Cost of care for the initial management of cervical cancer in women with commercial insurance

Non-use and inadequate use of cervical cancer screening among a representative sample of women in the United States

Introduction

Women's adherence to the United States (U.S.) Preventive Services Task Force guidelines for cervical cancer screening was determined by examining predisposing, enabling, and needs factors from Andersen's Behavioral Model of Health Services Use conceptual framework.

Methods

The outcome was operationalized as cervical cancer screening use, non-use, and inadequate-use. Multinomial logistic regression was conducted on data from the 2019 National Health Interview Survey of 7,331 eligible women aged 21-65.

Results

Compared with women who used cervical cancer screening services, women aged 30-65 were less likely to be Non-Users than those aged 21-29. Hispanic, Asian, and American Indian/Alaska Native (AIAN) women were more likely to be Non-Users than White women. More educated women were less likely to be Non-Users. Foreign-born women <10 years in the U.S. were more likely to be Non-Users than U.S.-born women. Women with financial hardship were less likely to be Non-Users. Poorer women and uninsured women were more likely to be Non-Users. Women with children in their household were less likely to be Non-Users than those without children. Women who had a well-visit in the past year were less likely to be Non-Users. Women with a history of human papillomavirus (HPV) vaccination were less likely to be Non-Users. Compared with women who used cervical cancer screening services, women aged 30-65 were less likely to be Inadequate-Users. AIAN women were more likely to be Inadequate-Users. Women of other races were less likely to be Inadequate-Users. Employed women were less likely to be Inadequate-Users. Uninsured women were more likely to be Inadequate-Users. Women who had a well-visit within a year were less likely to be Inadequate-Users. Women with past HPV vaccination were more likely to be Inadequate-Users. Smokers were less likely to be Inadequate-Users.

Discussion

Predisposing, enabling, and needs factors are differently associated with non-use and inadequate use of cervical cancer screening. Understanding factors associated with the use, non-use, and inadequate use of cervical cancer screening is crucial to avoid or curb unnecessary tests, increased costs to both society and individuals, and the ill-allocation of limited resources.

Reallocating Cervical Cancer Preventive Service Spending from Low- to High-Value Clinical Scenarios

Timely follow-up care after an abnormal cervical cancer screening test result is critical to the prevention and early diagnosis of cervical cancer. The current inadequate and inequitable delivery of these potentially life-saving services is attributed to several factors, including patient out-of-pocket costs. Waiving of consumer cost-sharing for follow-up testing (e.g., colposcopy and related cervical services) is likely to improve access and uptake, especially among underserved populations. One approach to defray the incremental costs of providing more generous coverage for follow-up testing is reducing expenditures on "low-value" cervical cancer screening services. To explore the potential fiscal implications of a policy that redirects cervical cancer screening resources from potentially low- to high-value clinical scenarios, we analyzed 2019 claims from the Virginia All-Payer Claims Database to quantify (i) total spending on low-value cervical cancer screening and (ii) out-of-pocket costs associated with colposcopy and related cervical services among commercially insured Virginians. In a cohort of 1,806,921 female patients (ages 48.1 ± 24.8 years), 295,193 claims for cervical cancer screening were reported, 100,567 (34.0%) of which were determined to be low-value ($4,394,361 total; $4,172,777 for payers and $221,584 out-of-pocket [$2/patient]). Claims for 52,369 colposcopy and related cervical services were reported ($40,994,016 total; $33,457,518 for payers and $7,536,498 out-of-pocket [$144/patient]). These findings suggest that reallocating savings incurred from unnecessary spending to fund more generous coverage of necessary follow-up care is a feasible approach to enhancing cervical cancer prevention equity and outcomes.

PREVENTION RELEVANCE

Out-of-pocket fees are a barrier to follow-up care after an abnormal cervical cancer screening test. Among commercially insured Virginians, out-of-pocket costs for follow-up services averaged $144/patient; 34% of cervical cancer screenings were classified as low value. Reallocating low-value cervical cancer screening expenditures to enhance coverage for follow-up care can improve screening outcomes. See related Spotlight, p. 363.

