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Morrish N, Snowsill T, Dodman S, Medina-Lara A. Preferences for Genetic Testing to Predict the Risk of Developing Hereditary Cancer: A Systematic Review of Discrete Choice Experiments. Med Decis Making 2024; 44:252-268. [PMID: 38323553 PMCID: PMC10988993 DOI: 10.1177/0272989x241227425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 01/03/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Understanding service user preferences is key to effective health care decision making and efficient resource allocation. It is of particular importance in the management of high-risk patients in whom predictive genetic testing can alter health outcomes. PURPOSE This review aims to identify the relative importance and willingness to pay for attributes of genetic testing in hereditary cancer syndromes. DATA SOURCES Searches were conducted in Medline, Embase, PsycINFO, HMIC, Web of Science, and EconLit using discrete choice experiment (DCE) terms combined with terms related to hereditary cancer syndromes, malignancy synonyms, and genetic testing. STUDY SELECTION Following independent screening by 3 reviewers, 7 studies fulfilled the inclusion criteria, being a DCE investigating patient or public preferences related to predictive genetic testing for hereditary cancer syndromes. DATA EXTRACTION Extracted data included study and respondent characteristics, DCE attributes and levels, methods of data analysis and interpretation, and key study findings. DATA SYNTHESIS Studies covered colorectal, breast, and ovarian cancer syndromes. Results were summarized in a narrative synthesis and the quality assessed using the Lancsar and Louviere framework. LIMITATIONS This review focuses only on DCE design and testing for hereditary cancer syndromes rather than other complex diseases. Challenges also arose from heterogeneity in attributes and levels. CONCLUSIONS Test effectiveness and detection rates were consistently important to respondents and thus should be prioritized by policy makers. Accuracy, cost, and wait time, while also important, showed variation between studies, although overall reduction in cost may improve uptake. Patients and the public would be willing to pay for improved detection and clinician over insurance provider involvement. Future studies should seek to contextualize findings by considering the impact of sociodemographic characteristics, health system coverage, and insurance policies on preferences. HIGHLIGHTS Test effectiveness and detection rates are consistently important to respondents in genetic testing for hereditary cancer syndromes.Reducing the cost of genetic testing for hereditary cancer syndromes may improve uptake.Individuals are most willing to pay for a test that improves detection rates, identifies multiple cancers, and for which results are shared with a doctor rather than with an insurance provider.
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Affiliation(s)
- N. Morrish
- Public Health Economics Group, Department of Public Health and Sport Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - T. Snowsill
- Health Economics Group, Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | | | - A. Medina-Lara
- Public Health Economics Group, Department of Public Health and Sport Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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Allen MJ, Doran R, Brain D, Powell EE, O'Beirne J, Valery PC, Barnett A, Hettiarachchi R, Hickman IJ, Kularatna S. A discrete choice experiment to elicit preferences for a liver screening programme in Queensland, Australia: a mixed methods study to select attributes and levels. BMC Health Serv Res 2023; 23:950. [PMID: 37670274 PMCID: PMC10481473 DOI: 10.1186/s12913-023-09934-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 08/17/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND In Australia, the overall prevalence of liver disease is increasing. Maximising uptake of community screening programmes by understanding patient preferences is integral to developing consumer-centred care models for liver disease. Discrete choice experiments (DCEs) are widely used to elicit preferences for various healthcare services. Attribute development is a vital component of a well-designed DCE and should be described in sufficient detail for others to assess the validity of outcomes. Hence, this study aimed to create a list of potential attributes and levels which can be used in a DCE study to elicit preferences for chronic liver disease screening programmes. METHODS Key attributes were developed through a multi-stage, mixed methods design. Focus groups were held with consumers and health care providers on attributes of community screening programmes for liver disease. Stakeholders then prioritised attributes generated from the focus group in order of importance via an online prioritisation survey. The outcomes of the prioritisation exercise were then reviewed and refined by an expert panel to ensure clinically meaningful levels and relevance for a DCE survey. RESULTS Fifteen attributes were generated during the focus group sessions deemed necessary to design liver disease screening services. Outcomes of the prioritisation exercise and expert panel stages recognised five attributes, with three levels each, for inclusion in a DCE survey to elicit consumer preferences for community screening for liver disease. This study also highlights broader social issues such as the stigma around liver disease that require careful consideration by policy makers when designing or implementing a liver screening programme. CONCLUSIONS The attributes and levels identified will inform future DCE surveys to understand consumer preferences for community screening programmes for liver disease. In addition, the outcomes will help inform the implementation of the LOCATE-NAFLD programme in real-world practice, and could be relevant for other liver and non-liver related chronic disease screening programmes.
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Affiliation(s)
- Michelle J Allen
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia.
