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PubMed2000

Cost-effectiveness of universal compared with voluntary screening for human immunodeficiency virus among pregnant women in Chicago.

OBJECTIVES: To determine and compare the cost-effectiveness of implementing 3 screening strategies to detect human immunodeficiency virus (HIV) infection among pregnant women in Chicago, Illinois: no screening, voluntary screening, and universal screening. METHODS: A decision-analysis model was developed, using standard cost-effectiveness analysis from a societal perspective. Reference case estimates were derived from a surveillance project conducted by the Illinois Department of Public Health and studies were published in the medical literature. Costs included direct and indirect medical costs associated with identification of pregnant women infected with HIV and identification, prevention, and treatment of perinatally HIV-infected newborns. Specifically, for each screening option, the cost per pregnant woman screened, the resulting number of pediatric HIV infections, and the number of newborn life-years were calculated. All costs were adjusted to the 1997 dollar value and discounted at 3%. Sensitivity analyses were determined for all variables included in the decision model. RESULTS: The estimated prevalence of HIV infection among pregnant women in Chicago is .41%. For every 100,000 pregnant women, it is estimated that 104.6 children would be infected with HIV if no screening strategy were implemented and 44.8 children would be infected if voluntary HIV testing (assuming a 92.7% acceptance rate) were available. In comparison, if universal HIV testing was performed, the number of children infected with HIV would decrease to 40 cases. Sensitivity analysis across a maternal HIV prevalence rate of.01% to 2.2% found that universal screening would be cost-saving in communities where the seroprevalence is.21%. In Chicago, it would take an estimated 5. 2 months of screening pregnant women to avert 1 case of pediatric HIV. Taking into consideration the lifetime costs of treating a child with HIV infection, universal HIV testing of 100,000 pregnant women would result in a cost-savings of $3.69 million when compared with no screening, and $269,445 when compared with voluntary screening. We estimated that it would cost $11.1 million to screen 100,000 pregnant women in Chicago. The cost-savings produced with increased screening are the direct result of reduced cases of newborns infected with HIV. A 2-way sensitivity analysis was performed to examine how costs vary as a function of the voluntary rates for HIV-positive and HIV-negative women. When screening falls below 50% for HIV-positive mothers, universal screening becomes cheaper than voluntary screening even if no HIV-negative mothers were screened. CONCLUSION: Reference case analyses showed that universal HIV screening of pregnant women in Chicago would both decrease the number of HIV-infected newborns and save money in comparison to voluntary or no testing strategies. Sensitivity analysis was robust across all variables for the conclusion that universal screening was more effective than voluntary screening. For many communities that have HIV prevalence rates for mothers of >.21%, universal screening would also save money in comparison to voluntary screening. For communities with prevalence rates <.21%, the benefits of universal screening may outweigh the costs for screening as we found that desirable incremental cost-effectiveness ratios were found for prevalence rates as low as.0075%.

AIDS Serodiagnosis↗
PubMed2004

Compliance of average- and intermediate-risk women to semiannual ovarian cancer screening.

OBJECTIVE: To report rates of compliance with an ovarian cancer screening protocol using serum CA125 and transvaginal sonography (TVS), performed semiannually on an alternating schedule, among participants at average or intermediate risk for developing ovarian cancer. METHODS: Two hundred ninety-two women at average or intermediate risk for developing ovarian cancer were randomly assigned to arms of a controlled clinical trial in which they received ovarian cancer screening consisting of serum CA125 alternating with TVS performed semiannually over 18 months, either alone or in combination with ovarian cancer risk education. A computerized tracking system generated screening appointment reminder letters and monitored adherence to scheduled screening. Participants overdue for scheduled screens received follow-up telephone calls consisting of up to four reminder messages left at 1-week intervals, and one to two interim attempts to reach participants between messages. The compliance rate for each screen was calculated as a ratio of the number of participants successfully completing the screen relative to the number expected to attend. Compliance rate by screen was: screen 1 (CA125) (97.3%), screen 2 (TVS) (82.5%), screen 3 (CA125) (79.0%), and screen 4 (TVS) (64.5%). One hundred seventy-two women completed all four screens and were classified as adherent to the screening protocol. Analysis by screening modality suggests that participants were more compliant to screens involving CA125. Age, educational background, distance from screening center, personal or family history of cancer, perceived risk of ovarian cancer, pre-enrollment ovarian cancer screening behavior, receiving an abnormal screen test result, and participation in ovarian cancer risk education sessions were not associated with adherence to the screening protocol or compliance to any of the screens. CONCLUSIONS: Despite extensive follow-up, compliance of average- and intermediate-risk women to an ovarian cancer screening protocol requiring semiannual screening diminishes rapidly. We propose that a semiannual ovarian cancer screening protocol, particularly one including TVS, may be too intensive for use in this population.

Adult↗
PubMed2000

Screening for colorectal cancer using the faecal occult blood test, hemoccult.

