous studies suggested increased clotting activity in portal circulation (PORC). This pilot study aimed to evaluate alterations and differences of coagulation function in PORC and in peripheral circulation (PERC) via rotational thromboelastometry during TIPS. Methods: Blood samples were collected from cirrhotic patients ($\it n$ = 13; median Model of End Stage Liver Disease, MELD Score: 12; median age: 60 years) undergoing TIPS (10/13 TIPSs were elective procedures due to refractory ascites) as follows: median cubital vein (MCV; PERC)—confluence of the three hepatic veins to the inferior cava vein (HV/ICV; PORC)—portal vein (PV; PORC)—TIPS (PORC). This research utilized four variables of the extrinsic test EXTEM, i.e., clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), and maximum lysis (ML). Results: EXTEM results [mean, M (range) $\pm$ standard deviation, SD (range)] showed no significant differences for CT [M (70–73) $\pm$ SD (9–13); $\it p$ = 0.93] or CFT [M (137–155) $\pm$ SD (75–112); $\it p$ = 0.97] or MCF [M (51–54) $\pm$ SD (9–10); $\it p$ = 0.90] or ML [M (9–10) $\pm$ SD (4–5); $\it p$ = 0.89] between the compartments, i.e., MCV vs. HV/ICV vs. PV vs. TIPS. Overall, we detected no differences in coagulation function between PERC and PORC. Conclusion: These results are in contrast to previous reports suggesting increased clotting activity in PORC vs. PERC in association with liver cirrhosis. Rotational thromboelastometry-based evaluation of coagulation function in PERC appears to reliably reflect coagulation function in PORC with respect to risk estimation for TT and/or PVT in cirrhotic patients undergoing TIPS

Sarcopenic dysphagia revisited

Oropharyngeal dysphagia (OD) is a frequent finding in older patients with potentially lethal complications such as aspiration pneumonia, malnutrition, and dehydration. Recent studies describe sarcopenia as a causative factor for OD, which is occasionally referred to as "sarcopenic dysphagia" in the absence of a neurogenic etiology. In most of the previous studies on sarcopenic dysphagia, the diagnosis was based only on clinical assessment. In this study, flexible endoscopic evaluation of swallowing (FEES) was used as an objective method to evaluate the presence of OD, its association with sarcopenia, and the presence of pure sarcopenic dysphagia. In this retrospective cross-sectional study, 109 acute care geriatric hospital patients with suspected OD received FEES examination and bioimpedance analysis (BIA) in clinical routine. 95% of patients had at least one neurological disease, 70% fulfilled the criteria for sarcopenia, and 45% displayed moderate or severe OD. Although the prevalence of sarcopenia and OD was high, there was no significant association between OD and sarcopenia. Considering these results, both the association between sarcopenia and OD and pure sarcopenic dysphagia appear questionable. Further prospective studies are needed to elucidate if sarcopenia is merely an epiphenomenon of severe disease or whether it plays a causative role in the development of OD

SUMMARY

Bayesian proportional hazards model with time-varyin