Are interventions to increase the uptake of screening for cardiovascular disease risk factors effective? A systematic review and meta-analysis

Changes in Health Care Access and Preventive Health Screenings by Race and Ethnicity

Importance

The COVID-19 pandemic led to unprecedented disruptions in health care. Little is known about whether health care access and preventive health screenings among US adults have recovered to prepandemic levels, and how patterns varied by race and ethnicity.

Objective

To evaluate health care access and preventive health screenings among eligible US adults in 2021 and 2022 compared with prepandemic year 2019, overall and by race and ethnicity.

Design, Setting, and Participants

This cross-sectional study used data from US adults aged 18 years or older who participated in the National Health Interview Survey in 2021 and 2022. Survey weights provided by the National Health Interview Survey were used to generate nationally representative estimates. Data were analyzed from May 23 to November 13, 2023.

Main Outcomes and Measures

Measures of health care access included the proportion of adults with a usual place for care, those with a wellness visit, and those who delayed or did not receive medical care due to cost within the past year. Preventive health screening measures included eligible adults who received blood pressure, cholesterol, or blood glucose screening within the past year (2021), as well as colorectal, cervical, breast, and prostate cancer screenings based on US Preventive Services Task Force guidelines.

Results

The unweighted study population included 89 130 US adults. The weighted population included 51.6% females; 16.8% Hispanic, 5.9% non-Hispanic Asian (hereafter, Asian), 11.8% non-Hispanic Black (hereafter, Black), 62.8% non-Hispanic White (hereafter, White) individuals; and 2.9% individuals of other races and ethnicities (including American Indian, Alaska Native, Native Hawaiian or other Pacific Islander, or multiracial). After adjusting for age and sex, having a usual place for health care did not differ among adults in 2021 or 2022 vs 2019 (adjusted rate ratio [ARR] for each year, 1.00; 95% CI, 0.99-1.01). However, fewer participants had wellness visits in 2022 compared with 2019 (ARR, 0.98; 95% CI, 0.97-0.99), with the most pronounced decline among Asian adults (ARR, 0.95; 95% CI, 0.92-0.98). In addition, adults were less likely to delay medical care (ARR, 0.79; 95% CI, 0.73-0.87) or to not receive care (ARR, 0.76; 95% CI, 0.69-0.83) due to cost in 2022 vs 2019. Preventive health screenings in 2021 remained below 2019 levels (blood pressure: ARR, 0.95 [95% CI, 0.94-0.96]; blood glucose: ARR, 0.95 [95% CI, 0.93-0.96]; and cholesterol: ARR, 0.93 [95% CI, 0.92-0.94]). Eligible adults were also significantly less likely to receive colorectal cancer screening (ARR, 0.88; 95% CI, 0.81-0.94), cervical cancer screening (ARR, 0.86; 95% CI, 0.83-0.89), breast cancer screening (ARR, 0.93; 95% CI, 0.90-0.97), and prostate cancer screening (ARR, 0.86 [0.78-0.94]) in 2021 vs 2019. Asian adults experienced the largest relative decreases across most preventive screenings, while Black and Hispanic adults experienced large declines in colorectal cancer screening (ARR, 0.78; 95% CI, 0.67-0.91) and breast cancer screening (ARR, 0.83; 95% CI, 0.75-0.91), respectively. Differences in preventive screening rates across years persisted after additional adjustment for socioeconomic factors (income, employment status, and insurance coverage).

Conclusions and Relevance

Results of this cohort study suggest that, in the US, wellness visits and preventive health screenings have not returned to prepandemic levels. These findings support the need for public health efforts to increase the use of preventive health screenings among eligible US adults.

Factors predicting participation and potential yield of screening-detected disease among non-participants in a Swedish population-based atrial fibrillation screening study

BACKGROUND

The success of any screening program is dependent on participation. The characteristics of participants vs. non-participants have been studied and non-participants usually have a higher risk of disease. The potential yield of screening-detected disease in non-participants could be of interest to several screening programs.

AIMS

This is a sub-study to STROKESTOP II, a Swedish atrial fibrillation screening study. The aim was to study factors predicting participation and to estimate the potential yield of screening-detected disease in non-participants.

METHODS

Individual, anonymized data for participants and non-participants with respect to socioeconomic factors, medical history and drugs dispensed were obtained from Swedish registries. A random forest model was trained to predict propensity scores for participation. The propensity scores were used to estimate potential screening-detected disease among non-participants.