| | - Rachael Doran
- Department of Economics and Related Studies, University of York, York, UK
| | - David Brain
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Elizabeth E Powell
- The University of Queensland, St Lucia, QLD, Australia
- Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - James O'Beirne
- University of the Sunshine Coast, Maroochydore DC, QLD, Australia
- Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | | | - Adrian Barnett
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | | | - Ingrid J Hickman
- The University of Queensland, St Lucia, QLD, Australia
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
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Diedrich L, Brinkmann M, Dreier M, Rossol S, Schramm W, Krauth C. Is there a place for sigmoidoscopy in colorectal cancer screening? A systematic review and critical appraisal of cost-effectiveness models. PLoS One 2023; 18:e0290353. [PMID: 37594967 PMCID: PMC10438011 DOI: 10.1371/journal.pone.0290353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/05/2023] [Indexed: 08/20/2023] Open
Abstract
INTRODUCTION Screening for colorectal cancer (CRC) is effective in reducing both incidence and mortality. Colonoscopy and stool tests are most frequently used for this purpose. Sigmoidoscopy is an alternative screening measure with a strong evidence base. Due to its distinct characteristics, it might be preferred by subgroups. The aim of this systematic review is to analyze the cost-effectiveness of sigmoidoscopy for CRC screening compared to other screening methods and to identify influencing parameters. METHODS A systematic literature search for the time frame 01/2010-01/2023 was conducted using the databases MEDLINE, Embase, EconLit, Web of Science, NHS EED, as well as the Cost-Effectiveness Registry. Full economic analyses examining sigmoidoscopy as a screening measure for the general population at average risk for CRC were included. Incremental cost-effectiveness ratios were calculated. All included studies were critically assessed based on a questionnaire for modelling studies. RESULTS Twenty-five studies are included in the review. Compared to no screening, sigmoidoscopy is a cost-effective screening strategy for CRC. When modelled as a single measure strategy, sigmoidoscopy is mostly dominated by colonoscopy or modern stool tests. When combined with annual stool testing, sigmoidoscopy in 5-year intervals is more effective and less costly than the respective strategies alone. The results of the studies are influenced by varying assumptions on adherence, costs, and test characteristics. CONCLUSION The combination of sigmoidoscopy and stool testing represents a cost-effective screening strategy that has not received much attention in current guidelines. Further research is needed that goes beyond a narrow focus on screening technology and models different, preference-based participation behavior in subgroups.
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Affiliation(s)
- Leonie Diedrich
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Melanie Brinkmann
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Maren Dreier
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Siegbert Rossol
- Department of Internal Medicine, Krankenhaus Nordwest, Frankfurt/M, Germany
| | - Wendelin Schramm
- GECKO Institute for Medicine, Informatics and Economics, Heilbronn University, Heilbronn, Germany
| | - Christian Krauth
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
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Brinkmann M, Diedrich L, Hemmerling M, Krauth C, Robra BP, Stahmeyer JT, Dreier M. Heterogeneous Preferences for Colorectal Cancer Screening in Germany: Results of a Discrete Choice Experiment. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:104-114. [PMID: 36031478 DOI: 10.1016/j.jval.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 07/06/2022] [Accepted: 07/13/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Colorectal cancer (CRC) screening tests differ in benefits, harms, and processes, making individual informed decisions preference based. The objective was to analyze the preferences of insurees in Germany for characteristics of CRC screening modalities. METHODS A generic discrete choice experiment with 2-alternative choice sets and 6 attributes (CRC mortality, CRC incidence, complications, preparation, need for transportation, and follow-up; 3 levels each) depicting characteristics of fecal testing, sigmoidoscopy, and colonoscopy was generated. Participants completed 8 choice tasks. Internal validity was tested using a within-set dominated pair. Between June and October 2020, written questionnaires were sent to a stratified random sample (n = 5000) of 50-, 55-, and 60-year-old insurees of the AOK (Allgemeine Ortskrankenkasse) Lower Saxony, who had previously received an invitation to participate in the organized screening program including evidence-based information. Preferences were analyzed using conditional logit, mixed logit, and latent-class model. RESULTS From 1282 questionnaires received (26% [1282 of 4945]), 1142 were included in the analysis. Approximately 42% of the respondents chose the dominated alternative in the internal validity test. Three heterogeneous preference classes were identified. Most important attributes were preparation (class 1; n = 505, 44%), CRC mortality (class 2; n = 347, 30%), and CRC incidence (class 3; n = 290, 25%). Contrary to a priori expectations, a higher effort was preferred for bowel cleansing (class 1) and accompaniment home (classes 1 and 2). CONCLUSION Internal validity issues of choice data need further research and warrant attention in future discrete choice experiment surveys. The observed preference heterogeneity suggests different informational needs, although the underlying reasons remained unclear.
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Affiliation(s)
- Melanie Brinkmann
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany.
| | - Leonie Diedrich
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | | | - Christian Krauth
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Bernt-Peter Robra
- Institute of Social Medicine and Health Systems Research, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Jona T Stahmeyer
- Health Services Research Unit, AOK Niedersachsen, Hannover, Germany
| | - Maren Dreier
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
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Brinkmann M, Fricke LM, Diedrich L, Robra BP, Krauth C, Dreier M. Attributes in stated preference elicitation studies on colorectal cancer screening and their relative importance for decision-making among screenees: a systematic review. HEALTH ECONOMICS REVIEW 2022; 12:49. [PMID: 36136248 PMCID: PMC9494881 DOI: 10.1186/s13561-022-00394-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 09/07/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION The SIGMO study (Sigmoidoscopy as an evidence-based colorectal cancer screening test - a possible option?) examines screening eligible populations' preferences for colorectal cancer (CRC) screening in Germany using a discrete choice experiment (DCE). Attribute identification and selection are essential for the construction of choice tasks and should be evidence-based. As a part of the SIGMO study this systematic review provides an overview of attributes included in studies eliciting stated preferences for CRC screening tests and their relative importance for decision-making. METHODS Systematic search (November 2021) for English-language studies published since January 2000 in PubMed, Embase, Web of Science, Biomedical Reference Collection: Corporate Edition, LIVIVO and PsycINFO. DCEs and conjoint analysis ranking or rating tasks on screening eligible populations' preferences for stool testing, sigmoidoscopy, and/or colonoscopy were included. Attributes were extracted and their relative importance was calculated and ranked. Risk of bias (RoB) of included studies was assessed using a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Study selection and RoB rating were carried out independently by two reviewers. Data were extracted by one reviewer and checked by another one. RESULTS A total of 23 publications on 22 studies were included. Overall RoB was rated as serious/critical for 21 studies and as moderate for 2 studies. Main reasons for high RoB were non-random sampling, low response rates, lack of non-responder analyses, and, to a lesser extent, weaknesses in the measurement instrument and data analysis. Extracted attributes (n = 120) referred to procedure-related characteristics (n = 42; 35%), structural characteristics of health care (n = 24; 20%), test characteristics (n = 23; 19%), harms (n = 16; 13%), benefits (n = 13; 11%), and level of evidence (n = 2; 2%). Most important attributes were reduction in CRC mortality (and incidence) (n = 7), test sensitivity (n = 7), out-of-pocket costs (n = 4), procedure (n = 3), and frequency (n = 2). CONCLUSIONS Health preference studies on CRC were found to have a high RoB. The composition of choice tasks revealed a lack of attributes on patient-important outcomes (like incidence reduction), while attributes not considered relevant for individual screening decisions (like sensitivity) were frequently used. Future studies eliciting stated preferences in cancer screening should apply the principles of informed decision-making in attribute identification and selection.