BACKGROUND: Colorectal cancer is a leading cause of illness and death in the Western world. In Australia, the United Kingdom and the United States, it is the second commonest cancer for women after breast cancer (age-standardised incidence 22-33 per 100,000), and men after prostate or lung cancer (age-standardised incidence 31-47 per 100,000) (Jeffs et al, 1996; Parkin et al, 1992). Just under half of all persons affected will die from their disease (Jeffs et al, 1996; Parkin et al, 1992) The human and financial costs of this disease have prompted considerable research efforts to evaluate the ability of screening tests to detect the cancer at an early curable stage. Tests which have been considered for screening include faecal occult blood tests, sigmoidoscopy and colonoscopy. OBJECTIVES: To determine whether screening for colorectal cancer using the faecal occult blood test, Hemoccult reduces colorectal cancer mortality and to consider the benefits and harms of screening. SEARCH STRATEGY: Published and unpublished data for this review were identified by: * retrieving studies included in a systematic review conducted by some of the authors in 1995, * searches of MEDLINE, Current Contents and the Cochrane Controlled Trials Register, * writing to trial lists. SELECTION CRITERIA: All controlled trials of screening for colorectal cancer using Hemoccult were eligible for inclusion in the review. DATA COLLECTION AND ANALYSIS: Data from the trials were independently extracted by two authors. Data analysis was performed using the group subjects were randomised to ('intention to screen'), whether or not they were ever screened. To estimate the effect of Hemoccult screening on colorectal cancer mortality, we calculated relative risks and risk differences for each trial, and then overall, using fixed and random effects models and tested for heterogeneity of effects. We calculated summary measures of effect including all trials and also for just the randomised controlled trials. We also calculated a summary measure of effect, adjusted for attendance at screening in each trial (not shown in Meta-view). MAIN RESULTS: Meta-analysis of mortality results from the randomised controlled trials shows that those allocated to screening had a reduction in colorectal cancer mortality of 16% (RR 0.84, CI: 0.77-0.93). When adjusted for screening attendance in the individual studies, the mortality reduction is 23% (RR 0.77, CI: 0.57-0.89). Overall, if 10 000 people were offered a biennial Hemoccult screening program and two-thirds attended for at least one Hemoccult test, there would be 8.5 deaths (CI: 3.6-13.5) from colorectal cancer prevented over 10 years. However, the screening program would also result in 2 800 participants having at least one colonoscopy, if screening harms from the Minnesota trial are considered, and there would be 3.4 colonoscopy complications (perforation or haemorrhage). If screening harms from the Gothenburg trial are considered, approximately 600 participants would need at least one sigmoidoscopy and double contrast barium enema, resulting in 1.8 perforations or haemorrhages. REVIEWER'S CONCLUSIONS: Screening benefits include reduction in colorectal cancer mortality, possible reduction in cancer incidence through detection and removal of colorectal adenomas and potentially, treatment of early colorectal cancers may involve less invasive surgery. Harmful effects of screening include the physical complications of colonoscopy, disruption to lifestyle, stress and discomfort of testing and investigations, and the anxiety caused by falsely positive screening tests. Although screening benefits are likely to outweigh harms for populations at increased risk of colorectal cancer, we need more information about the harmful effects of screening, the community's responses to screening and screening costs for different health care systems before widespread screening can be recommended.

Colorectal Neoplasms↗
PubMed2002

Impact of undergoing prostate carcinoma screening on prostate carcinoma-related knowledge and distress.

BACKGROUND: Despite the ongoing controversy regarding the utility of prostate carcinoma (PCa) screening, the prevalence of asymptomatic men who participate in free PCa screening programs is on the rise. However, this increased awareness has not been associated with increased knowledge about the potential limitations of PCa creening. We conducted a prospective assessment to delineate men's motivations for undergoing screening and to determine the impact of screening on psychological distress and on men's knowledge about PCa screening. METHODS: We conducted two telephone interviews with a group of 136 men registered to undergo free PCa screening at two hospital-based sites. The first interview was conducted before screening and the second interview followed receipt of the screening results. Interviews assessed demographics and screening history, reasons for undergoing the current screening, cancer-related and general psychological distress, knowledge of risk factors for PCa, and knowledge of the benefits and limitations of screening. Only participants with normal screening results were included in these analyses. RESULTS: "Seeking peace of mind about prostate cancer" was rated as the most important reason for undergoing screening. PCa-related distress decreased following receipt of a negative result (P < 0.01). Stratified analyses indicated that this was particularly true among younger men and African American men (both Ps < 0.001). Awareness of the benefits of screening was very high, but awareness of limitations was low, with fewer limitations reported following screening compared with prescreening (P < 0.01). Although awareness of the established risk factors improved following screening, controversial risk factors (i.e., those with limited empirical support) and factors that were unrelated to PCa risk were also rated as more important in the development of PCa than they were before screening (all Ps < 0.05). Therefore, the results may reflect that following screening, participants were simply more likely to endorse plausible risk factors, rather than actually reflecting an increase in participants' knowledge. CONCLUSIONS: These results suggest the importance of developing informed consent procedures and educational programs for the asymptomatic men who participate in free prostate screening programs each year, as the decision to be screened is being made without the benefit of a full understanding of the current state of medical knowledge about PCa screening. Until the definitive results of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial are available, improved patient education is needed to assist men in making screening decisions consistent with their own preferences.

Black or African American↗
PubMed2005

Associations in breast and colon cancer screening behavior in women.

