Packaging health services when resources are limited: the example of a cervical cancer screening visit

Implementation research: including breast examinations in a cervical cancer screening programme, Rwanda

Objective

To evaluate whether integrating breast and cervical cancer screening in Rwanda's Women's Cancer Early Detection Program led to early breast cancer diagnoses in asymptomatic women.

Methods

Launched in three districts in 2018-2019, the early detection programme offered clinical breast examination screening for all women receiving cervical cancer screening, and diagnostic breast examination for women with breast cancer symptoms. Women with abnormal breast examinations were referred to district hospitals and then to referral hospitals if needed. We examined how often clinics were held, patient volumes and number of referrals. We also examined intervals between referrals and visits to the next care level and, among women diagnosed with cancer, their initial reasons for seeking care.

Findings

Health centres held clinics > 68% of the weeks. Overall, 9763 women received cervical cancer screening and clinical breast examination and 7616 received breast examination alone. Of 585 women referred from health centres, 436 (74.5%) visited the district hospital after a median of 9 days (interquartile range, IQR: 3-19). Of 200 women referred to referral hospitals, 179 (89.5%) attended after a median of 11 days (IQR: 4-18). Of 29 women diagnosed with breast cancer, 19 were ≥ 50 years and 23 had stage III or stage IV disease. All women with breast cancer whose reasons for seeking care were known (23 women) had experienced breast cancer symptoms.

Conclusion

In the short-term, integrating clinical breast examination with cervical cancer screening was not associated with detection of early-stage breast cancer among asymptomatic women. Priority should be given to encouraging women to seek timely care for symptoms.

Willingness to pay for packaging cancer screening of Chinese rural residents

BACKGROUND

This study examined the acceptance and willingness to pay (WTP) of rural residents toward packaging cancer screening (PCS) to provide a reference basis for promoting the screening sustainable development.

METHODS

A face-to-face questionnaire survey was conducted among rural residents aged 40-69. The combination of double-bounded dichotomous choices and open-ended questions in the Contingent Valuation Method was used to guide participants' WTP. Logistic regression was used to explore the influencing factors of participants' screening acceptance, and Tobit model was used to analyze the associated factors of WTP.

RESULTS

Of the 959 respondents, 89.36% were willing to accept PCS, but 10.64% stated unwillingness for the dominant reason that they did not attend clinics until symptom onset. Willingness to accept screening was significantly associated with region (Dongchangfu, OR = 0.251, 95%CI: 0.113~0.557; Linqu, OR = 0.150, 95%CI: 0.069~0.325), age with 60-69 (OR = 0.321, 95%CI: 0.126~0.816), annual income with 10,000-30,000 (OR = 1.632, 95%CI: 1.003~2.656) and having cancer-screening experience (OR = 0.581, 95%CI: 0.371~0.909). And 57.66% of participants were willing to pay part of the screening cost among those willing to accept PCS. The residents' average WTP was ¥622, accounting for 20.73% of the total cost (¥3000). Willingness to pay for PCS was positively correlated with male gender, self-employed occupation, residence in Feicheng (than Linqu), higher income, and having cancer-screening experience.

CONCLUSIONS

Most rural residents were willing to accept free PCS, more than half of them were willing to pay part of the ¥3000 total cost, but their WTP-values were low. It is necessary to carry out PCS publicity activities to improve public awareness and participation in precancerous screening. Additionally, for expanding the coverage and sustainability of screening, the appropriate proportion of rural residents to pay for screening costs should be controlled at about 20%, and governments, insurance and other sources are encouraged to actively participate to cover the remaining costs.

Accounting for Capacity Constraints in Economic Evaluations of Precision Medicine: A Systematic Review

BACKGROUND AND OBJECTIVE

Precision (stratified or personalised) medicine is underpinned by the premise that it is feasible to identify known heterogeneity using a specific test or algorithm in patient populations and to use this information to guide patient care to improve health and well-being. This study aimed to understand if, and how, previous economic evaluations of precision medicine had taken account of the impact of capacity constraints.

