Background In 2004, France implemented a nationally organised mammography breast cancer screening programme for women aged 50-74 years. The French programme is based on: A Systematic invitation by letter send every 2 years to one half of the target population With the mammography, the screening includes systematic Breast clinical examination and immediate assessment by a radiologist (the first reader) The French programme includes also a Quality insurance system. But the French particularity is that all normal screens are read by a second radiologist ( 2 nd reader) Early efficacy indicators meet the European quality standard rates… except participation rates In fact, in 2009, the programme reached only an estimated 52.5% of its target population, far below the recommended European objective (around 70 to 80%). The other particularity of France is that women retain the option of having screening mammography following medical prescription. This opportunistic screening has no quality insurance process and around 10% of women participates to this screening. This possibility could explain the low participation level in the organised programme It could also have an important impact on efficiency and cost effectiveness of the organised screening programme That’s why we simulated transition scenarios to explore possible strategies for increasing/improving participation in BCS in France, especially the organised programme.
Objectives Our first objective was to determine the best approach to improve the effectiveness and cost-effectiveness of breast cancer screening in France. That means 3 possibilities Do not change anything: remain in the same situation (current situation) with combined/mixed screening or, Switch the entire target population to organised screening or, Stop the organised programme and switch all women to opportunistic screening. So first, we evaluated this 3 situations in terms of global participation of women, effectiveness (number of cancers detected) and costs.
Once having find the optimal screening situation for France, our second objective was to evaluate the ability of 5 possible strategies to reach this objective. I will return in detail on these scenarios later in the presentation. Concerning the method, We made simulations based on a static analytic model to evaluate organisational and budgetary impacts.
So regarding our 1st objective which was to determine the best target situation. We evaluated the number of cancers detected and costs for the current situation. That was our reference point. Then we evaluated the switch of all women to opportunistic screening and the switch of all women to organised screening. Here, I will only present you figures for the switch to organised screening as it corresponded to the optimal situation for us. So in this situation: We’ve got around 300 additional cancers detected compared to the current situation, In terms of costs, we have a reduction of total costs of - 3 millions of Euros, Moreover, a very important decrease of costs for women and supplementary insurance (- 12 millions of Euros) due to the 100% coverage of mammography in OS. So as a conclusion: Compared with the current situation, full switch to OS increase the total number of cancers detected and reduce total costs Moreover, from a public health point of view, compared with opportunistic screening, OS includes a Quality Insurance system and ensures equal access to screening. So, we defined “full switch to OS” as a target for BCS or as an objective insofar as it corresponded to the optimum.
Here are the 5 scenarios and their rational or justification. The scenarios have been defined in close connection with specialists from breast cancer and from Public Health First, a scenario of delisting the opportunistic mammography (S1); Second scenario: introducing quality control in opportunistic screening (S2); Third, making some operational changes in organized screening (S3), roughly that means allowing more ultrasound exam in the programme; Scenario 4, changing fees/Tariff of mammography and ultrasound when they are combined in order to encourage practitioners to switch to the OS programme (S4), And last scenario 5, settle qualitative incentives for health care practitioners in order to encourage them to switch women from one screening to another (S5).
To model the impact of the different scenarios, we have introduced parameters reproducing the possible behavior of women relative to expected changes . that is, first of all, prospective switching rates of one screening modality to the another. And a discontinuation rate of BC screening, whatever the modality. These parameters related only to scenario 1 and 5 This has resulted in 4 sub-models for these 2 scenarios based on assumptions about the expected values of switching and BCS ‘giving-up’ parameters.
Here are the results presented graphically in terms of cost-effectiveness. The orange dot represents the current situation. The Red lozenge represents the optimum situation to which we must strive. The scenarios and their variants are represented in blue. We see that the scenario 2, 3 and 4 could not not achieve the optimum anyway. Only scenarios 1 and 5 can indeed achieve the target objective. Note that with an average switching rate and a significant BCS giving-up rate, the scenario 1 moves away from the optimum (S1d). With S1b and S5b, we could totally move to the optimum, the Target Situation.
Compared with the current situation, full switch to organised screening appears to increase the total number of cancers detected and reduce total costs. Strategies S2, S3 and S4 lead to worsened situations. Only S1 and S5 would lead to the transfer of the entire target population to organised screening. Compared with the current situation, these 2 strategies would result in 71 to 283 additional cancers detected and in savings of €0.9M to €3.1M. But results are highly sensitive to BCS giving up rates and to switching rates from OPPS to OS, in particular the non reimbursement of OPPS mammography.
What are the implications for French Health system? The transition strategies are hypothetical and could be combined. Alongside the delisting of opportunistic mammography, various incentives toward health care practitioners could be designed, to increase participation and at the same time detecting more cancers at a lower cost. We think that this work could be useful for French health decision-makers in adjusting breast cancer screening policy. This work has resulted in Guidelines from the French National Health Authority that have just been published. This work also identify several knowledge gaps for further research: Studies are needed to assess what could be the switching and giving-up rates from screening of women in case of delisting of opportunistic screening mamographies. As opportunistic screening is not subject to any assessment in routine, perhaps ad hoc studies are needed to evaluate it. Finally, our work has highlighted the need for a full assessment of BCS in France, both in terms of effectiveness (morbidity and mortality) as well as in terms of costs.
Thank you for your attention. I will be pleased to answer your questions.
Evaluation of transition scenarios for breast cancer screeningin France to increase participation of women aged 50 to 74 years.