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Affiliation(s)
- Melanie Brinkmann
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany.
| | - Lara Marleen Fricke
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Leonie Diedrich
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Bernt-Peter Robra
- Institute of Social Medicine and Health Systems Research, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Christian Krauth
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Maren Dreier
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
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Methodology to derive preference for health screening programmes using discrete choice experiments: a scoping review. BMC Health Serv Res 2022; 22:1079. [PMID: 36002895 PMCID: PMC9400308 DOI: 10.1186/s12913-022-08464-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 08/08/2022] [Indexed: 12/18/2022] Open
Abstract
Background While involving users in healthcare decision-making has become increasingly common and important, there is a lack of knowledge about how to best design community-based health screening programs. Reviews of methods that incorporate discrete choice experiments (DCEs) are scarce, particularly for non-cancer illnesses like cardiovascular disease, diabetes and liver disease. We provide an overview of currently available applications and methods available by using DCEs in health screening programs, for chronic conditions. Methods A scoping review was undertaken, where four electronic databases were searched for key terms to identify eligible DCE studies related to community health screening. We included studies that met a pre-determined criteria, including being published between 2011 and 2021, in English and reported findings on human participants. Data were systematically extracted, tabulated, and summarised in a narrative review. Results A total of 27 studies that used a DCE to elicit preferences for cancer (n = 26) and cardiovascular disease screening (n = 1) programmes were included in the final analysis. All studies were assessed for quality, against a list of 13 criteria, with the median score being 9/13 (range 5–12). Across the 27 studies, the majority (80%) had the same overall scores. Two-thirds of included studies reported a sample size calculation, approximately half (13/27) administered the survey completely online and over 75% used the general public as the participating population. Conclusion Our review has led to highlighting several areas of current practice that can be improved, particularly greater use of sample size calculations, increased use of qualitative methods, better explanation of the chosen experimental design including how choice sets are generated, and methods for analysis. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08464-7.
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Fazeli S, Covarrubias Y, Bassirian S, Cuevas J, Fowler K, Vodkin I, Kono Y, Marks R, Loomba R, Taouli B, Sirlin C, Carlos R. Eliciting Patient Preferences for Hepatocellular Carcinoma Screening: A Choice-Based Conjoint Analysis. J Am Coll Radiol 2022; 19:502-512. [DOI: 10.1016/j.jacr.2022.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/04/2022] [Accepted: 01/04/2022] [Indexed: 12/22/2022]
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Conjoint Analysis: A Research Method to Study Patients’ Preferences and Personalize Care. J Pers Med 2022; 12:jpm12020274. [PMID: 35207762 PMCID: PMC8879380 DOI: 10.3390/jpm12020274] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/29/2022] [Accepted: 02/10/2022] [Indexed: 02/01/2023] Open
Abstract
This article aims to describe the conjoint analysis (CA) method and its application in healthcare settings, and to provide researchers with a brief guide to conduct a conjoint study. CA is a method for eliciting patients’ preferences that offers choices similar to those in the real world and allows researchers to quantify these preferences. To identify literature related to conjoint analysis, a comprehensive search of PubMed (MEDLINE), EMBASE, Web of Science, and Google Scholar was conducted without language or date restrictions. To identify the trend of publications and citations in conjoint analysis, an online search of all databases indexed in the Web of Science Core Collection was conducted on the 8th of December 2021 without time restriction. Searching key terms covered a wide range of synonyms related to conjoint analysis. The search field was limited to the title, and no language or date limitations were applied. The number of published documents related to CA was nearly 900 during the year 2021 and the total number of citations for CA documents was approximately 20,000 citations, which certainly shows that the popularity of CA is increasing, especially in the healthcare sciences services discipline, which is in the top five fields publishing CA documents. However, there are some limitations regarding the appropriate sample size, quality assessment tool, and external validity of CA.