RATIONALE AND OBJECTIVES: Gender-based psychosocial factors appear to influence colorectal cancer (CRC) screening adherence. Given its near-universal acceptance by the public, screening mammography represents a potential "teachable moment" for educating patients about the risk of CRC. Accordingly, to better understand screening behaviors among women, data from the Behavioral Risk Factors Surveillance Survey (BRFSS) were analyzed to identify potential relationships that would allow interventions to enhance CRC screening. MATERIALS AND METHODS: Women 50 years and older who participated in the BRFSS 2001 survey were included in the analysis. Colorectal, breast, and cervical cancer screening adherence with American Cancer Society guidelines was determined. We identified the association between breast and cervical cancer screening adherence and general health and demographic characteristics with CRC screening adherence. RESULTS: After adjustment for sociodemographic factors in a multivariate analysis, women 60-69 years old (adjusted odds ratio [OR], 1.50; P < .01) and 70-79 years old (adjusted OR, 1.39; P < .01), having achieved at least some high school (adjusted OR, 1.62; P < .01) or college (adjusted OR, 2.11; P < .01) education, having health coverage (adjusted OR, 1.67; P < .01) or a personal physician (adjusted OR, 1.60; P < .01), and adherence to screening mammography (adjusted OR, 2.42; P < .01) and Pap smear (adjusted OR, 1.70; P < .01) were independently associated with an increased likelihood CRC screening adherence. Women in self-reported good general health were less likely to have adhered to CRC screening guidelines (adjusted OR, 0.79; P < .01). Current smokers were also less likely to have adhered to CRC screening guidelines than were women who never smoked or formerly smoked (adjusted OR, 0.76; P < .01). Participants who adhered to both mammography and Pap smear guidelines were significantly more likely to adhere to CRC screening (51.5% CRC screening adherence) compared with women who adhered to neither screening test (8.2% CRC screening adherence), with an adjusted OR of 5.67 (P < .001). Participants who adhered to both mammography and Pap smear guidelines were significantly more likely to adhere to CRC screening than were women who adhered to either screening test (38.0% CRC screening adherence) with an adjusted OR of 1.94 (P < .001). CONCLUSION: Women with up-to-date mammography and cervical cancer screening were more likely to be up-to-date with CRC screening. Regardless of the increased association between non-CRC-related cancer screening and CRC screening, rates of CRC screening utilization remained low in these otherwise compliant populations.

Aged↗
PubMed2004

Vision health care providers' attitudes and experiences with preschool vision screening in Ontario.

PURPOSE: The validity of preschool vision screening has been questioned in the light of the World Health Organization's criteria for determining the validity of screening programs. However, recommendations toward preschool screening have been made by a number of organizations. Given the contrasting views of screening, the purpose of this study was to examine visual health care provider experiences and attitudes toward preschool screening. METHOD: Optometrists, public health administrators, pediatric ophthalmologists, and orthoptists were surveyed about opinions of, recommendations for, and experiences with preschool vision screening in Ontario. The survey focused on four areas, including general opinion of preschool screening, screening standards and practices, provider experience with preschool screening, and barriers to preschool screening. In addition, survey responses were broken down by regional access to health care. RESULTS: Overall, strong support for preschool vision screening and movement toward standardization of screening practice was found among all surveyed groups. Although support for vision screening in low health care access areas was strong, providers estimated that parent compliance to screening was weaker in low access areas. Providers also reported considerable variability in vision screening practices. In addition, although the majority of providers had been involved in a screening program, the majority was no longer involved because of lack of program organization, structure, and funding. Lack of sufficient funding, public education, organization of screening, training, and government support were listed as barriers to preschool vision screening. CONCLUSION: Providers are interested in the development of structured screening programs. However, although screening may be a way to offer some level of vision care service to low health care access areas, a number of factors need to be addressed in discussions of vision screening program standards or screening best practice. In general, preschool screening programs need to be structured, be supported, have quality control, and be evaluated.

Attitude of Health Personnel↗
PubMed1998

Benefits of neonatal screening for congenital adrenal hyperplasia (21-hydroxylase deficiency) in Sweden.

OBJECTIVES: The aim of this study was to evaluate the benefits of neonatal screening for congenital adrenal hyperplasia (CAH). METHODS: All children with CAH born in Sweden from January 1989 to December 1994 were subjected to a systematic follow-up. Clinical symptoms were recorded and laboratory data collected. The clinical diagnosis versus diagnosis by screening was investigated. The results were compared with those of a retrospective study of all patients diagnosed during 1969-1986 (before the introduction of neonatal screening). RESULTS: The prevalence of CAH in Sweden was 1:9800 with screening. Patients with CAH were identified earlier by screening. Half of the infants (47%) were not diagnosed at the time of recall, which was 8 days (median). In the study population, 25% of the girls and 73% of the boys were diagnosed by screening alone. The median age at the time of the definite diagnosis in boys was 21 days before screening as compared with 9 days (median) during the last part of the screening period. During the screening period, only 1 boy had a severe salt loss crisis, which occurred at the age of 8 days. Before screening, (1969-1986) 2 boys had died in the neonatal period because of an adrenal crisis. The lowest serum sodium recorded at the time of diagnosis was 124 mmol/L (median; range, 93-148) before, as compared with 134 mmol/L (median; range, 115-148) after the introduction of screening. The number of girls who were initially considered to be boys was not reduced by screening (17% vs 18%). The period of uncertainty regarding gender attributable to virilization was shortened considerably, as well as the time it took to make a correct gender assignment: 23 days (median) before screening versus 3 days (median) with screening. The maximum time it took to make the correct gender assignment was 960 days before screening and 14 days with screening. The number of patients diagnosed late, ie, after the first year of life, decreased considerably after the introduction of screening. The false-positive rate (when a new filter paper blood sample was requested or when a child was referred to a pediatrician for follow-up) was <0.05% and in about 60% of the cases, it was attributable to preterm infants. The cost of screening was US dollar 2.70 per screened infant. CONCLUSION: The main benefits of screening were avoidance of serious salt loss crises, earlier correct gender assignment in virilized girls, and detection of patients who would have otherwise been missed in the neonatal period. Deaths in the neonatal period were prevented by screening. The aim of the screening program was to identify patients with the severe forms of CAH. Nevertheless, it must be considered a distinct benefit that a number of patients with milder forms of CAH were detected earlier, because earlier therapy results in decreased virilization, normalized growth and puberty, and, in all probability, an improved psychosocial situation for these children. We conclude that, in the Swedish health care system, the benefits of screening for CAH outweigh the costs.