Evaluation of transition scenarios for breast cancer screeningin France to increase participation of women aged 50 to 74 years S.Barré, I.Hirtzlin, C.Rumeau-Pichon Haute Autorité de Santé Economic Evaluation and Public Health www.has-sante.fr
Background• 2 possible modalities of Breast Cancer Screening (BCS) for women aged 50 to 74 years Nationally organised Opportunistic screening screening programme (OPPS) (OS) Invitation Systematic, every 2 years No Target population 50-74 y _ Quality Insurance System Yes No Coverage 52.5% 10% Equality of access Yes Not ensured• OPPS lower participation level & efficiency of OS• Simulation to explore strategies for increasing participation in BCS in France HTAi 2012 Breast cancer screening in France (50-74 ans) 3
Objectives & methods (1/2)1. To determine the best approach to improve effectiveness and cost-effectiveness of BCS • 3 possible target situations: • Status quo (current situation) • Switch full population to OS • Stop OS programme and switch full population to OPPS • Evaluation: • Participation, screening tests, diagnostics tests, ACR, etc. • Numbers of cancers detected, • Costs • National Health Insurance, Women and/or supplementary insurance, Total HTAi 2012 Breast cancer screening in France (50-74 ans) 4
Objectives & methods (2/2)2. To evaluate the ability of 5 scenarios to reach the objective • Non reimbursement of OPPS mammography (S1); • Quality control in OPPS (S2); • Operational changes in OS (S3); • Fees changes (S4), • Incentives for health care practitioners (S5)• Methods • Simulation based on a static analytic model • Organizational and budgetary impact HTAi 2012 Breast cancer screening in France (50-74 ans) 5
Results: full switch to organised screening Health Co-payment/ Number of Total Insurance supplementary women costs costs health insuranceTarget situation (full switch to OS):Mammography 2 722 813 180.8 M€ - € 180.8 M€ nd2 reading (normal mammography) 2 630 237 15.0 M€ - € 15.0 M€Ultrasound 588128 8.6 M€ 3.7 M€ 12.2 M€Aspiration cytology 5 446 0.3 M€ 0.2 M€ 0.5 M€Biopsy 21 783 3. M€ 1.3 M€ 4.5 M€ACR 3 follow-up 57 724 1.5 M€ 0.6 M€ 2.1 M€Total number of women screened 2 722 813Participation rate 62.5%Total number of cancers detected 19 343Total cost 209.4 M€ 5.8 € 215.2 M€Current Situation:Total number of cancers detected 19 060Total cost 200.3 M€ 18.0 M€ 218.4 M€Difference/Current Situation + 283 + 9.1 M€ - 12.2 M€ - 3.2 M€ HTAi 2012 Breast cancer screening in France (50-74 ans) 7
Results: Transition scenarios to full switchScenarios Rational/justification S1: Non reimbursement of OPPS mammography (recommendation from several French institutional reports) S2: Quality Control in OPPS (2nd reader) S3: Operational changes in OS (ultrasound more systematically, no more 2nd reading) S4: Fee changes for mammography & ultrasound (limitation of co-prescriptions) S5: Qualitative measures & incentives for Health Care practitioners (to facilitate inclusion in OS) HTAi 2012 Breast cancer screening in France (50-74 ans) 8
Results: Transition scenario to full switch • Changes in women’s behaviour: – Switching rates from OPPS to OS – ‘Giving-up’ rates from BCS • 4 variants for S1 and S5 (resp.non reimbursement of OPPS mammography & Qualitative incentives) : – Switch 0% Give-up 0% (S1a et S5a) – Switch 100%, Give-up 0% (S1b et S5b) – Switch 50% , Give-up 0% (S1c et S5d) – Switch 25%, Give-up 0% (S5c) – Switch 50%, Give-up 25% (S1d) HTAi 2012 Breast cancer screening in France (50-74 ans) 9
Results: cost-effectiveness of scenarios Number of cancers detected 19 700 19 450 TS, S1b, S5b S2 S1c 19 200 S5d S5c S4 S0 S1a, S5a 18 950 18 700 18 450 S1d 18 200 17 950 17 700 17 450 S3 17 200 205 210 215 220 225 230 235 240 245 Total cost (millions of €)Variants for S1 et S5 : S1a = transfer 0% and withdrawal 0%, S5a = transfer 0%, S1b = transfer 100% and withdrawal 0%, S5b = transfer 100%, S1c = transfer 50% and withdrawal 0%, S5c = transfer 25%, S1d = transfer 50% and withdrawal 25%; S5d = transfer 50% HTAi 2012 Breast cancer screening in France (50-74 ans) 10
03Discussion and implications for the health system
Discussion• Switch to OS for women participating in OPPS is cost effective • More cancers detected at a lower cost• Strategies S2, S3 & S4 lead to worsened situations (compare to current situation)• Only S1 and S5 would lead to the transfer of the entire target population to OS • 71 to 283 additional cancers detected • Savings of 0.9 M to 3.1 M€ … but subject to • High transfer rate to OS and/or • Low withdrawal rate from BCS HTAi 2012 Breast cancer screening in France (50-74 ans) 12
Implications for the French Healthsystem• Strategies that could be combined • Various incentives toward HC professionals could be designed • Alongside discontinuation of OPPS mammography coverage• Adjusting French BCS policy• Knowledge gaps/further research • Women’s behaviour (transfer and withdrawal rates) • Effectiveness and C/E of OPPS • Full evaluation of BCS in France (impact on mortality, morbidity, C/E) HTAi 2012 Breast cancer screening in France (50-74 ans) 13
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