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Diedrich L, Brinkmann M, Dreier M, Schramm W, Krauth C. Additional offer of sigmoidoscopy in colorectal cancer screening in Germany: rationale and protocol of the decision-analytic modelling approach in the SIGMO study. BMJ Open 2022; 12:e050698. [PMID: 34992106 PMCID: PMC8739067 DOI: 10.1136/bmjopen-2021-050698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION In Germany, statutory insured persons are entitled to a stool test (faecal immunochemical test (FIT)) or colonoscopy for colorectal cancer (CRC) screening, depending on age and sex, yet participation rates are rather low. Sigmoidoscopy is a currently not available screening measure that has a strong evidence base for incidence and mortality reduction. Due to its distinct characteristics, it might be preferred by some, who now reject colonoscopy. The objective of this study is to estimate the economic consequences of the additional offer of sigmoidoscopy for CRC screening in Germany compared with the present screening practice while considering the preferences of the general population. METHODS AND ANALYSIS A decision-analytic modelling approach will be developed that compares the present CRC screening programme in Germany (FIT, colonoscopy) with a programme extended by sigmoidoscopy from a societal perspective. A decision tree and Markov model will be combined to assess both short-term and long-term effects, such as CRC and adenoma detection rates, the number of CRC cases, CRC mortality as well as complications. The incremental cost per quality-adjusted life year gained for each alternative will be calculated. The model will incorporate the general population's preferences based on a discrete choice experiment. Further, input parameters will be taken from the literature, the German cancer registry and health insurance claims data. ETHICS AND DISSEMINATION Ethical approval for the study was obtained from the Ethics Committee of Hannover Medical School (ID: 8671_BO_K_2019). The findings of the study will be published in peer-reviewed journals and presented at national and/or international conferences. TRIAL REGISTRATION NUMBER DRKS00019010.
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Affiliation(s)
- Leonie Diedrich
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Melanie Brinkmann
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Maren Dreier
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Wendelin Schramm
- GECKO Institute for Medicine, Informatics and Economics, Heilbronn University, Heilbronn, Baden-Württemberg, Germany
| | - Christian Krauth
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Niedersachsen, Germany
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Zhao Z, Du L, Wang L, Wang Y, Yang Y, Dong H. Preferred Lung Cancer Screening Modalities in China: A Discrete Choice Experiment. Cancers (Basel) 2021; 13:6110. [PMID: 34885217 PMCID: PMC8656503 DOI: 10.3390/cancers13236110] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 11/17/2022] Open
Abstract
This study aimed to identify preferred lung cancer screening modalities in a Chinese population and predict uptake rates of different modalities. A discrete choice experiment questionnaire was administered to 392 Chinese individuals aged 50-74 years who were at high risk for lung cancer. Each choice set had two lung screening options and an option to opt-out, and respondents were asked to choose the most preferred one. Both mixed logit analysis and stepwise logistic analysis were conducted to explore whether preferences were related to respondent characteristics and identify which kinds of respondents were more likely to opt out of any screening. On mixed logit analysis, attributes that were predictive of choice at 1% level of statistical significance included the screening interval, screening venue, and out-of-pocket costs. The preferred screening modality seemed to be screening by low-dose computed tomography (LDCT) + blood test once a year in a general hospital at a cost of RMB 50; this could increase the uptake rate by 0.40 compared to the baseline setting. On stepwise logistic regression, those with no endowment insurance were more likely to opt out; those who were older and housewives/househusbands, and those with a health check habit and with commercial endowment insurance were less likely to opt out from a screening programme. There was considerable variance between real risk and self-perceived risk of lung cancer among respondents. Lung cancer screening uptake can be increased by offering various screening modalities, so as to help policymakers further design the screening modality.
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Affiliation(s)
- Zixuan Zhao
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou 310058, China; (Z.Z.); (Y.Y.)
| | - Lingbin Du
- Department of Cancer Prevention, Institute of Cancer and Basic Medicine, Chinese Academy of Sciences, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (L.D.); (L.W.); (Y.W.)
| | - Le Wang
- Department of Cancer Prevention, Institute of Cancer and Basic Medicine, Chinese Academy of Sciences, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (L.D.); (L.W.); (Y.W.)
| | - Youqing Wang
- Department of Cancer Prevention, Institute of Cancer and Basic Medicine, Chinese Academy of Sciences, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (L.D.); (L.W.); (Y.W.)
| | - Yi Yang
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou 310058, China; (Z.Z.); (Y.Y.)
| | - Hengjin Dong
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou 310058, China; (Z.Z.); (Y.Y.)
- The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu 322000, China
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Hall R, Medina-Lara A, Hamilton W, Spencer AE. Attributes Used for Cancer Screening Discrete Choice Experiments: A Systematic Review. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 15:269-285. [PMID: 34671946 DOI: 10.1007/s40271-021-00559-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/26/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Evidence from discrete choice experiments can be used to enrich understanding of preferences, inform the (re)design of screening programmes and/or improve communication within public campaigns about the benefits and harms of screening. However, reviews of screening discrete choice experiments highlight significant discrepancies between stated choices and real choices, particularly regarding willingness to undergo cancer screening. The identification and selection of attributes and associated levels is a fundamental component of designing a discrete choice experiment. Misspecification or misinterpretation of attributes may lead to non-compensatory behaviours, attribute non-attendance and responses that lack external validity. OBJECTIVES We aimed to synthesise evidence on attribute development, alongside an in-depth review of included attributes and methodological challenges, to provide a resource for researchers undertaking future studies in cancer screening. METHODS A systematic review was conducted to identify discrete choice experiments estimating preferences towards cancer screening, dated between 1990 and December 2020. Data were synthesised narratively. In-depth analysis of attributes led to classification into four categories: test specific, service delivery, outcomes and monetary. Attribute significance and relative importance were also analysed. The International Society for Pharmacoeconomics and Outcomes Research conjoint analysis checklist was used to assess the quality of reporting. RESULTS Forty-nine studies were included at full text. They covered a range of cancer sites: over half (26/49) examined colorectal screening. Most studies elicited general public preferences (34/49). In total, 280 attributes were included, 90% (252/280) of which were significant. Overall, test sensitivity and mortality reduction were most frequently found to be the most important to respondents. CONCLUSIONS Improvements in reporting the identification, selection and construction of attributes used within cancer screening discrete choice experiments are needed. This review also highlights the importance of considering the complexity of choice tasks when considering risk information or compound attributes. Patient and public involvement and stakeholder engagement are recommended to optimise understanding of unavoidably complex choice tasks throughout the design process. To ensure quality and maximise comparability across studies, further research is needed to develop a risk-of-bias measure for discrete choice experiments.