RESULTS

Non-participants (n = 7086) had lower income, were more likely to have been hospitalized and had higher CHA₂DS₂-VASc scores compared to participants (n = 6868). The strongest factor predicting non-attendance was low income. The weighted estimates suggested that the yield of new atrial fibrillation was 2.4% in non-participants compared to 2.3% in the participants, which was not significant.

CONCLUSIONS

Non-participants had higher CHA₂DS₂-VASc scores, indicating a higher stroke-risk and presumable benefit from attending screening, although estimated new atrial fibrillation detected was not significantly more common when compared to participants. Low income was the strongest factor for predicting non-attendance and should be a focus area when planning future screening scenarios.

Gender gap in annual preventive care services in France

BACKGROUND

In France, screening for cardiovascular risk factors is recommended during annual preventive visits. However, data are lacking on the temporal trend in women's uptake to preventive care services, and in cardiovascular and mortality outcomes. The aim of the study was to investigate the participation and mortality of women in annual preventive care services in a major preventive medicine center in France.

METHOD

Ee conducted repeated cross-sectional studies including a total of 366,270 individuals who had a first examination at the Centre d'Investigations Préventives et Cliniques, France, between January 1992 and December 2011.

FINDINGS

Women's participation was low below 50 years of age, then increases from 50 to 70 years, and is lower for women older than 70 years. The gap in female participation was more pronounced among individuals with high education, low social deprivation, and no depressive symptoms. Compared with the general population, the screened population had significantly lower standardized mortality ratios (SMRs) among both men and women, for all age ranges. Screened women aged 18-49 years showed a lower mortality gain compared with men of the same age; SMRs did not differ significantly by sex for individuals over 50 years.

INTERPRETATION

In this community-based sample, compared with men, women's participation to annual preventive care services was lower, and screened women had a lower mortality gain. Despite the demonstrated benefit of annual check-ups on health, there is a gender gap in adherence to preventive programs and in efficiency of screening programs, especially in the young age range. This gap in cardiovascular disease prevention may result in poorer cardiovascular health in women. Urgent adaptations to overcome this gender gap in preventive screening in France are warranted.

FUNDING

Bamba Gaye is supported by the Fondation Recherche Médicale grant.

Effectiveness of an Out-of-Pocket Cost Removal Intervention on Health Check Attendance in Japan

Annual health checks are important for identifying individuals at high risk for cardiometabolic diseases. However, there are socioeconomic disparities in health check attendance rates, and an intervention to lower financial barriers could be useful for increasing health check utilization. In this study, we aimed to evaluate the effectiveness of an out-of-pocket cost removal intervention on health check attendance in Japan. Data were obtained on beneficiaries of the National Health Insurance system of Yokohama City, Kanagawa Prefecture, Japan. In 2018, Yokohama started an intervention to remove out-of-pocket costs for specific health checks for all National Health Insurance beneficiaries. We analyzed data from 2015-2018 (131,295 people aged 40-74 years; 377,660 observations). A generalized estimating equation showed that people were more likely to receive specific health checks in 2018 (after the out-of-pocket cost removal intervention started) than in 2017 (immediately before the intervention; odds ratio [95% confidence interval] = 1.167 [1.149-1.185]), after adjusting for age, gender, tax exemption, and residential area. Stratified analyses revealed that the effectiveness of the out-of-pocket cost removal intervention was greater among the older age group and those who did not receive a tax exemption (i.e., those with relatively higher income). The present study showed that the out-of-pocket cost removal intervention could promote specific health check utilization. This indicates that removing financial barriers could motivate people's behavior regarding health check attendance.

Characteristics and motives of non-responders in a stepwise cardiometabolic disease prevention program in primary care

BACKGROUND

A high response rate is an important condition for effective prevention programs. We aimed at gaining insight into the characteristics and motives of non-responders in different stages of a stepwise prevention program for cardiometabolic diseases (CMD) in primary care.

METHODS

We performed a non-response analysis within a randomized controlled trial assessing the effectiveness of a stepwise CMD prevention program in the Netherlands. Patients between 45 and 70 years without known CMD were invited for stage 1 of the program, completing a CMD risk score. Patients with an increased risk were advised to visit their general practice for additional measurements, stage 2 of the program. We analyzed determinants of non-response using data from the risk score, electronic medical records, questionnaires and Statistics Netherlands.

RESULTS

Non-response in stage 1 was associated with a younger age, male sex, a migration background, a low prosperity score, self-employment, being single and having lower consultations rates in general practice. Non-response in stage 2 was associated with a low prosperity score, being employed, having no chronic illness, smoking, a normal waist circumference, a negative family history for cardiovascular disease or diabetes and having a lower consultation rate. More than half of the non-responders in stage 2 reported not visiting the GP because they did not expect to have any CMD, despite their increased risk.