Racial disparities in diagnostic evaluation of uterine cancer among Medicaid beneficiaries

BACKGROUND

To inform reasons contributing to Black-White disparity in early diagnosis of uterine cancer, we compared the quality of diagnostic evaluation received by Black vs White patients with abnormal uterine bleeding (AUB) ultimately diagnosed with uterine cancer.

METHODS

Using 2008-2019 MarketScan Multi-State Medicaid Database, we identified Black (n = 858) and White (n = 1749) patients with uterine cancer presenting with AUB. Quality of diagnostic evaluation was measured by delayed diagnosis (>1 year after AUB reporting), not receiving guideline-recommended diagnostic procedures, delayed time to first diagnostic procedure (>2 months after AUB reporting), number of diagnostic procedures received, and number of evaluation and management visits for AUB. The association between race and quality indicators was examined by multivariable regressions adjusting for patient characteristics.

RESULTS

Black patients were more likely than White patients to experience delayed diagnosis (11.3% vs 8.3%, P = .01; adjusted odds ratio [OR] = 1.71, 95% confidence interval [CI] = 1.27 to 2.29) or to not receive guideline-recommended diagnostic procedures (10.1% vs 5.0%, P < .001; adjusted OR = 1.94, 95% CI = 1.40 to 2.68). Even when they did receive recommended diagnostic procedures, Black patients were more likely than White patients to experience delay in time to the first diagnostic procedure (adjusted OR = 1.46, 95% CI = 1.09 to 1.97). In addition, Black patients underwent more evaluation and management visits for AUB before getting diagnosed compared with White patients (adjusted mean ratio = 1.13, 95% CI = 1.04 to 1.23).

CONCLUSIONS

Black and White patients with uterine cancer differed in the quality of diagnostic evaluation received. Improving equity in this area may help reduce Black-White disparity in stage at diagnosis.

Insurance status and access to cervical cancer treatment in a specialized cancer center in Mexico

To describe access to complete treatment in women with cervical cancer and state-sponsored insurance versus no insurance. We conducted a retrospective observational study. The source population consisted of women treated for cervical cancer from January 2000 to December 2015 in a tertiary care hospital. We included 411 women with state-sponsored insurance and 400 without insurance. We defined access to cervical cancer treatment as complete treatment (according NCCN/ESMO (National Comprehensive Cancer Network/European Society for Medical Oncology) standards) and timely initiation of treatment (less than 4 weeks). Clinical and sociodemographic characteristics were described and analyzed with logistic regression using complete treatment as the main outcome. A total of 811 subjects were included, the median age was 46 (IQR (Interquartile range) 42-50) years. Most of them were married (36.1%), unemployed (50.4%), and had completed primary school (44.0%). The most common clinical stages at diagnosis were II (38.2%) and III (24.7%). In the adjusted regression model, being married (OR (odds ratio): 4.3, 95% CI (confidence interval): 1.74-10.61) and having paid employment (OR: 2.79, 95% CI: 1.59-4.90) or state-sponsored insurance (OR: 1.54, 95% CI: 1.04-2.26) were positively associated with the possibility of having a complete treatment. Women with insurance were likely to be younger and receive timely treatment compared with uninsured women. Complete treatment was associated to insurance status and advanced stages of cervical cancer. State-sponsored insurance improves access to complete treatment. Government policies are needed to avoid social and economic inequity and provide better management of cervical cancer in our country.

