The influence of health systems on breast, cervical and colorectal cancer screening: an overview of systematic reviews using health systems and implementation research frameworks.

Objectives Screening for breast, cervical and colorectal cancer in an average-risk population is widely recommended in national and international guidelines although their implementation varies. Using a conceptual framework that draws on implementation and health systems research, we provide an overview of systematic literature reviews that address health system and service barriers or facilitators to effective cancer screening. Methods Using a systematic approach, we searched Cochrane Database of Systematic Reviews, Ovid Medline, Ovid Embase, Web of Science, PsychInfo and other internet sources. We included systematic reviews of screening interventions (i.e. targeting people at average risk) for breast, cervical and colorectal cancer. The analysis included 90 systematic reviews. Results This review identified a multitude of barriers and facilitators affecting the health system, the capabilities of individuals in the system and their intentions. A large proportion of the available evidence focused on uptake. The reviews demonstrated that health system factors influenced participation, as well as quality and effectiveness of the service provided. The barriers with the biggest impact were knowledge/education, mainly of clients but also providers (capability barriers) and beliefs and values (intention barriers) of the eligible population. These findings complement the usual focus on psychological and social barriers to informed participation by individuals that dominate the screening literature. The facilitators with the most supporting evidence were educational interventions (overcoming capability and intention barriers), invitation letters, reminders and appointments. These were mainly directed at eligible individuals and, to a lesser extent, to providers and healthcare professionals. Only a small number of reviews, mainly from Europe, specified organized, rather than opportunistic, screening programmes. In those, low participation was the most frequently cited barrier and invitation letters (including physician endorsement, phone calls and reminders to non-responders and healthcare professionals) were the most prevalent facilitators. Conclusion Despite evidence of barriers and facilitators to screening participation and opportunistic screening, further health systems research covering the entire screening system for organized programmes is required. </jats:sec

Key indicators of organized cancer screening programs: Results from a Delphi study

Objective To maximize benefits and reduce potential harms of organized cancer screening programs in Europe, monitoring, quality assurance, and evaluation of long-term impact are required. We aimed to identify the most important indicators to be collected and reported. The study was designed to establish a consensus within a European-level working group and suggest a manageable list of key indicators. Methods We conducted a Delphi study among policymakers, researchers, and program coordinators who were experts in breast, cervical, or colorectal cancer screening. Study participants evaluated the importance of screening indicators on a 5-point Likert scale. Results The top 10 indicators by study participants were interval cancer rate, detection rate, screening attendance, screening coverage, cancer incidence

Gender injustice in compensating injury to autonomy in English and Singaporean negligence law

The extent to which English law remedies injury to autonomy (ITA) as a stand-alone actionable damage in negligence is disputed. In this article I argue that the remedy available is not only partial and inconsistent (Keren-Paz in Med Law Rev, 2018) but also gendered and discriminatory against women. I first situate the argument within the broader feminist critique of tort law as failing to appropriately remedy gendered harms, and of law more broadly as undervaluing women’s interest in reproductive autonomy. I then show by reference to English remedies law’s first principles how imposed motherhood cases—Rees v Darlington and its predecessor McFarlane v Tayside Health Board—result in gender injustice when compared with other autonomy cases such as Chester v Afshar and Yearworth v North Bristol NHS Trust: A minor gender-neutral ITA is better remedied than the significant gendered harm of imposing motherhood on the claimant; men’s reproductive autonomy is protected to a greater extent than women’s; women’s reproductive autonomy is protected by an exceptional, derisory award. Worst of all, courts refuse to recognise imposed motherhood as detriment; and the deemed, mansplained, nonpecuniary joys of motherhood are used to offset pecuniary upkeep costs, forcing the claimant into a position she sought to avoid and thus further undermining her autonomy. The recent Singaporean case ACB v Thomson Medical Pte Ltd, awarding compensation for undermining the claimant’s genetic affinity in an IVF wrong-sperm-mix-up demonstrates some improvement in comparison to English law, and some shared gender injustices in the context of reproductive autonomy. ACB’s analysis is oblivious to the nature of reproductive autonomy harm as gendered; and prioritises the father’s interest in having genetic affinity with the baby over a woman’s interest in not having motherhood imposed upon her

Model validation.

