Health Technology Assessment (HTA) Report: Interventions to increase participation to organised cancer screening programs

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Health Technology Assessment (HTA) Report: Interventions to increase participation to organised cancer screening programs

Ministry of Health Grant for Applied Research

Giorgi Rossi P, Camilloni L, Ferroni E, Jimenez B, Furnari G, Guasticchi G, Borgia P.

Laziosanità – Agenzia di Sanità Pubblica della Regione Lazio

Published in: Health & Medicine
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Health Technology Assessment (HTA) Report: Interventions to increase participation to organised cancer screening programs

  1. 1. HTAi 2012- BilbaoHealth Technology Assessment (HTA) Report: Interventions to increase participation to organised cancer screening programs Ministry of Health Grant for Applied Research Giorgi Rossi P, Camilloni L, Ferroni E, Jimenez B, Furnari G, Guasticchi G, Borgia P. Laziosanità – Agenzia di Sanità Pubblica della Regione Lazio
  2. 2. Background• The most important barrier reducing the effectiveness of oncological screening program is low participation of the target population.• High participation rates are necessary to obtain a significant impact on population health.• Compliance to invitation should be achieved by encouraging “informed” participation by individuals who are aware of the benefits, limitations and disadvantages of the screening program.
  3. 3. Objective To synthesize the scientific evidence produced by International research on the efficacy of interventions to increase participation in screening programs.
  4. 4. Methods: the HTA process• Identification of a multi-discipliner working group including all the principal investigators who conducted studies with public funding on screening participation in Italy• Scope definition• Stakeholder consultation• Assessment and draft of the report• Stakeholder consultation• Final report
  5. 5. Methods: PICOSPopulation: breast 49-69; cervix 25-64; colorectal 50-74Intervention: any type of intervention or strategy aimed atincreasing participationComparison: standard invitation letter (with or without recall)Outcome: participation to screening program;Study: RCT, cRCT, controlled non-randomised, before/afterstudies.We updated the systematic review by Jepson et al 2000.
  6. 6. Methods: assessment domains 1.Efficacy 2.Cost-effectiveness 3.Organizational impact 4.Social (inequalities), ethic (informed participation) and legal (privacy) issues
  7. 7. Study selection Flow chart Potentially relevant citations (titles) identified and screened (n=5879) Excluded irrelevant citations (n=4821) Potentially relevant abstracts identified and screened (n=958) Excluded QT irrelevant abstracts but useful for QL Review (n=813) Retrieve full text for critical appraisal (n=145) Excluded irrelevant QT studies but useful for QT Studies full field QL Review (n=93) inclusion criteria (n=52) Studies from Jepson Final set (n=122) Review (n=70)
  8. 8. Classification of the interventions, according to thetarget•To the target population: •the individual: invitations, reminders, etc. •the population: health education, information campaigns by the mass-media.•Screening tests: new tests or new procedures; self-administered tests; etc.•Health professionals: training; stimuli for physicians, auditand feedback, etc.•Health service organization: removing financial oreconomic barriers, involving more providers, fixed or openappointments, etc.
  9. 9. Interventions targeted to individuals•There is strong evidence of a positive effect of mail recall
  10. 10. Interventions targeted to individuals•And phone recall
  11. 11. Interventions targeted to individuals•Heterogenous results for face to face recall
  12. 12. Interventions targeted to individuals•Thre isconsistentevidence of amodest positiveeffect of the GP’ssign on theinvitation letter
  13. 13. Interventions targeted to individuals•Informational matherial mailed with the letter hasno effect on participation
  14. 14. Interventions targeted to the population Few studies evaluated the effect of mass media campaigns and there are several methodological problems Other studies evaluating multi-facetted interventions, including mass media campaigns, showed non consistent results
  15. 15. Interventions that make screening tests easieror more acceptable •Diet restrictions have a negative effect on FOBT compliance•Higher number of evacuations have a negative effect on GuaiacFOBT compliance
  16. 16. Interventions that make screening tests easier or more acceptable Self-sampling for HPV increases participation in non- responders compared to recall letter self-sampling direct mail standard recall Risk Ratio Risk RatioStudy or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CIGiorgi Rossi 2010 121 616 86 619 48.5% 1.41 [1.10, 1.82]Gok 2010 7404 26920 46 277 51.5% 1.66 [1.27, 2.16]Total (95% CI) 27536 896 100.0% 1.54 [1.28, 1.85]Total events 7525 132Heterogeneity: Chi² = 0.73, df = 1 (P = 0.39); I² = 0% 0.1 0.2 0.5 1 2 5 10Test for overall effect: Z = 4.59 (P < 0.00001) standard self sampling
  17. 17. Interevtions targeted to health service organizationFixed appointment has higher participation than open invitation
  18. 18. Interevtions targeted to health service organization Remainder addressed to the GP flagging not screened people have a a modest consistent positive effect
  19. 19. Interevtions targeted to health service organizationDirect mailing of the FOBT vs piking up at the clinc showedheterogenous mostly positve results Direct mailing has better results than on demand mailing
  20. 20. Cost-effectiveness Given the low cost per QALY of the three cancer screening, we might spend up to 40€ to gain an unscreened woman to Pap test, 130€ for mammography, 80€ an individual to FOBT and 800€ for sygmoidoscopy. We found economic evaluations only for few interventions and results are often context dependent: •Recall letters are consistently cost effective •Results for reminders to GPs are more heterogeneous
  21. 21. Social issues •Some interventions have effects on inequalities: •Longer and more detailed letters increase differneces in access. •GP involvement is effective in increasing participation specifically of more disadvantaged people. •Phone recalls are more effective in women with low educational level.
  22. 22. Conclusions Many interventions have been implemented to increase patrticipation to screening, but only few of them have been evaluated Effectiveness of these interventions may be context dependent. Some interventions showed consistent positive results in many context and can be implemented with few resources: •Mail recall •GP’s sign •Fixed appointment
  23. 23. Thank you!HTA report available at: Epiprev.it

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