METHODS

A meta-review was conducted of published systematic reviews of economic evaluations of precision medicine (test-treat interventions) and individual studies included in these reviews. Due to the volume of studies identified, a sample of papers published from 2007 to 2015 was collated. A narrative analysis identified whether potential capacity constraints were discussed qualitatively in the studies and, if relevant, which quantitative methods were used to account for capacity constraints.

RESULTS

A total of 45 systematic reviews of economic evaluations of precision medicine were identified, from which 222 studies focusing on test-treat interventions, published between 2007 and 2015, were extracted. Of these studies, 33 (15%) qualitatively discussed the potential impact of capacity constraints, including budget constraints; quality of tests and the testing process; ease of use of tests in clinical practice; and decision uncertainty. Quantitative methods (nine studies) to account for capacity constraints included static methods such as capturing inefficiencies in trials or models and sensitivity analysis around model parameters; and dynamic methods, which allow the impact of capacity constraints on cost effectiveness to change over time.

CONCLUSIONS

Understanding the cost effectiveness of precision medicine is necessary, but not sufficient, evidence for its successful implementation. There are currently few examples of evaluations that have quantified the impact of capacity constraints, which suggests an area of focus for future research.

Extended Cost-Effectiveness Analysis for Health Policy Assessment: A Tutorial

Health policy instruments such as the public financing of health technologies (e.g., new drugs, vaccines) entail consequences in multiple domains. Fundamentally, public health policies aim at increasing the uptake of effective and efficient interventions and at subsequently leading to better health benefits (e.g., premature mortality and morbidity averted). In addition, public health policies can provide non-health benefits in addition to the sole well-being of populations and beyond the health sector. For instance, public policies such as social and health insurance programs can prevent illness-related impoverishment and procure financial risk protection. Furthermore, public policies can improve the distribution of health in the population and promote the equalization of health among individuals. Extended cost-effectiveness analysis was developed to address health policy assessment, specifically to evaluate the health and financial consequences of public policies in four domains: (1) the health gains; (2) the financial risk protection benefits; (3) the total costs to the policy makers; and (4) the distributional benefits. Here, we present a tutorial that describes both the intent of extended cost-effectiveness analysis and its keys to allow easy implementation for health policy assessment.

Moving toward comprehensive acute heart failure risk assessment in the emergency department: the importance of self-care and shared decision making

Nearly 700,000 emergency department (ED) visits were due to acute heart failure (AHF) in 2009. Most visits result in a hospital admission and account for the largest proportion of a projected $70 billion to be spent on heart failure care by 2030. ED-based risk prediction tools in AHF rarely impact disposition decision making. This is a major factor contributing to the 80% admission rate for ED patients with AHF, which has remained unchanged over the last several years. Self-care behaviors such as symptom monitoring, medication taking, dietary adherence, and exercise have been associated with decreased hospital readmissions, yet self-care remains largely unaddressed in ED patients with AHF and thus represents a significant lost opportunity to improve patient care and decrease ED visits and hospitalizations. Furthermore, shared decision making encourages collaborative interaction between patients, caregivers, and providers to drive a care path based on mutual agreement. The observation that “difficult decisions now will simplify difficult decisions later” has particular relevance to the ED, given this is the venue for many such issues. We hypothesize patients as complex and heterogeneous as ED patients with AHF may need both an objective evaluation of physiologic risk as well as an evaluation of barriers to ideal self-care, along with strategies to overcome these barriers. Combining physician gestalt, physiologic risk prediction instruments, an evaluation of self-care, and an information exchange between patient and provider using shared decision making may provide the critical inertia necessary to discharge patients home after a brief ED evaluation.