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Affiliation(s)
- Rebekah Hall
- College of Medicine and Health, University of Exeter, South Cloisters, St Luke's Campus, Heavitree, Exeter, EX1 2LU, UK.
| | - Antonieta Medina-Lara
- College of Medicine and Health, University of Exeter, South Cloisters, St Luke's Campus, Heavitree, Exeter, EX1 2LU, UK
| | - Willie Hamilton
- College of Medicine and Health, University of Exeter, South Cloisters, St Luke's Campus, Heavitree, Exeter, EX1 2LU, UK
| | - Anne E Spencer
- College of Medicine and Health, University of Exeter, South Cloisters, St Luke's Campus, Heavitree, Exeter, EX1 2LU, UK
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Colorectal Cancer Screening: Have We Addressed Concerns and Needs of the Target Population? GASTROINTESTINAL DISORDERS 2021. [DOI: 10.3390/gidisord3040018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Despite the recognized benefits of colorectal cancer (CRC) screening, uptake is still suboptimal in many countries. In addressing this issue, one important element that has not received sufficient attention is population preference. Our review provides a comprehensive summary of the up-to-date evidence relative to this topic. Four OVID databases were searched: Ovid MEDLINE® ALL, Biological Abstracts, CAB Abstracts, and Global Health. Among the 742 articles generated, 154 full texts were selected for a more thorough evaluation based on predefined inclusion criteria. Finally, 83 studies were included in our review. The general population preferred either colonoscopy as the most accurate test, or fecal occult blood test (FOBT) as the least invasive for CRC screening. The emerging blood test (SEPT9) and capsule colonoscopy (nanopill), with the potential to overcome the pitfalls of the available techniques, were also favored. Gender, age, race, screening experience, education and beliefs, the perceived risk of CRC, insurance, and health status influence one’s test preference. To improve uptake, CRC screening programs should consider offering test alternatives and tailoring the content and delivery of screening information to the public’s preferences. Other logistical measures in terms of the types of bowel preparation, gender of endoscopist, stool collection device, and reward for participants can also be useful.
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Hyams T, Golden B, Sammarco J, Sultan S, King-Marshall E, Wang MQ, Curbow B. Evaluating preferences for colorectal cancer screening in individuals under age 50 using the Analytic Hierarchy Process. BMC Health Serv Res 2021; 21:754. [PMID: 34325701 PMCID: PMC8320058 DOI: 10.1186/s12913-021-06705-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 06/28/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND In 2021, the United States Preventive Services Task Force updated their recommendation, stating that individuals ages 45-49 should initiate screening for colorectal cancer. Since several screening strategies are recommended, making a shared decision involves including an individual's preferences. Few studies have included individuals under age 50. In this study, we use a multicriteria decision analysis technique called the Analytic Hierarchy Process to explore preferences for screening strategies and evaluate whether preferences vary by age. METHODS Participants evaluated a hierarchy with 3 decision alternatives (colonoscopy, fecal immunochemical test, and computed tomography colonography), 3 criteria (test effectiveness, the screening plan, and features of the test) and 7 sub-criteria. We used the linear fit method to calculate consistency ratios and the eigenvector method for group preferences. We conducted sensitivity analysis to assess whether results are robust to change and tested differences in preferences by participant variables using chi-square and analysis of variance. RESULTS Of the 579 individuals surveyed, 556 (96%) provided complete responses to the AHP portion of the survey. Of these, 247 participants gave responses consistent enough (CR < 0.18) to be included in the final analysis. Participants that were either white or have lower health literacy were more likely to be excluded due to inconsistency. Colonoscopy was the preferred strategy in those < 50 and fecal immunochemical test was preferred by those over age 50 (p = 0.002). These results were consistent when we restricted analysis to individuals ages 45-55 (p = 0.011). Participants rated test effectiveness as the most important criteria for making their decision (weight = 0.555). Sensitivity analysis showed our results were robust to shifts in criteria and sub-criteria weights. CONCLUSIONS We reveal potential differences in preferences for screening strategies by age that could influence the adoption of screening programs to include individuals under age 50. Researchers and practitioners should consider at-home interventions using the Analytic Hierarchy Process to assist with the formulation of preferences that are key to shared decision-making. The costs associated with different preferences for screening strategies should be explored further if limited resources must be allocated to screen individuals ages 45-49.