17-alpha-Hydroxyprogesterone↗
PubMed1998

On what grounds do women participate in prenatal screening?

Along with the rapid biomedical development of prenatal screening tests, target groups' attitudes and decision-making about, and the acceptance of, screening procedures have come into focus. To understand users' decision-making, it is essential to understand users' knowledge and perceptions of a procedure. The aim of this study was to examine Finnish women's knowledge and perceptions of, and stated reasons to participate in, two prenatal screening tests: serum screening and mid-trimester ultrasound screening. Subjects (n=1035) for the serum screening survey were catered for in the maternity care centres of two Finnish towns, where serum screening is available for all pregnant women. After one reminder, 88 per cent returned the questionnaire. Subjects (n=497) for the mid-trimester ultrasound screening survey were catered for in the obstetrical and gynaecological outpatient clinic of the city hospital of another town; the response rate was 85 per cent. Women's perceptions of the studied prenatal screening tests, serum screening and mid-trimester ultrasound screening, differed significantly, even though both are used to detect fetal malformations. Serum screening was far more often perceived to be connected with finding diseases or abnormalities than ultrasound screening. Another interesting finding was that the stated reasons for screening in general and the subjective reasons for participation were different. Reassurance was the personal reason most often mentioned in both the serum screening and the ultrasound group. Almost all women had the most superficial knowledge about serum screening; they knew whether it had been offered and that it is done to screen for Down syndrome. The greatest gaps in knowledge concerned the sensitivity of serum screening, its use in screening for congenital nephrosis, and diagnostic tests and their risks. Knowledge was poorer among women without a high school education. When counselling women about prenatal screening tests, more emphasis should be given to the sensitivity of serum screening, all of its screening uses, and the possible diagnostic tests and their risks. The fact that ultrasound screening can detect conditions which may lead to the possibility of a selective abortion should also be explained more fully.

Amniocentesis↗
PubMed2006

Sequential and contingent prenatal screening for Down syndrome.

OBJECTIVE: To compare the Integrated test in three policies for prenatal Down syndrome screening: Integrated screening for all women, sequential screening (first-trimester tests allowing early completion of screening for high-risk pregnancies), and Contingent screening (early completion of screening for high- and low-risk pregnancies). DESIGN AND METHODS: Estimation of detection rates (DRs) and false-positive rates (FPRs) using Monte Carlo simulation and cost effectiveness for each method. SETTING AND POPULATION: Down syndrome affected and unaffected pregnancies studied in the Serum Urine and Ultrasound Screening Study (SURUSS). RESULTS AND MAIN OUTCOMES: Integrated screening has the best screening performance. The performance of the other two policies approached that of Integrated screening as the first-trimester test FPR decreased. If the first-trimester FPR is set to 0.5% (risk >or= 1 in 30) with an overall DR of 90%, sequential and contingent screening yield overall FPRs of 2.25% and 2.42%, respectively, and 66% of the affected pregnancies are detected by the first-trimester test. The Integrated test on all women yields an FPR of 2.15%. With sequential screening, 99.5% of women would proceed to an Integrated test, or 30% with contingent screening if those with first-trimester test risks of <or=1 in 2000 are classified screen-negative and receive no further testing. About 20% of affected pregnancies identified in the first trimester using sequential or contingent screening would have unnecessary terminations (they would miscarry before the early second trimester). Contingent screening is the most cost-effective if there is no alphafetoprotein screening for neural tube defects, otherwise Integrated screening is more cost-effective. CONCLUSIONS: Integrated screening for all women is the simplest, most effective, and the safest policy. Contingent screening is the most complex with the lowest screening performance. Making an earlier diagnosis with sequential and contingent screening has adverse consequences that are sufficient to discourage their use.

Cost-Benefit Analysis↗
PubMed2002

Projected cost-effectiveness of statewide universal newborn hearing screening.