Shared decision making: examining key elements and barriers to adoption into routine clinical practice

For many patients, the time spent meeting with their physician-the clinical encounter-is the most opportune moment for them to become engaged in their own health through the process of shared decision making. In the United States shared decision making is being promoted for its potential to improve the health of populations and individual patients, while also helping control care costs. In this overview we describe the three essential elements of shared decision making: recognizing and acknowledging that a decision is required; knowing and understanding the best available evidence; and incorporating the patient's values and preferences into the decision. To achieve the promise of shared decision making, more physicians need training in the approach, and more practices need to be reorganized around the principles of patient engagement. Additional research is also needed to identify the interventions that are most effective.

Exploiting biospectroscopy as a novel screening tool for cervical cancer: towards a framework to validate its accuracy in a routine clinical setting

Biospectroscopy is an emerging field that harnesses the platform of physical sciences with computational analysis in order to shed novel insights on biological questions. An area where this approach seems to have potential is in screening or diagnostic clinical settings, where there is an urgent need for new approaches to objectively interrogate large numbers of samples in an objective fashion with acceptable levels of sensitivity and specificity. This review outlines the benefits of biospectroscopy in screening for precancer lesions of the cervix due to its ability to separate different grades of dysplasia. It evaluates the feasibility of introducing this technique into cervical screening programs on the basis of its ability to identify biomarkers of progression within derived spectra (‘biochemical‑cell fingerprints’).

Using HPV vaccination for promotion of an adolescent package of care: opportunity and perspectives

Background

Adolescents are a difficult population to access for preventive health care, particularly in less resourced countries. Evidence from developed countries indicates that the HPV vaccine schedule may be a useful platform from which to deliver other adolescent health care services. We conducted a qualitative cross sectional study to assess the potential for using the HPV vaccine in the South African public health care system as an opportunity for integrated health care services for adolescents.

Methods

Parents, young adolescents, community members and key informants participated in interviews and focus group discussions about feasibility and acceptability, particularly the use of the HPV vaccination as the basis for an integrated adolescent package of care. Health care providers in both provinces participated in focus group discussions and completed a pairwise ranking exercise to compare and prioritise interventions for inclusion in an adolescent package of care.

Results

Participants were in favour of integration and showed preference for detailed information about the HPV vaccine, general health information and specific sexual and reproductive health information. Among health care workers, results differed markedly by location. In North West, prioritisation was given to information, screening and referral for tobacco and alcohol abuse, and screening for hearing and vision. In Gauteng integration with referral for male circumcision, and information, screening and referral for child abuse were ranked most highly.

Conclusions

There is generally support for the delivery of adolescent preventive health services. Despite national priorities to address adolescent health needs, our data suggest that national policies might not always be appropriate for vastly different local situations. While decisions about interventions to include have traditionally been made at country level, our results suggest that local context needs to be taken account of. We suggest low resource strategies for ensuring that national policies are introduced at local level in a manner that addresses local priorities, context and resource availability.

Trends in cervical cancer screening in developing countries

Developing countries suffer the highest burden of cervical cancers but have the lowest resources. Effective cervical cytology screening programme, along with a network of diagnostic and therapeutic colposcopy centres, like developed countries, is almost impossible to be reproduced in developing countries. Visual inspection methods [e.g., Visual inspection with Lugol’s iodine (VILI) and Visual Inspection with Acetic Acid (VIA)] which are cheaper, require less expertise and have the advantage of possible treatment in one setting have been shown to be effective alternatives. The sensitivity to detect CIN2+, by VIA and VILI, have been shown to be 80% and 91% respectively, with a specificity rate of 92% and 85% respectively. Screening by human papillomavirus (HPV) testing has high sensitivity (96.4%) but low specificity (94.1%) to detect CIN2+, when compared to Pap Smear (sensitivity, 55.4% and specificity, 96.8%). A single lifetime HPV testing in a large unscreened population has been shown to significantly reduce cervical cancer incidence and mortality when compared to cervical cytology, VIA or no screening. HPV testing of self-collected vaginal specimens also helps to overcome religious and socio-cultural barriers towards pelvic examination amongst women in developing countries. Current HPV testing methods are expensive, skill/infrastructure demanding and takes time to produce results. A cheaper HPV test, called careHPV™, which is able to provide results within 2.5 h and requires minimal skill/infrastructure to operate, was designed for use in developing countries. One stop screen and treat facilities using VIA or rapid HPV testing, and cryotherapy, can overcome non-compliance to follow-up which is a major issue in developing countries. Cure rates of 81.4% for CIN1, 71.4% for CIN2 and 68.0% for CIN3 at 6 mo after treatment have been reported. Incorporating telemedicine with cervicography of VIA or VILI or even telecolposcopy, has great potential in cervical cancer screening, especially in countries with vast geographical areas.