<p>Observed versus predicted validation endpoints (internal and external) and validation to published T1DM model output (costs and quality adjusted life years). Overall validation coefficient of determination for clinical endpoints, <i>R</i>² = 0.863; internal <i>R</i>² = 0.999; external <i>R</i>² = 0.823; total costs <i>R</i>² = 0.979; total QALYs <i>R</i>² = 0.951.</p

Identifying the barriers to effective breast, cervical and colorectal cancer screening in thirty one European countries using the Barriers to Effective Screening Tool (BEST).

The aim of this study was to identify barriers to effective breast, cervical and colorectal cancer screening programmes throughout the whole of the European region using the Barriers to Effective Screening Tool (BEST). The study was part of the scope of the EU-TOPIA (TOwards imProved screening for breast, cervical and colorectal cancer In All of Europe) project and respondents were European screening organisers, researchers and policymakers taking part in a workshop for the project in Budapest in September 2017. 67 respondents from 31 countries responded to the online survey. The study found that there are many barriers to effective screening throughout the system from identification of the eligible population to ensuring appropriate follow-up and treatment for the three cancers. The most common barriers were opportunistic screening, sub-optimal participation, limited capacity (including trained human resource), inadequate and/or disjointed information technology systems and complex administration procedures. Many of the barriers were reported consistently across different countries. This study identified the barriers that, in general, require further investment of resources

The Health Economic Value of Changes in Glycaemic Control, Weight and Rates of Hypoglycaemia in Type 1 Diabetes Mellitus

<div><p>Aims</p><p>Therapy-related consequences of treatment for type 1 diabetes mellitus (T1DM), such as weight gain and hypoglycaemia, act as a barrier to attaining optimal glycaemic control, indirectly influencing the incidence of vascular complications and associated morbidity and mortality. This study quantifies the individual and combined contribution of changes in hypoglycaemia frequency, weight and HbA1c to predicted quality-adjusted life-years (QALYs) within a T1DM population.</p><p>Materials and methods</p><p>We describe the Cardiff Type 1 Diabetes (CT1DM) Model, originally informed by the Diabetes Control and Complications Trial (DCCT) and updated with the Epidemiology of Diabetes Interventions and Complications (EDIC) study and Swedish National Diabetes Registry for microvascular and cardiovascular complications respectively. We report model validation results and the QALY impact of HbA1c, weight and hypoglycaemia changes.</p><p>Results</p><p>Validation results demonstrated coefficients of determination for clinical endpoints of R² = 0.863 (internal R² = 0.999; external R² = 0.823), costs R² = 0.980 and QALYs R² = 0.951. Achieving and maintaining a 1% HbA1c reduction was estimated to provide 0.61 additional discounted QALYs. Weight changes of ±1kg, ±2kg or ±3kg led to discounted QALY changes of ±0.03, ±0.07 and ±0.10 respectively, while modifying hypoglycaemia frequency by -10%, -20% or -30% resulted in changes of -0.05, -0.11 and -0.17. The differences in discounted costs, life-years and QALYs associated with HbA1c 6% versus 10% were -£19,037, 2.49 and 2.35 respectively.</p><p>Conclusions</p><p>Using a model updated with contemporary epidemiological data, this study presents an outcome-focused perspective to assessing the health economic consequences of differing levels of glycaemic control in T1DM with and without weight and hypoglycaemia effects.</p></div

Baseline cohort characteristics and model inputs.

<p>Baseline cohort characteristics and model inputs.</p

Weight and hypoglycaemia QALY plot.

<p>Assessing the impact of changes in weight and rates of hypoglycaemia events on per-patient lifetime quality-adjusted life year (QALY) difference. The reference point relates to a 1% reduction in HbA1c (%) with no associated changes in weight or hypoglycaemia, which was associated with a predicted QALY gains of 0.99. This figure illustrates the relative impact of weight change <i>±</i>3 kg and hypoglycaemia changes <i>±</i>30% on the QALY gained, beyond those already seen with the reference point.</p