CONCLUSIONS

To achieve a larger and more equal uptake of prevention programs for CMD, we should use methods adapted to characteristics of non-responders, such as targeted invitation methods and improved risk communication.

Modelling tool to support decision-making in the NHS Health Check programme: workshops, systematic review and co-production with users

BACKGROUND

Local authorities in England commission the NHS Health Check programme to invite everyone aged 40-74 years without pre-existing conditions for risk assessment and eventual intervention, if needed. However, the programme's effectiveness, cost-effectiveness and equity impact remain uncertain.

AIM

To develop a validated open-access flexible web-based model that enables local commissioners to quantify the cost-effectiveness and potential for equitable population health gain of the NHS Health Check programme.

OBJECTIVES

The objectives were as follows: (1) co-produce with stakeholders the desirable features of the user-friendly model; (2) update the evidence base to support model and scenario development; (3) further develop our computational model to allow for developments and changes to the NHS Health Check programme and the diseases it addresses; (4) assess the effectiveness, cost-effectiveness and equity of alternative strategies for implementation to illustrate the use of the tool; and (5) propose a sustainability and implementation plan to deploy our user-friendly computational model at the local level.

DESIGN

Co-production workshops surveying the best-performing local authorities and a systematic literature review of strategies to increase uptake of screening programmes informed model use and development. We then co-produced the workHORSE (working Health Outcomes Research Simulation Environment) model to estimate the health, economic and equity impact of different NHS Health Check programme implementations, using illustrative-use cases.

SETTING

Local authorities in England.

PARTICIPANTS

Stakeholders from local authorities, Public Health England, the NHS, the British Heart Foundation, academia and other organisations participated in the workshops. For the local authorities survey, we invited 16 of the best-performing local authorities in England.

INTERVENTIONS

The user interface allows users to vary key parameters that represent programme activities (i.e. invitation, uptake, prescriptions and referrals). Scenarios can be compared with each other.

MAIN OUTCOME MEASURES

Disease cases and case-years prevented or postponed, incremental cost-effectiveness ratios, net monetary benefit and change in slope index of inequality.

RESULTS

The survey of best-performing local authorities revealed a diversity of effective approaches to maximise the coverage and uptake of NHS Health Check programme, with no distinct 'best buy'. The umbrella literature review identified a range of effective single interventions. However, these generally need to be combined to maximally improve uptake and health gains. A validated dynamic, stochastic microsimulation model, built on robust epidemiology, enabled service options analysis. Analyses of three contrasting illustrative cases estimated the health, economic and equity impact of optimising the Health Checks, and the added value of obtaining detailed local data. Optimising the programme in Liverpool can become cost-effective and equitable, but simply changing the invitation method will require other programme changes to improve its performance. Detailed data inputs can benefit local analysis.

LIMITATIONS

Although the approach is extremely flexible, it is complex and requires substantial amounts of data, alongside expertise to both maintain and run.

CONCLUSIONS

Our project showed that the workHORSE model could be used to estimate the health, economic and equity impact comprehensively at local authority level. It has the potential for further development as a commissioning tool and to stimulate broader discussions on the role of these tools in real-world decision-making.

FUTURE WORK

Future work should focus on improving user interactions with the model, modelling simulation standards, and adapting workHORSE for evaluation, design and implementation support.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019132087.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 35. See the NIHR Journals Library website for further project information.

Invitations and incentives: a qualitative study of behavioral nudges for primary care screenings in Armenia

BACKGROUND

Non-communicable diseases account for a growing proportion of deaths in Armenia, which require early detection to achieve disease control and prevent complications. To increase rates of screening, demand-side interventions of personalized invitations, descriptive social norms, labeled cash transfers, and conditional cash transfers were tested in a field experiment. Our complementary qualitative study explores factors leading to the decision to attend screening and following through with that decision, and experiences with different intervention components.

METHODS

Informed by the Health Belief Model as our conceptual framework, we collected eighty in-depth interviews with service users and twenty service providers and analyzed them using open coding and thematic analysis.

RESULTS

An individual's decision to screen depends on 1) the perceived need for screening based on how they value their own health and perceive hypertension and diabetes as a harmful but manageable condition, and 2) the perceived utility of a facility-based screening, and whether screening will provide useful information on disease status or care management and is socially acceptable. Following through with the decision to screen depends on their knowledge of and ability to attend screenings, as well as any external motivators such as an invitation or financial incentive.