White paper report of the 2011 RAD-AID Conference on International Radiology for Developing Countries: integrating multidisciplinary strategies for imaging services in the developing world

The 2011 RAD-AID Conference on International Radiology for Developing Countries discussed data, experiences, and models pertaining to radiology in the developing world, where widespread shortages of imaging services significantly reduce health care quality and increase health care disparities. This white paper from the 2011 RAD-AID conference represents consensus advocacy of multidisciplinary strategies to improve the planning, accessibility, and quality of imaging services in the developing world. Conference presenters and participants discussed numerous solutions to imaging and health care disparities, including (1) economic development for radiologic service planning, (2) public health mechanisms to address disease and prevention at the population and community levels, (3) comparative clinical models to implement various clinical and workflow strategies adapted to unique developing world community contexts, (4) education to improve training and optimize service quality, and (5) technology innovation to bring new technical capabilities to limited-resource regions.

Heterogeneity in breast and cervical cancer screening practices among female Hispanic immigrants in the United States

This study examined differences in cervical and breast cancer (CC and BC) screening among a heterogeneous group of Hispanic women. Data from 247 women (mean age = 38.7 ± 13.3) from Mexico, the Dominican Republic, Puerto Rico, and countries throughout Central and South America regarding participation in Pap smears, mammography, clinical breast exam (CBE) and breast self-exams (BSE), CC and BC knowledge, and acculturation were analyzed. Differences in CBE and BSE screening behaviors were found based on country of origin (P < .01). However, after adjusting for the independent variables, only acculturation and knowledge remained significant correlates to BSE and CBE (P < .01). Dominican women had higher BC knowledge scores (P < .01) adhered most to BC screening guidelines. Heterogeneity in BC and CC screening was found among Hispanic sub-groups and suggests that health promotion programs should be tailored appropriately, particularly among recent immigrants.

SOGC–GOC–SCC Joint Policy Statement. No. 255, March 2011. Cervical cancer prevention in low-resource settings

OBJECTIVE

To help care providers understand the current status of cervical cancer in low-resource countries.

OPTIONS

The most effective and practical options for cervical screening and treatment in low-resource countries are evaluated.

OUTCOMES

Improvement in rates of prevention and early detection of cervical cancer in low-resource countries.

EVIDENCE

PubMed or Medline, CINAHL, and The Cochrane Library were searched for studies published in English between January 2006 and December 2009. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table). RECOMMENDATIONS 1. All girls 9 years old or over should have access to the cervical cancer vaccine before they become sexually active. (I-A) 2. Cervical cancer screening by visual inspection with acetic acid is suggested for low-resource settings acceptable. Cervical cytology or human papillomavirus testing may also be used when practical. (II-2B) 3. Cryotherapy is a safe, effective, and low-cost therapy that should be included in pre-invasive cervical cancer treatment. (III-B) 4. All countries should have a documented cervical cancer prevention strategy that includes public education built on existing outreach programs. (III-C) 5. Countries should define a centre or centres of excellence for the management of cervical cancer. (III-C) Because these units would serve a larger population, they would be able to identify leaders and develop their skills, and would be able to invest in costly radiation equipment. 6. All women with cervical cancer should have access to pain management. (III-C).