Health care personnel's perspectives on human papillomavirus (HPV) self-sampling for cervical cancer screening: a pre-implementation, qualitative study

BACKGROUND

Persistent infection with high-risk human papillomavirus (hrHPV) types is a well-documented cause of cervical cancer. Since the implementation of cervical cancer screening methods (e.g., Pap tests), cervical cancer rates have declined. However, Pap tests are still unacceptable to many women and require complex infrastructure and training. Self-sampling techniques for collecting HPV specimens (or "HPV self-sampling") have been proposed as a possible alternative to overcome these barriers. The objective of this study was to capture perspectives from health care personnel (providers, leaders, and clinic staff) across primary care systems on the potential implementation of an HPV self-sampling practice.

METHODS

Between May and July 2021, a study invitation was emailed to various health care professional networks across the Midwest, including a snowball sampling of these networks. Eligible participants were invited to a 45-60-min Zoom-recorded interview session and asked to complete a pre-interview survey. The survey collected sociodemographics on age, occupation, level of educational attainment, race/ethnicity, gender, and awareness of HPV self-sampling. The semi-structured interview was guided by the Consolidated Framework for Implementation Research and asked participants about their views on HPV self-sampling and its potential implementation. All interviews were audio-recorded, transcribed, and analyzed using NVivo 12.

RESULTS

Key informant interviews were conducted with thirty health care personnel-13 health care providers, 6 clinic staff, and 11 health care leaders-from various health care systems. Most participants had not heard of HPV self-sampling but reported a general enthusiasm for wanting to implement it as an alternative cervical cancer screening tool. Possible barriers to implementation were knowledge of clinical evidence and ease of integration into existing clinic workflows. Potential facilitators included the previous adoption of similar self-sampling tools (e.g., stool-based testing kits) and key decision-makers.

CONCLUSION

Although support for HPV self-sampling is growing, its intervention's characteristics (e.g., advantages, adaptability) and the evidence of its clinical efficacy and feasibility need to be better disseminated across US primary care settings and its potential adopters. Future research is also needed to support the integration of HPV self-sampling within various delivery modalities (mail-based vs. clinic-based).

Phase-specific and lifetime economic burden of cervical cancer and endometrial cancer in a commercially insured United States population

AIM

To estimate the incremental phase-specific and lifetime economic burden among newly diagnosed cervical and endometrial cancer patients vs. non-cancer controls.

METHODS

Cervical and endometrial cancer patients newly diagnosed between January 2015 and June 2018 were identified in the Optum Clinformatics DataMart database. The index date was the date of the first diagnosis for cancer cases and the first claim date after 12 months of continuous enrollment for non-cancer controls. Patients were followed until death/loss of enrollment/end of data availability. Per patient per month (PPPM) costs attributable to cancer were calculated for four phases: pre-diagnosis (3 months before diagnosis), initial (6 months post-diagnosis), terminal (6 months pre-death), and continuation (remaining time between initial and terminal phases). Survival data were obtained to determine the monthly proportion of patients in each phase. Total survival adjusted monthly costs were obtained by multiplying the proportion of patients in each phase by the total cost incurred during that month. Phase-specific and lifetime incremental costs of cervical and endometrial cancer were obtained using generalized linear models.

RESULTS

The analytic cohort included 1,002 cervical cancer patients and 4,005 matched non-cancer controls and 5,003 endometrial cancer patients matched with 19,999 non-cancer controls. Mean adjusted incremental PPPM lifetime costs (95% CI) for cervical cancer and endometrial cancer cases were $5,910 ($5,373-$6,446) and $3,475 ($3,259-$3,691), respectively. Incremental total PPPM phase-specific costs attributable to cervical and endometrial cancer were pre-diagnosis (cervical: $1,057; endometrial: $3,315), initial ($12,084; $8,618), continuation ($2,732; $1,147), and terminal ($2,702; $5,442). Incremental costs were significantly higher for cancer patients vs. non-cancer controls across patient lifetime and all phases of care (except terminal phase costs for cervical cancer). Outpatient costs were the major driver of costs across all post-diagnosis phases.

CONCLUSION

This study highlights the cost burden associated with cervical/endometrial cancer and cost variation by phases of care.