OBJECTIVES: Early identification of hearing impairment may improve language outcomes and subsequent school and occupational performance of the deaf. Universal newborn hearing screening (UNHS), currently mandated by 32 states, can reduce the median age of identification of hearing impairment from 12 to 18 months to 6 months or less. However, because false-negative tests must be minimized, the prevalence of congenital deafness is low, and screening tests are imperfect, UNHS results in many false-positive results and has a low positive predictive value (PPV). The objective of this study was to evaluate UNHS and selective screening in terms of both short- and long-term benefits, harms, and financial costs and to identify steps in the screening process that could be improved to increase cost-effectiveness. METHODS: The cost-effectiveness analysis, conducted from the societal perspective, compared the projected outcomes of 1) no newborn hearing screening, 2) selective newborn hearing screening, and 3) UNHS for a hypothetical state birth cohort of 80 000 infants. Probability and cost estimates for the decision model were obtained from published studies, expert opinion, and national and state sources. The main outcomes were incremental cost per infant whose deafness was diagnosed by 6 months, which included only the cost of screening and diagnostic evaluation; and incremental cost per deaf child with normal language, which also included the costs of medical care, education and assistive devices, and lost productivity over the lifetime of the deaf individual. RESULTS: Selective screening identified 62 of the 128 deaf infants in the birth cohort, referred 0.18% of all infants for diagnostic evaluation, and had a PPV of 43%. UNHS identified 116 of the 128 deaf infants, referred 1.6% of all infants, and had a PPV of 8.8%. Our model simulated real-world conditions in which some infants whose deafness is identified at screening do not receive a definitive diagnosis of being deaf before 6 months; and a portion of deaf and hard-of-hearing infants who 1) have false-negative screening test results, 2) are not screened, or 3) fail the hearing screen but are not immediately followed up with diagnostic evaluation nonetheless receive a diagnosis by 6 months of age. In the absence of newborn hearing screening, approximately 30 deaf infants were identified by 6 months of age by passive detection alone at a cost of $69 000. The selective screening protocol, when compared with no newborn hearing screening, resulted in an additional 36 infants whose deafness was diagnosed by 6 months at an additional cost of approximately $600 000, yielding an incremental cost-effectiveness of approximately $16 000 per additional infant whose deafness was diagnosed by 6 months. Compared with selective screening, the UNHS protocol resulted in 33 additional infants whose deafness was diagnosed by 6 months of age at an additional cost of approximately $1.5 million, yielding an incremental cost-effectiveness of approximately $44 000 per additional infant whose deafness was diagnosed by 6 months of age. Increasing the rate of follow-up to diagnostic evaluation from the base-case estimate of 77% to 100% decreased the incremental cost of UNHS to $38 000 per additional infant whose deafness was diagnosed by 6 months. Under the base-case assumptions about lifetime savings that result from normal language with early intervention, UNHS resulted in normal language achievement for more deaf children and was cost saving in the long term compared with both selective screening and no screening. CONCLUSIONS: The short-term cost-effectiveness of UNHS is comparable to the cost per case diagnosed of other newborn screening programs and could be improved by increasing the rate of follow-up to diagnostic evaluation after positive screening test results. If early identification results in improved language abilities, lower educational and vocational costs, and increased lifetime productivity, then UNHS has the potential for long-term cost savings compared with selective hearing screening and no screening. To understand the actual long-term economic effects of UNHS, better evidence is needed regarding the impact of early intervention on language outcomes and subsequent changes in educational costs and lifetime productivity.

Cohort Studies↗
PubMed1996

Cost-effective policies for cervical cancer screening. An international review.

Screening programmes for cervical cancer have been credited with reducing the incidence of and mortality from cervical cancer. The main components of these screening programmes are: (i) their level of organisation; (ii) the age at which women begin screening; (iii) the age at which women discontinue screening; (iv) the interval between repeat screens; (v) the frequency at which the programmes provide screening; and (vi) the response to an abnormal screening test. However, not all screening programmes are equally efficient and differences in programme components can result in big differences in their cost effectiveness. Studies that employ cost-effectiveness analysis (CEA) to examine the efficiency of different programme components can inform the development of cost-effective programmes. This article presents findings of an international review of cost-effectiveness studies of cervical cancer screening. These studies consistently find that certain types of programmes are more cost effective than others. Programmes that are centrally organised and implemented by the public sector are reported to be more cost effective than those that use public funds for screening at other medical visits (convenience screening), or those that provide guidelines for healthcare professionals and the public to promote spontaneous discretionary screening. There is also substantial agreement about the cost effectiveness of other programme components. When multiple screenings are possible, studies report that they should generally begin at age 25 to 35 years and end at age 65 to 70 years, although it is important that older women have 3 normal Papanicolaou (Pap) smears before the discontinuation of screening. The interval for repeat screens that is reported to provide the best balance between cost and life-years saved is between 3 and 5 years. However, when a choice must be made between screening more women fewer times, or screening fewer women more times, most studies indicate that it is more cost effective to prioritize resources to obtain at least one screening for each woman. The screening of previously unscreened and high-risk populations has been shown to be especially cost effective. Despite this agreement, many studies report that models of the cost effectiveness of screening for cervical cancer are sensitive to a number of parameters. Changes in the attendance rate of the programme, the quality of the Pap smear, and the cost of the Pap smear can markedly change the cost effectiveness of a screening programme. Finally, this review discusses different perspectives of social choice analysis (e.g. CEA and cost-benefit analysis), when the objective is to prevent cervical cancer and the options are to screen, detect and treat, to reduce behavioural risk factors, and/or to pursue promising biological research.

Cost-Benefit Analysis↗
PubMed2005

First-trimester or second-trimester screening, or both, for Down's syndrome.