Meeting global health challenges through operational research and management science

This paper considers how operational research and management science can improve the design of health systems and the delivery of health care, particularly in low-resource settings. It identifies some gaps in the way operational research is typically used in global health and proposes steps to bridge them. It then outlines some analytical tools of operational research and management science and illustrates how their use can inform some typical design and delivery challenges in global health. The paper concludes by considering factors that will increase and improve the contribution of operational research and management science to global health.

Improving Breast Cancer Control via the Use of Community Health Workers in South Africa: A Critical Review

Breast cancer is a growing concern in low- and middle-income countries (LMCs). We explore community health worker (CHW) programs and describe their potential use in LMCs. We use South Africa as an example of how CHWs could improve access to breast health care because of its middle-income status, existing cancer centers, and history of CHW programs. CHWs could assume three main roles along the cancer control continuum: health education, screening, and patient navigation. By raising awareness about breast cancer through education, women are more likely to undergo screening. Many more women can be screened resulting in earlier-stage disease if CHWs are trained to perform clinical breast exams. As patient navigators, CHWs can guide women through the screening and treatment process. It is suggested that these roles be combined within existing CHW programs to maximize resources and improve breast cancer outcomes in LMCs.

Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions

OBJECTIVE

To update a systematic review on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals.

METHODS

From March to December 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched. Studies were included if they reported on health professionals' perceived barriers and facilitators to implementing shared decision-making in practice. Quality of the included studies was assessed. Content analysis was performed with a pre-established taxonomy.

RESULTS

Out of 1130 titles, 10 new eligible studies were identified for a total of 38 included studies compared to 28 in the previous version. The vast majority of participants (n=3231) were physicians (89%). The three most often reported barriers were: time constraints (22/38) and lack of applicability due to patient characteristics (18/38) and the clinical situation (16/38). The three most often reported facilitators were: provider motivation (23/38) and positive impact on the clinical process (16/38) and patient outcomes (16/38).

CONCLUSION

This systematic review update confirms the results of the original review.

PRACTICE IMPLICATIONS

Interventions to foster implementation of shared decision-making in clinical practice will need to address a range of factors.

Breast cancer screening policies in developing countries: a cost-effectiveness analysis for India

BACKGROUND

India, the largest developing country, has a steadily rising incidence of breast cancer. Estimates and comparisons of the cost-effectiveness of feasible breast cancer screening policies in developing countries and identification of the determinants of cost and efficacy are needed.

METHODS

A Microsimulation Screening Analysis model of breast cancer was calibrated to available data on breast cancer incidence, stage distribution, and mortality in India. The model was used to estimate the costs of screening for breast cancer in India, its effects on mortality, and its cost-effectiveness (ie, costs of screening per life-year gained or life saved). Screening using clinical breast examination (CBE) or mammography among different age groups and at various frequencies was analyzed. Costs were expressed in international dollars (Int.$), the currency used by the World Health Organization, which has the same purchasing power in India as the US dollar has in the United States. To determine which factors influenced cost-effectiveness, sensitivity analyses were performed.

RESULTS

The estimated mortality reduction was the greatest for programs targeting women between age 40 and 60 years. Using a 3% discount rate, a single CBE at age 50 had an estimated cost-effectiveness ratio of Int.$793 per life year gained and a breast cancer mortality reduction of 2%. The cost-effectiveness ratio increased to Int.$1135 per life year gained for every-5-year CBE (age 40-60 years) and to Int.$1341 for biennial CBE (age 40-60 years); the corresponding reductions in breast cancer mortality were 8.2% and 16.3%, respectively. CBE performed annually from ages 40 to 60 was predicted to be nearly as efficacious as biennial mammography screening for reducing breast cancer mortality while incurring only half the net costs. The main factors affecting cost-effectiveness were breast cancer incidence, stage distribution, and cost savings on prevented palliative care.

CONCLUSION

The estimated cost-effectiveness of CBE screening for breast cancer in India compares favorably with that of mammography in developed countries. However, in view of competing priorities and economic conditions, the introduction of screening in India represents a greater challenge than it has been in more developed countries.