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Affiliation(s)
- Travis Hyams
- Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, USA. .,Division of Cancer Control and Population Sciences, Office of the Director, National Cancer Institute, Bethesda, USA.
| | - Bruce Golden
- Department of Decision, Operations, and Information Technologies, Robert H. Smith School of Business, University of Maryland, College Park, USA
| | - John Sammarco
- Definitive Business Solutions, Inc., 11921 Freedom Drive, Suite 550, Reston, VA, 20190, USA
| | - Shahnaz Sultan
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, USA
| | - Evelyn King-Marshall
- Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, USA
| | - Min Qi Wang
- Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, USA
| | - Barbara Curbow
- Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, USA
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Abstract
In recommending and offering screening, health services make a health claim ('it's good for you'). This article considers ethical aspects of establishing the case for cancer screening, building a service programme, monitoring its operation, improving its quality and integrating it with medical progress. The value of (first) screening is derived as a function of key parameters: prevalence of the target lesion in the detectable pre-clinical phase, the validity of the test and the respective net utilities or values attributed to four health states-true positives, false positives, false negatives and true negatives. Decision makers as diverse as public regulatory agencies, medical associations, health insurance funds or individual screenees can legitimately come up with different values even when presented with the same evidence base. The main intended benefit of screening is the reduction of cause-specific mortality. All-cause mortality is not measurably affected. Overdiagnosis and false-positive tests with their sequelae are the main harms. Harms and benefits accrue to distinct individuals. Hence the health claim is an invitation to a lottery with benefits for few and harms to many, a violation of the non-maleficence principle. While a public decision maker may still propose a justified screening programme, respect for individual rights and values requires preference-sensitive, autonomy-enhancing educational materials-even at the expense of programme effectiveness. Opt-in recommendations and more 'consumer-oriented' qualitative research are needed.
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Affiliation(s)
- Bernt-Peter Robra
- Institute for Social Medicine and Health Services Research, Otto-von-Guericke-University Magdeburg, Leipziger Str. 44, D-39140, Magdeburg, Germany.
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McFerran E, Boeri M, Kee F. Patient Preferences in Surveillance: Findings From a Discrete Choice Experiment in the "My Follow-Up" Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1373-1383. [PMID: 33032782 DOI: 10.1016/j.jval.2020.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 04/26/2020] [Accepted: 05/26/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Approximately 800 000 people die globally from colorectal cancer (CRC) every year. Prevention programs promote early detection, but for people with precancerous lesions, tailoring surveillance to include lifestyle-change programs could enhance prevention potential and improve outcomes. METHODS Those with intermediate or high-risk polyps removed during CRC screening colonoscopy within the Northern Ireland CRC Screening Programme were invited to complete 8 discrete choice questions about tailored surveillance, analyzed using random-parameters logit and a latent class modeling approach. RESULTS A total of 231 participants (77% male) self-reported comorbid hypertension (53%), high cholesterol (48%), and mean body mass index of 28.7 (overweight). Although 39% of participants were unaware of their CRC risk status, 30.9% indicated they were already making changes to reduce their risk. Although all respondents were significantly risk- and cost-averse, the latent class analysis identified 3 segments (classes): 1. Class 1 (26.8%) significantly favored phone or email support for a lifestyle change, a 17-month testing interval, and noninvasive testing. 2. Class 2 (48.4%) preferred the status quo. 3. Class 3 (24.7%) significantly favored further risk reduction and invasive testing. CONCLUSIONS This is the first documented preference study focusing on postpolypectomy surveillance offering lifestyle interventions. Although current care is strongly preferred, risk and cost aversion are important for participants. Latent class analysis shows that some respondents are willing to change diet and lifestyle behaviors, reflecting a teachable moment, with opportunities to personalize and optimize surveillance. Significant discordance between perceived and known risk of recurrence and limited recall of risk information provided within current practice suggest necessary improvements to surveillance programs.
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Affiliation(s)
- Ethna McFerran
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Block B, Royal Victoria Hospital, Belfast, Northern Ireland, UK.
| | - Marco Boeri
- RTI Health Solutions, Belfast, Northern Ireland, UK
| | - Frank Kee
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Block B, Royal Victoria Hospital, Belfast, Northern Ireland, UK
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Public preferences for using quantitative faecal immunochemical test versus colonoscopy as diagnostic test for colorectal cancer: evidence from an online survey. BJGP Open 2020; 4:bjgpopen20X101007. [PMID: 32019773 PMCID: PMC7330201 DOI: 10.3399/bjgpopen20x101007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND There has been interest in using the non-invasive, home-based quantitative faecal immunochemical test (FIT) to rule out colorectal cancer (CRC) in high-risk symptomatic patients. AIM To elicit public preferences for FIT versus colonoscopy (CC) and its delivery in primary care. DESIGN & SETTING A cross-sectional online survey in England. METHOD A total of 1057 adults (without CRC symptoms and diagnosis) aged 40-59 years were invited from an English online survey panel. Responders were asked to imagine they had been experiencing CRC symptoms that would qualify them for a diagnostic test. Participants were presented with choices between CC and FIT in ascending order of number of CRCs missed by FIT (from 1-10%). It was measured at what number of missed CRCs responders preferred CC over FIT. RESULTS While 150 participants did not want either of the tests when both missed 1% CRCs, the majority (n = 741, 70.0%) preferred FIT to CC at that level of accuracy. However, this preference reduced to 427 (40.4%) when FIT missed one additional cancer. Women were more likely to tolerate missing CRC when using FIT. Having lower numeracy and perceiving a higher level of risk meant participants were less likely to tolerate a false negative test. Most of those who chose FIT preferred to return it by mail (62.2%), to be informed about normal test results by letter (42.1%), and about abnormal test results face to face (32.5%). CONCLUSION While the majority of participants preferred FIT over CC when both tests had the same sensitivity, tolerance for missed CRCs was low.