BACKGROUND: It is uncertain how best to screen pregnant women for the presence of fetal Down's syndrome: to perform first-trimester screening, to perform second-trimester screening, or to use strategies incorporating measurements in both trimesters. METHODS: Women with singleton pregnancies underwent first-trimester combined screening (measurement of nuchal translucency, pregnancy-associated plasma protein A [PAPP-A], and the free beta subunit of human chorionic gonadotropin at 10 weeks 3 days through 13 weeks 6 days of gestation) and second-trimester quadruple screening (measurement of alpha-fetoprotein, total human chorionic gonadotropin, unconjugated estriol, and inhibin A at 15 through 18 weeks of gestation). We compared the results of stepwise sequential screening (risk results provided after each test), fully integrated screening (single risk result provided), and serum integrated screening (identical to fully integrated screening, but without nuchal translucency). RESULTS: First-trimester screening was performed in 38,167 patients; 117 had a fetus with Down's syndrome. At a 5 percent false positive rate, the rates of detection of Down's syndrome were as follows: with first-trimester combined screening, 87 percent, 85 percent, and 82 percent for measurements performed at 11, 12, and 13 weeks, respectively; with second-trimester quadruple screening, 81 percent; with stepwise sequential screening, 95 percent; with serum integrated screening, 88 percent; and with fully integrated screening with first-trimester measurements performed at 11 weeks, 96 percent. Paired comparisons found significant differences between the tests, except for the comparison between serum integrated screening and combined screening. CONCLUSIONS: First-trimester combined screening at 11 weeks of gestation is better than second-trimester quadruple screening but at 13 weeks has results similar to second-trimester quadruple screening. Both stepwise sequential screening and fully integrated screening have high rates of detection of Down's syndrome, with low false positive rates.

Adult↗
PubMed2000

A cost-effectiveness analysis of newborn hearing screening strategies.

CONTEXT: Congenital hearing loss affects between 1 and 3 out of every 1,000 children. Screening of all neonates has been made possible by the development of portable automated devices. Universal screening is a 2-stage screening process using automated transient-evoked otoacoustic emissions, followed when indicated by automated auditory brain response testing. Targeted screening reserves the 2-stage screening process for those infants at risk for congenital hearing loss. OBJECTIVE: To compare the expected costs and benefits of targeted screening with universal screening for the detection of significant bilateral congenital hearing loss. DESIGN: Cost-effectiveness analysis from the health care system perspective. including costs directly related to screening and initial follow-up evaluation. MAIN OUTCOME MEASURES: Number of cases identified, number of false positives, and cost per case. RESULTS: For every 100,000 newborns screened, universal screening detects 86 of 110 cases of congenital hearing loss, at a cost of $11,650 per case identified. Targeted screening identifies 51 of 110 cases, at $3,120 per case identified. Universal screening produces 320 false-positive results, 304 more than targeted screening. Switching to universal screening from targeted screening would cost an additional $23, 930 for each extra case detected. CONCLUSIONS: Universal screening detects more cases of congenital hearing loss, at the expense of both greater cost and more false-positive screening results. Little is known about the negative impact of false-positive screening and about the benefits of early intervention for congenital hearing loss. Those who advocate adoption of universal screening should be aware not only of the direct costs of universal screening, but of the indirect costs and strategies to increase the benefits of screening.

Cost-Benefit Analysis↗
PubMed2002

The impact of organized mammography service screening on breast carcinoma mortality in seven Swedish counties.

BACKGROUND: The evaluation of organized mammographic service screening programs is a major challenge in public health. In particular, there is a need to evaluate the effect of the screening program on the mortality of breast carcinoma, uncontaminated in the screening epoch by mortality from 1) cases diagnosed in the prescreening period and 2) cases diagnosed among unscreened women (i.e., nonattenders) after the initiation of organized screening. METHODS: In the current study, the authors ascertained breast carcinoma deaths in the prescreening and screening epochs in 7 Swedish counties from tumors diagnosed in these epochs and in the age group 40-69 years in 6 counties and 50-69 years in 1 county. Data regarding deaths were obtained from the Uppsala Regional Oncologic Center in conjunction with the National Cause of Death Register. The total number of women in the eligible age range living in each county was obtained from the annual population data of Statistics Sweden. Detailed screening data were provided by the screening centers in the seven counties, including the number of invited, the number attended, and whether each individual breast carcinoma case was exposed (screen-detected and interval cases combined) or unexposed (not-invited or nonattenders) to mammographic screening. There were 2044 breast carcinoma deaths from 14,092 incident tumors diagnosed in the prescreening and screening epochs, and the total number of person-years was 7.5 million. Data were analyzed using Poisson regression with corrections for self-selection bias and lead-time bias when appropriate. RESULTS: The mortality reduction for breast carcinoma in all 7 counties combined for women actually exposed to screening compared with the prescreening period was 44% (relative risk [RR] = 0.56; 95% confidence interval [95% CI], 0.50-0.62). When all incident tumors were considered, both those exposed and those unexposed to screening combined, counties with > 10 years of screening were found to demonstrate a significant 32% mortality reduction (RR = 0.68; 95% CI, 0.60-0.77) and counties with < or = 10 years of screening showed a significant 18% reduction in breast carcinoma mortality (RR = 0.82; 95% CI, 0.72-0.94) for the screening epoch compared with the prescreening epoch. Within the screening epoch, after adjustment for self-selection bias, a 39% mortality reduction (RR = 0.61; 95%CI, 0.55-0.68) was observed in association with invitation to screening. CONCLUSIONS: Organized service screening in 7 Swedish counties, covering approximately 33% of the population of Sweden, resulted in a 40-45% reduction in breast carcinoma mortality among women actually screened. The policy of offering screening is associated with a mortality reduction in breast carcinoma of 30% in the invited population, exposed and unexposed combined. The results of the current study indicate that the majority of the breast carcinoma mortality reduction is indeed due to the screening.