CONCLUSIONS

Personalized invitations from physicians can prompt individuals to reconsider their need for screening and can, along with financial incentives, motivate individuals to follow through with the decision to screen. The effect of descriptive social norms in invitations should be further studied. Efforts to increase preventive screenings as an entry point into primary care in Armenia may benefit from implementation of tailored messages and financial incentives.

TRIAL REGISTRATION

The protocol was approved on January 11, 2019 by the Institutional Review Board of the Center of Medical Genetics and Primary Health Care in Armenia (02570094). https://www.socialscienceregistry.org/trials/3776 .

Feasibility and success rates of response enhancing strategies in a stepwise prevention program for cardiometabolic diseases in primary care

Background

Prevention programs for cardiometabolic diseases (CMD), including cardiovascular disease, diabetes mellitus and chronic kidney disease are feasible, but evidence for the cost-effectiveness of selective CMD prevention programs is lacking. Response rates have an important role in effectiveness, but methods to increase response rates have received insufficient attention. The aim of the current study is to determine the feasibility and the success rate of a variety of response enhancing strategies to increase the participation in a selective prevention program for CMD.

Methods

The INTEGRATE study is a Dutch randomised controlled trial to assess the effectiveness and cost-effectiveness of a stepwise program for CMD prevention. During the INTEGRATE study we developed ten different response enhancing strategies targeted at different stages of non-response and different patient populations and evaluated these in 29 general practices.

Results

A face-to-face reminder by the GP increased the response significantly. Digital reminders targeted at patients with an increased CMD risk showed a positive trend towards participation. Sending invitations and reminders by e-mail generated similar response rates, but at lower costs and time investment than the standard way of dissemination. Translated materials, information gatherings at the practice, self-management toolkits, reminders by telephone, information letters, local media attention and SMS text reminders did not increase the response to our program.

Conclusions

Inviting or reminding patients by e-mail or during GPs consultation may enhance response rates in a selective prevention program for CMD. Different response-enhancing strategies have different patient target populations and implementation issues, therefore practice characteristics need to be taken into account when implementing such strategies.

Trial registration

Dutch trial Register number NTR4277. Registered 26 November 2013.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12875-020-01293-9.

Gender differences in factors influencing intention to undergo cardiovascular disease health checks: A cross-sectional survey

Background

Undergo a health check for cardiovascular disease (CVD) is an important strategy to improve cardiovascular (CV) health. Men are reported to be less likely to undergo cardiovascular disease (CVD) health check than women. Gender difference could be one of the factors influencing health seeking behaviour of men and women. We aimed to identify gender differences in factors influencing the intention to undergo CVD health checks.

Methods

This was a cross-sectional survey using mall intercept interviews. Malaysians aged ≥30 years without known CVD were recruited. They were asked for their intention to undergo CVD health checks and associated factors. The factors included seven internal factors that were related to individuals’ attitude, perception and preparedness for CVD health checks and two external factors that were related to external resources. Hierarchical ordinal regression analysis was used to evaluate the importance of the factors on intention to undergo CVD health checks, for men and women separately.

Results

397 participants were recruited, 60% were women. For men, internal factors explained 31.6% of the variances in likeliness and 9.6% of the timeline to undergo CVD health checks, with 1.2% and 1.8% added respectively when external factors were sequentially included. For women, internal factors explained 18.9% and 22.1% of the variances, with 3.1% and 4.2% added with inclusion of the external factors. In men, perceived drawbacks of health checks was a significant negative factor associated with likeliness to undergo CVD health checks (coefficient = -1.093; 95%CI:-1.592 to -0.594), and timeline for checks (coefficient = -0.533; 95%CI:-0.975 to -0.091). In women, readiness to handle outcomes following health checks was significantly associated with likeliness to undergo the checks (coefficient = 0.575; 95%CI: 0.063 to 1.087), and timeline for checks (coefficient = 0.645; 95%CI: 0.162 to 1.128). Both external factors 1) influence by significant others (coefficient = 0.406; 95%CI: 0.013 to 0.800) and 2) external barriers (coefficient = -0.440; 95%CI:-0.869 to -0.011) were also significantly associated with likeliness to undergo CVD health checks in women.

Conclusions

Both men and women were influenced by internal factors in their intention to undergo CVD health checks, and women were also influenced by external factors. Interventions to encourage CVD health checks need to focus on internal factors and be gender sensitive.

Transforming Screening Uptake in Low-resource and Underinformed Populations: A Preliminary Study of Factors Influencing Women's Decisions to Uptake Screening

OBJECTIVES

The objective of this study was to assess the factors influencing women's decision to uptake screening mammography in an underinformed population.

