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Health Technology Assessment... May 2004To update an earlier published report reviewing the effectiveness and cost-effectiveness of liquid-based cytology (LBC). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
To update an earlier published report reviewing the effectiveness and cost-effectiveness of liquid-based cytology (LBC).
DATA SOURCES
Electronic bibliographic databases, relevant articles, sponsor submissions and various health services research-related resources.
REVIEW METHODS
The selected data were reviewed and assessed with respect to the quality of the evidence. Pooled estimates of the parameters of interest were derived from the original and the updated studies. Meta-analyses were undertaken where appropriate. The mathematical model developed for the original rapid review of LBC was adapted to synthesise the updated data to estimate costs, survival and quality-adjusted survival of patients tested using LBC and using Papanicolaou (Pap) smear testing. Cost data from published sources were incorporated into the above model to allow economic, as well as clinical, implications of treatment to be assessed. The primary incremental cost-effectiveness ratio is the cost per life year gained (LYG), although estimates of the cost per quality-adjusted life-year (QALY) gained are also presented. A sensitivity analysis was undertaken to identify the key parameters that determine the cost-effectiveness of the treatments, with the objective of identifying how robust the results of the economic analysis are, given the current level of evidence.
RESULTS
From the evidence available, it is likely that the LBC technique will reduce the number of false-negative test results. Modelling analyses undertaken as part of this study indicate that this would reduce the incidence of invasive cancer. There is now more evidence to support improvements emanating from the use of LBC screening in terms of a reduced number of unsatisfactory specimens and a decrease in the time needed to obtain the smear samples. The estimated annual gross cost of consumables and operating equipment, and other one-off conversion costs associated with introducing the new technique, will be between 17 British pounds and 38 British pounds million in England and Wales, depending on the LBC system and the configuration of the service. Analyses based on models of disease natural history, conducted in this study, showed that conventional Pap smear screening was extendedly dominated by LBC (LBC was always more cost-effective than conventional Pap smear testing over the same screening interval). Comparing LBC across alternative screening intervals gave a cost-effectiveness of under 10,000 British pounds per LYG when screening was undertaken every 3 years. The cost-effectiveness results were relatively stable under most conditions, although if screening outcomes such as borderline results and colposcopy are assumed to induce even small amounts of disutility then LBC screening at 5-yearly intervals may be the most cost-effective option.
CONCLUSIONS
This updated analysis provides more certainty with regard to the potential cost-effectiveness of LBC compared with conventional Pap smear testing. However, there is uncertainty regarding the relative effectiveness (and cost-effectiveness) of the two main LBC techniques. Further research in the area of utility assessment may be worthwhile and possibly a full cost-effectiveness study of LBC based on a trial of its introduction in a low-prevalence population, although the results of the modelling analysis provide a robust argument that LBC is a cost-effective alternative to conventional cervical cancer screening. A randomised comparison of the two main techniques may also be useful.
Topics: Cost-Benefit Analysis; Female; Humans; Mass Screening; Papanicolaou Test; Sensitivity and Specificity; Uterine Cervical Neoplasms; Vaginal Smears
PubMed: 15147611
DOI: 10.3310/hta8200 -
The Journal of the American Board of... 2003Many women fail to adhere to Papanicolaou smear screening guidelines. Although many interventions have been developed to increase screening, the effectiveness of... (Review)
Review
BACKGROUND
Many women fail to adhere to Papanicolaou smear screening guidelines. Although many interventions have been developed to increase screening, the effectiveness of different types of interventions is unclear.
METHODS
We performed a systematic review of interventions to increase Papanicolaou smear use published between 1980 and April 2001 and included concurrently or randomized controlled studies with defined outcomes. Interventions were classified as targeted to patients, providers, patients and providers, or health care systems and as behavioral, cognitive, sociologic, or a combination based on the expected action of the intervention. Effect sizes and 95% confidence intervals were calculated for each intervention.
RESULTS
Forty-six studies with 63 separate interventions were included. Most interventions increased Papanicolaou smear use, although in many cases the increase was not statistically significant. Behavioral interventions targeted to patients (eg, mailed or telephone reminders) increased Papanicolaou smear use by up to 18.8%; cognitive and sociologic interventions were only marginally effective, although a single culturally specific, sociologic intervention using a lay health worker increased use by 18.0% (95% confidence interval [CI]: 7.6, 28.4). Provider-targeted interventions were heterogeneous. Interventions that targeted both patients and providers did not appear to be any more effective than interventions targeted to either patients or providers alone. One of the most effective interventions, which introduced a system change by integrating a nurse-practitioner and offered same-day screening, increased screening by 32.7% (95% CI: 20.5, 44.9).
CONCLUSIONS
Overall, most interventions increased Papanicolaou smear use, although there was tremendous variability in their effectiveness. Selection of intervention strategies will depend on provider and patient population characteristics and feasibility of implementation.