Adult↗
PubMed2002

Skin cancer screening by dermatologists: prevalence and barriers.

BACKGROUND: The incidence of skin cancers is increasing at an alarming rate, and there is currently no consensus by major health policy organizations regarding skin cancer screening. It has previously been shown that primary care physicians do not screen a majority of patients for skin cancer. OBJECTIVE: This study was undertaken to determine the prevalence of skin cancer screening among dermatologists and to detect barriers to screening. As a secondary objective, we set out to determine the prevalence of dermatoscopy use. METHODS: With the use of membership data from the 1999-2000 directory of the American Academy of Dermatology, a random sample of 464 American dermatologists was surveyed to assess their skin cancer screening practices and perceived obstacles to this practice. We then determined whether differences in knowledge of skin cancer screening recommendations, emphasis of skin cancer screening in training, or physician age affected the prevalence of screening. RESULTS: A total of 190 dermatologists responded (41%). Fifty-seven respondents (30%) reported performing full-body skin cancer screening on all of their adult patients and 93 more (49%) reported screening only patients perceived to be at increased risk. Eighty respondents (42%) reported lack of time as an impediment to screening. Only 18 (9%) did not screen patients because of potential patient embarrassment, whereas 17 (9%) did not perform screening because of lack of financial reimbursement. Sixty-two dermatologists (33%) reported being aware of official skin cancer screening recommendations, but they were not more likely to screen all patients (P =.64) or partake in screening of all patients or only those at increased risk (P =.84). One hundred nineteen respondents (63%) reported that skin cancer screening was emphasized during their medical training and they were more likely to screen all patients (P =.04) or either all or high-risk patients (P =.02). Younger age groups of dermatologists were significantly more likely to screen all patients for skin cancer (P =.03). Twenty-two percent of respondents reported using dermatoscopy for suspicious lesions. CONCLUSION: Dermatologists report a high rate of screening for skin cancer despite not having knowledge of skin cancer screening recommendations. Inadequate time to perform full-body skin examinations and lack of emphasis during training were identified as possible barriers to this practice.

Adult↗
PubMed2001

Survey of pediatrician practices in retrieving statewide authorized newborn screening results.

OBJECTIVE: Mandated state newborn screening programs for the approximately 4 million infants born each year in the United States involves the following 5 components: 1) initial screening, 2) immediate follow-up testing of the screen-positive newborn, 3) diagnosis confirmation (true positive versus false positive), 4) immediate and long-term care, and 5) evaluation of all of the components of the system, including process and outcomes measures. Smooth functioning of this system requires pretest education of the parents as well as education and involvement of all health care providers who interact with the newborn screening system. Although extensive literature is available concerning public health aspects, technical standards/protocols, and discussion of the interfaces among the 5 components of the system, little information is available regarding physician awareness, involvement, and interactions with the system. The objective of this study was to determine, through a survey, primary care pediatricians' satisfaction with their state's newborn screening program. This was reflected in survey questions that asked how pediatricians were notified of the results of newborn screening tests that were performed on infants in their practice. METHODS: Two thousand questionnaires were sent to primary care pediatricians in all 50 states and the District of Columbia regarding their practices in retrieving statewide newborn screening results. Of the 2000 surveys, 574 (29%) responses from primary care pediatricians who care for at least 1 to 5 newborns each week form the basis of this report. Also reported are the commentaries of the physicians concerning their specific practices, overall assessment of the system, and ideas for improvement. RESULTS: Physicians reported their general satisfaction with the newborn screening system's ability to retrieve screen-positive infants for follow-up testing. However, communication and partnership with the primary care pediatrician regarding accessibility and timely retrieval of newborn screening test results was deemed less than optimal. Thirty-one percent of respondents indicated that notification for screen-positive test results was greater than 10 days, whereas 26% indicated that they do not receive the results of screen-negative tests and need to develop office procedures (contact birth hospital or state laboratory) to obtain results. Twenty-eight percent indicated that they do not actively seek results of newborn screening for their patients and presume that "no news is good news." Barriers to retrieving test results included that infants were born at hospitals where the physician does not have privileges, there were new transfers to the practice, infants were born in other states, personnel time was needed to track results, and there was a lack of a cohesive communication/reporting system that includes the primary care physician as an integral partner in the newborn screening communication process. Ninety-two percent of physicians would welcome an enhanced state system with direct communication to the primary care pediatrician as well as the birth hospital. CONCLUSION: Pediatricians recognize and endorse the benefits of newborn screening and believe that they play an important role in the efficient functioning of the system. An enhanced physician partnership with the newborn screening program will enable the timely follow-up of the screen-positive newborn for confirmatory testing. All test results need to be communicated to the pediatrician in a timely and efficient manner: 7 days for screen-positive results and 10 to 14 days for all results. Newborn screening test results of new patients who enter the practice should be available at the time of the first well-infant visit, ideally by 2 weeks of age. The majority of primary care pediatricians acknowledge the need to establish office protocols for the retrieval of newborn screening test results and would welcome an enhanced direct communication system with the state newborn screening program.

Attitude of Health Personnel↗
PubMed2005

Newborn screening for congenital heart defects: a systematic review and cost-effectiveness analysis.