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Mansfield C, Ekwueme DU, Tangka FKL, Brown DS, Smith JL, Guy GP, Li C, Hauber B. Colorectal Cancer Screening: Preferences, Past Behavior, and Future Intentions. THE PATIENT 2018; 11:599-611. [PMID: 29740804 PMCID: PMC6226356 DOI: 10.1007/s40271-018-0308-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Screening rates for colorectal cancer are below the Healthy People 2020 goal. There are several colorectal cancer screening tests that differ in terms of accuracy, recommended frequency, and administration. In this article, we compare how a set of personal characteristics correlates with preferences for colorectal cancer screening test attributes, past colorectal cancer screening behavior, and future colorectal cancer screening intentions. METHODS We conducted a discrete-choice experiment survey to assess relative preferences for attributes of colorectal cancer screening tests among adults aged 50-75 years in USA. We used a latent class logit model to identify classes of preferences and calculated willingness to pay for changes in test attributes. A set of personal characteristics were included in the latent class analysis and analyses of self-reported past screening behavior and self-assessed likelihood of future colorectal cancer screening. RESULTS Latent class analysis identified three types of respondents. Class 1 valued test accuracy, class 2 valued removing polyps and avoiding discomfort, and class 3 valued cost. Having had a prior colonoscopy and a higher income were predictors of the likelihood of future screening and membership in classes 1 and 2. Health insurance and a self-reported higher risk of developing colorectal cancer were associated with prior screening and higher future screening intentions, but not class membership. CONCLUSION We identified distinct classes of preferences focusing on different test features and personal characteristics associated with reported behavior and intentions. Healthcare providers should engage in a careful assessment of patient preferences when recommending colorectal cancer test options to encourage colorectal cancer screening uptake.
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Affiliation(s)
- Carol Mansfield
- RTI Health Solutions, RTI International, 200 Park Offices Drive, PO Box 12194, Research Triangle Park, NC, 27709-2194, USA.
| | - Donatus U Ekwueme
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Florence K L Tangka
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Derek S Brown
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Judith Lee Smith
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Gery P Guy
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Chunyu Li
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Brett Hauber
- RTI Health Solutions, RTI International, 200 Park Offices Drive, PO Box 12194, Research Triangle Park, NC, 27709-2194, USA
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Broekhuizen H, Groothuis-Oudshoorn CGM, Vliegenthart R, Groen HJM, IJzerman MJ. Assessing Lung Cancer Screening Programs under Uncertainty in a Heterogeneous Population. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1269-1277. [PMID: 30442273 DOI: 10.1016/j.jval.2018.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 12/22/2017] [Accepted: 01/03/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Lung cancer screening can reduce cancer mortality. Most implementation studies focus only on low-dose computed tomography (LDCT) and clinical attributes of screening and do not include preferences of potential participants. In this study we evaluated the perceived value of screening programs based on LDCT, breath analysis (BA), or blood biomarkers (BB) according to the perspective of the target population. METHODS A multi-criteria decision analysis framework was adopted. The weights of seven attributes of screening (sensitivity, specificity, radiation burden, duration of screening process, waiting time until results are communicated, location of screening, and mode of screening) were obtained from an earlier study that included a broad sample from the Netherlands. Performance data for the screening modalities was obtained from clinical trials and expert opinion. Parameter uncertainty about clinical performances was incorporated probabilistically, while heterogeneity in preferences was analyzed through subgroup analyses. RESULTS The mean overall values were 0.58 (CI: 0.57 to 0.59), 0.57 (CI: 0.56 to 0.59), and 0.44 (CI: 0.43 to 0.45) for BB, BA, and LDCT, respectively. Seventy-seven per cent of respondents preferred BB or BA. For most subgroups, the overall values were similar to those of the entire sample. BA had the highest value for respondents who would have been eligible for earlier screening trials. DISCUSSION BB and BA seem valuable to participants because they can be applied in a primary care setting. Although LDCT still seems preferable given its strong and positive evidence base, it is important to take non-clinical attributes into account to maximize attendance.
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Affiliation(s)
- Henk Broekhuizen
- Radboud University Medical Center, Department of Health Evidence, Nijmegen, The Netherlands.
| | - Catharina G M Groothuis-Oudshoorn
- University of Twente, Faculty of Behavioural Management and Social Sciences, Technical Medical Centre, Department of Health Technology and Services Research, Enschede, The Netherlands
| | - Rozemarijn Vliegenthart
- University of Groningen, University Medical Center Groningen, Department of Radiology, Groningen, The Netherlands
| | - Harry J M Groen
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, The Netherlands
| | - Maarten J IJzerman
- Radboud University Medical Center, Department of Health Evidence, Nijmegen, The Netherlands; University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences and Victorian Comprehensive Cancer Centre, Melbourne, Australia
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Lee SJ, O'Leary MC, Umble KE, Wheeler SB. Eliciting vulnerable patients' preferences regarding colorectal cancer screening: a systematic review. Patient Prefer Adherence 2018; 12:2267-2282. [PMID: 30464417 PMCID: PMC6216965 DOI: 10.2147/ppa.s156552] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Patient preferences are important to consider in the decision-making process for colorectal cancer (CRC) screening. Vulnerable populations, such as racial/ethnic minorities and low-income, veteran, and rural populations, exhibit lower screening uptake. This systematic review summarizes the existing literature on vulnerable patient populations' preferences regarding CRC screening. METHODS We searched the CINAHL, PsycINFO, PubMed, Scopus, and Web of Science databases for articles published between January 1, 1996 and December 31, 2017. We screened studies for eligibility and systematically abstracted and compared study designs and outcomes. RESULTS A total of 43 articles met the inclusion criteria, out of 2,106 articles found in our search. These 43 articles were organized by the primary sub-population(s) whose preferences were reported: 27 report on preferences among racial/ethnic minorities, eight among low-income groups, six among veterans, and two among rural populations. The majority of studies (n=34) focused on preferences related to test modality. No single test modality was overwhelmingly supported by all sub-populations, although veterans seemed to prefer colonoscopy. Test attributes such as accuracy, sensitivity, cost, and convenience were also noted as important features. Furthermore, a preference for shared decision-making between vulnerable patients and providers was found. CONCLUSION The heterogeneity in study design, populations, and outcomes of the selected studies revealed a wide spectrum of CRC screening preferences within vulnerable populations. More decision aids and discrete choice experiments that focus on vulnerable populations are needed to gain a more nuanced understanding of how vulnerable populations weigh particular features of screening methods. Improved CRC screening rates may be achieved through the alignment of vulnerable populations' preferences with screening program design and provider practices. Collaborative decision-making between providers and vulnerable patients in preventive care decisions may also be important.