Topics: Female; Humans; Papanicolaou Test; Patient Education as Topic; Randomized Controlled Trials as Topic; Reminder Systems; Vaginal Smears
PubMed: 12755245
DOI: 10.3122/jabfm.16.3.188 -
Canadian Journal of Public Health =... 2002To evaluate and summarize evidence of the effectiveness of interventions available to public health staff that could be used to increase cervical cancer screening to... (Review)
Review
OBJECTIVE
To evaluate and summarize evidence of the effectiveness of interventions available to public health staff that could be used to increase cervical cancer screening to women.
METHOD
A thorough literature review was conducted, articles screened for relevance and assessed for quality.
RESULTS
Of 42 relevant studies, 1 was rated 'strong', 18 'moderate' and 23 'weak'. Among the strong/moderate studies, 10 were aimed at disadvantaged women. The most frequently used intervention was mass media campaigns, alone or combined with individual strategies; followed by individual education using lay health educators; and last, letters of invitation. Thirteen of the moderate/strong studies evaluated strategies that reported statistically significant increases in Pap smear rates and other outcomes.
CONCLUSIONS
Strategies that combined mass media campaigns with direct tailored education to women and/or health care providers seemed most successful. The importance of accurate centralized cytology databases for recall is underscored.
Topics: Adolescent; Adult; Aged; Community Participation; Female; Health Promotion; Humans; Mass Screening; Middle Aged; Patient Acceptance of Health Care; Poverty; Practice Patterns, Physicians'; Program Evaluation; Public Health Practice; Uterine Cervical Neoplasms
PubMed: 12353463
DOI: 10.1007/BF03404575 -
Magyar Onkologia 2002The increasing premature mortality due to cancer has made population based screening programs for cervical,breast and colorectal cancers inevitable in Hungary. However,... (Review)
Review
PURPOSE
The increasing premature mortality due to cancer has made population based screening programs for cervical,breast and colorectal cancers inevitable in Hungary. However, when confronted with limited resources, the aim is that, within the budget constrain, the greatest possible health gain should be "produced".
METHODS
The authors made a systematic review of the international literature concerning the cost-effectiveness of screening programs for the above tumours.
RESULTS
In case of cervical cancer the Papanicolaou test, in case of breast cancer the mammography meet the WHO criteria for population-based mass screening. The well-designed organised screening programs are more cost-effective than the opportunistic screening. Among sexually active women, according to structure the mobile screening buses, according to age group screening of the 30-39 years old women seems the most favourable. For breast cancer, screening the 60-70 years old population every second year is the reference strategy from a health economic perspective. The cost-effectiveness results of either increasing the frequency of screening, extending the program for other age groups, or selecting a high-risk population are contradictory. In case of colorectal cancer there is no screening method, which would meet the WHO criteria. The two-day FOBT seems the most favourable, followed by colonoscopy for positive results, in the 55-74 years old population every second year.
CONCLUSION
In addition to fulfilling requirements for a population-based screening method, the cost-effectiveness perspective should be taken into account.
Topics: Adolescent; Adult; Age Factors; Aged; Breast Neoplasms; Child; Child, Preschool; Colorectal Neoplasms; Cost-Benefit Analysis; Europe; Female; Health Care Costs; Humans; Hungary; Infant; Infant, Newborn; Male; Mass Screening; Middle Aged; Neoplasms; Population Surveillance; Time Factors; Uterine Cervical Neoplasms
PubMed: 12202891
DOI: No ID Found -
The British Journal of General Practice... Mar 1999It has been reported that many women referred to outpatient colposcopy clinics fail to attend for their appointments. The aim of this paper is to search the literature... (Review)
Review
It has been reported that many women referred to outpatient colposcopy clinics fail to attend for their appointments. The aim of this paper is to search the literature to assess the extent of default from colposcopy and to identify interventions, suitable for implementation within primary care, to reduce the proportion of women defaulting. Searches were performed on MEDLINE, PsychLIT, Bids and Cancerlit from 1986 to September 1997 using the terms colposcopy or cervical/Pap smear in association with default, non-attendance, adherence, patient compliance, treatment refusal, patient dropouts, attendance, barriers or intervention. The inclusion criteria for primary papers were that they contained data that enables the calculation of default rates for colposcopy or the results of interventions aimed at improving the default rates. Thirteen publications describing default rates and four describing interventions were included as primary papers. Combining the data from these studies suggests default rates of 3%, 11%, and 12% for assessment/treatment visits, first review, and second review respectively. The intervention studies suggested a need to tailor the intervention to the population and the type of information to suit the individual. Varying definitions make comparison of default rates difficult, and the use of a crude non-attendance rate may result in an overestimate of default rates. The vast majority of women invited to colposcopy eventually attend. It is questionable if there is a need for interventions to increase compliance. Where necessary, greater cooperation across the primary/secondary care interface and use of the extended primary care team may be a more cost-effective means of increasing compliance.
Topics: Colposcopy; Cost-Benefit Analysis; Female; Humans; Papanicolaou Test; Primary Health Care; Treatment Refusal; Uterine Cervical Neoplasms; Vaginal Smears
PubMed: 10343430
DOI: No ID Found