OBJECTIVES: To provide evidence to inform policy decisions about the most appropriate newborn screening strategy for congenital heart defects, identifying priorities for future research that might reduce important uncertainties in the evidence base for such decisions. DATA SOURCES: Electronic databases. Groups of parents and health professionals. REVIEW METHODS: A systematic review of the published medical literature concerning outcomes for children with congenital heart defects was carried out. A decision analytic model was developed to assess the cost-effectiveness of alternative screening strategies for congenital heart defects relevant to the UK. A further study was then carried out using a self-administered anonymous questionnaire to explore the perspectives of parents and health professionals towards the quality of life of children with congenital heart defects. The findings from a structured review of the medical literature regarding parental experiences were linked with those from a focus group of parents of children with congenital heart defects. RESULTS: Current newborn screening policy comprises a clinical examination at birth and 6 weeks, with specific cardiac investigations for specified high-risk children. Routine data are lacking, but under half of affected babies, not previously identified antenatally or because of symptoms, are identified by current newborn screening. There is evidence that screen-positive infants do not receive timely management. Pulse oximetry and echocardiography, in addition to clinical examination, are alternative newborn screening strategies but their cost-effectiveness has not been adequately evaluated in a UK setting. In a population of 100,000 live-born infants, the model predicts 121 infants with life-threatening congenital heart defects undiagnosed at screening, of whom 82 (68%) and 83 (69%) are detected by pulse oximetry and screening echocardiography, respectively, but only 39 (32%) by clinical examination alone. Of these, 71, 71 and 34, respectively, receive a timely diagnosis. The model predicts 46 (0.5%) false-positive screening diagnoses per 100,000 infants with clinical examination, 1168 (1.3%) with pulse oximetry and 4857 (5.4%) with screening echocardiography. The latter includes infants with clinically non-significant defects. Total programme costs are predicted of pound 300,000 for clinical examination, pound 480,000 for pulse oximetry and pound 3.54 million for screening echocardiography. The additional cost per additional timely diagnosis of life-threatening congenital heart defects ranges from pound 4900 for pulse oximetry to pound 4.5 million for screening echocardiography. Including clinically significant congenital heart defects gives an additional cost per additional diagnosis of pound 1500 for pulse oximetry and pound 36,000 for screening echocardiography. Key determinants for cost-effectiveness are detection rates for pulse oximetry and screening echocardiography. Parents and health professionals place similar values on the quality of life outcomes of children with congenital heart defects and both are more averse to neurological than to cardiac disability. Adverse psychosocial effects for parents are focused around poor management and/or false test results. CONCLUSIONS: Early detection through newborn screening potentially can improve the outcome of congenital heart defects; however the current programme performs poorly, and lacks monitoring of quality assurance, performance management and longer term outcomes. Pulse oximetry is a promising alternative newborn screening strategy but further evaluation is needed to obtain more precise estimates of test performance and to inform optimal timing, diagnostic and management strategies. Although screening echocardiography is associated with the highest detection rate, it is the most costly strategy and has a 5% false-positive rate. Improving antenatal detection of congenital heart defects increases the cost per timely postnatal diagnosis afforded by any newborn screening strategy but does not alter the relative effects of the strategies. An improvement of timely management of screen positive infants is essential. Further research is required to refine the detection rate and other aspects of pulse oximetry, to evaluate antenatal screening strategies more directly, and to investigate the psychosocial effects of newborn screening for congenital heart defects.

Adolescent↗
PubMed2004

Screening for type 2 diabetes mellitus: a cost-effectiveness analysis.

BACKGROUND: No randomized, controlled trial of screening for diabetes has been conducted. In the absence of direct evidence, cost-effectiveness models may provide guidance about preferred screening strategies. OBJECTIVE: To estimate the incremental cost-effectiveness of 2 diabetes screening strategies: screening targeted to people with hypertension and universal screening. DESIGN: Markov model. DATA SOURCES: United Kingdom Prospective Diabetes Study, Hypertension Optimal Treatment trial, and recent cost data. TARGET POPULATION: General primary care population in the United States. TIME HORIZON: Lifetime. PERSPECTIVE: Health care system. INTERVENTIONS: Diabetes screening targeted to people with hypertension and universal screening. OUTCOME MEASURES: Cost per quality-adjusted life-year (QALY) gained. Costs (in 1997 U.S. dollars) and QALYs discounted at a 3% annual rate. RESULTS OF BASE-CASE ANALYSIS: At all ages, incremental cost-effectiveness ratios were more favorable for screening targeted to people with hypertension than for universal screening. For example, at age 55 years, the cost per QALY for targeted screening compared with no screening was 34,375 dollars, whereas the cost per QALY for universal screening compared with targeted screening was 360,966 dollars. Screening was more cost-effective for ages 55 to 75 years than for younger ages. RESULTS OF SENSITIVITY ANALYSIS: In single-way and probabilistic sensitivity analyses, findings were robust to therapy costs, screening costs, screening lead time, reduced effectiveness of intensive antihypertensive therapy, and increased relative risk reduction for stroke attributable to intensive hypertension control. LIMITATIONS: We did not consider screening targeted to persons with dyslipidemia, and we used studies of people whose diabetes was detected clinically to estimate screening benefits. CONCLUSIONS: Diabetes screening targeted to people with hypertension is more cost-effective than universal screening. The most cost-effective strategy is targeted screening at age 55 to 75 years.

Adult↗