STUDY DESIGN

The study is a cross-sectional survey of factors influencing screening uptake.

METHODS

A modified breast cancer awareness measure was used to assess women's knowledge of breast cancer, mammography, and factors that influence screening uptake. A second questionnaire investigated health professionals' (HPs') attitude to screening and the criteria for screening recommendation. Descriptive statistics were used to assess women's breast cancer awareness, factors that influence screening uptake, and HPs' attitude to breast cancer education and mammography recommendation. We ranked HPs' responses pertaining to criteria for screening recommendation using a Kendall's W test.

RESULTS

Sixty-nine percent (n = 180) of women were aware of breast cancer, and half of them had performed breast self-examination (n = 131). About 53% (n = 138) of women were not aware of mammography, and only 15.4% (n = 40) of them have had a screening mammogram. Women's awareness of breast cancer risk factors and symptoms was poor. Many women would consider having a screening mammogram if instructed to do so by their husbands (87.7%; n = 228), HPs (96.2%; n = 250), and if government-funded screening programmes are available (90%; n = 234). Less than 40% (n = 21) of HPs had referred at least one woman for screening mammography within the last 6 months. Family history, age, and reproductive factors ranked as the highest criteria for screening recommendation.

CONCLUSIONS

Spouses and HPs may be crucial to changing the current status quo around screening utilisation and government-funded screening programmes may increase screening uptake.

Do Non-participants at Screening have a Different Threshold for an Acceptable Benefit-Harm Ratio than Participants? Results of a Discrete Choice Experiment

OBJECTIVE

The objective of the study was to investigate non-participants' preferences for cardiovascular disease screening programme characteristics and whether non-participation can be rationally explained by differences in preferences, decision-making styles and informational needs between non-participants and participants.

METHODS

We conducted a discrete choice experiment at three screening sites between June and December 2017 among 371 male non-participants and 830 male participants who were asked to trade different levels of five key programme characteristics (chance of health benefit, risk of overtreatment, risk of later regret, screening duration and screening location). Data were analysed using a multinomial mixed-logit model. Health benefit was used as a payment vehicle for estimation of marginal substitution rates.

RESULTS

Non-participants were willing to accept that 0.127 (95% confidence interval 0.103-0.154) fewer lives would be saved to avoid overtreatment of one individual, whilst participants were willing to accept 0.085 (95% confidence interval 0.077-0.094) fewer lives saved. This translates into non-participants valuing health benefits 7.9 times higher than overtreatment. The corresponding value of participants is 11.8. Similarly, non-participants had higher requirements than participants for advanced technology and a quicker screening duration. With regard to their participation decision, 64% of the non-participants felt certain about their choice compared with 89% among participants.

CONCLUSIONS

This study shows that non-participants have different preferences than participants at screening as they express relatively more concern about overtreatment and have higher requirements for a high-tech screening programme. Non-participants also report to be more uncertain about their participation decision and more often seek additional information to the standard information provided in the invitation letter. Further studies on informational needs and effective communication strategies are warranted to ensure that non-participation is a fully informed choice.

What are the determinants for individuals to undergo cardiovascular disease health checks? A cross sectional survey

BACKGROUND

There is a need to improve public's participation in health checks for early identification of individuals at high risk of CVD for prevention. The objective of this study is to identify significant determinants associated with individuals' intention to undergo CVD health checks. These determinants could be used to develop effective strategies to improve CVD health check participation.

METHODS

This was a cross sectional survey using mall intercept interviews. It was carried out in a hypermarket surrounded by housing estates with a population of varying socioeconomic backgrounds. Inclusion criteria were Malaysian nationality and age 30 years and older. The validated CVD health check questionnaire was used to assess participants' intention and the determinants that influenced their intention to undergo CVD health checks.

RESULTS

A total of 413 participants were recruited. The median age of the participants was 45 years (IQR 17 years) and 60% of them were female. Participants indicated they were likely (45.0%) or very likely (38.7%) to undergo CVD health checks while 16.2% were not sure, unlikely or very unlikely to undergo health checks. Using ordinal regression analysis, perception of benefits, drawbacks of CVD health checks, perception of external barriers and readiness to handle outcomes following CVD health checks were the significant determinants of individuals' intention to undergo CVD health checks.

CONCLUSIONS

To improve individuals' participation in CVD health checks, we need to develop strategies to address their perception of benefits and drawbacks of CVD health checks, the perceived external barriers and their readiness to handle outcomes following CVD health checks.