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Affiliation(s)
- Samuel J Lee
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,
| | - Meghan C O'Leary
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,
| | - Karl E Umble
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,
| | - Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,
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Fritzell K, Stake Nilsson K, Jervaeus A, Hultcrantz R, Wengström Y. The importance of people's values and preferences for colorectal cancer screening participation. Eur J Public Health 2018; 27:1079-1084. [PMID: 28160484 DOI: 10.1093/eurpub/ckw266] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background To explore how individuals reason when they make decisions about participating in colorectal cancer (CRC) screening. Methods Individuals randomized to FIT or colonoscopy included in the Screening of Swedish Colons (SCREESCO) program was invited to focus group discussions and individual telephone interviews. The concept of shared decision-making (SDM: information; values/preferences; involvement) was used as a matrix for the analyses. To validate findings, additional focus group discussions using the nominal group technique were performed. Results Lack of knowledge of CRC and CRC screening was prominent for participants and non-participants, while the results differed between the groups in relation to their values and preferences. The influence of significant others promoted participation while it prevented it among non-participants. Those who participated and those who did not made it clear that there was no need to involve health care professionals when making the decision. Conclusions Based on the results, a display of different ways to spread knowledge and communicate about CRC and CRC-screening could be applied such as, community-based information campaigns, decisions aids, interactive questionnaires, chat-functions and telephone support. The disparity in values and preferences between participants and non-participants may be the key to understand why non-participants make their decisions not to participate and warrant further exploration.
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Affiliation(s)
- Kaisa Fritzell
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden
| | | | - Anna Jervaeus
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden
| | - Rolf Hultcrantz
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Yvonne Wengström
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden.,Breast and Sarcoma Unit, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
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Bianchi F, Ciuti G, Koulaouzidis A, Arezzo A, Stoyanov D, Schostek S, Oddo CM, Menciassi A, Dario P. An innovative robotic platform for magnetically-driven painless colonoscopy. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:421. [PMID: 29201873 DOI: 10.21037/atm.2017.09.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Colorectal cancer (CRC) represents a significant medical threat with a dramatic impact on the healthcare system with around 1.3 million patients worldwide, causing more than 700 thousand deaths annually. A key-aspect to successful and cost-effective disease management is represented by the early detection of CRC at asymptomatic stage. For this reason, population screening is highly recommended for patients older than 50 years or at high risk for familiarity. Currently, the standard endoscopic techniques do not meet this need. In recent years, innovative endoscopic robotic techniques and active locomotion devices have been developed as alternatives to conventional colonoscopy. The magnetically-driven robotic platform, presented by the authors, is conceived to perform less invasive and more comfortable colonoscopy with the aim to promote screening campaigns for detection of early colorectal neoplasm.
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Affiliation(s)
- Federico Bianchi
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Gastone Ciuti
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Danail Stoyanov
- Centre for Medical Image Computing and the Department of Computer Science, University College London, London, UK
| | | | | | | | - Paolo Dario
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
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Brown L, Lee TH, De Allegri M, Rao K, Bridges JF. Applying stated-preference methods to improve health systems in sub-Saharan Africa: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2017; 17:441-458. [PMID: 28875767 DOI: 10.1080/14737167.2017.1375854] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Sub-Saharan African health systems must balance shifting disease burdens with desires for robust institutions. Stated-preference methods have been applied extensively to elicit health care workers' preferences and priorities for rural practice. This systematic review characterizes the range of their applications to African health systems problems. Areas covered: A PRISMA protocol was submitted to PROSPERO. Six databases were queried for peer-reviewed articles using quantitative stated-preference methods to evaluate a health systems-related trade-off. Quality was assessed using the PREFS checklist. Seventy-seven articles published between 1996 and 2017 met review criteria. Methods were primarily choice-based: discrete-choice experiments (n = 46), ranking/allocation techniques (n = 21), conjoint analyses (n = 7), and best-worst scaling (n = 3). Trade-offs fell into six 'building blocks': service features (n = 27), workforce incentives (n = 17), product features (n = 14), system priorities (n = 14), insurance features (n = 4), and research priorities (n = 1). Five countries dominated: South Africa (n = 11), Ghana (n = 9), Malawi (n = 9), Uganda (n = 9), and Tanzania (n = 8). Discrete-choice experiments were of highest quality (mean score: 3.36/5). Expert commentary: Stated-preference methods have been applied to many health systems contexts throughout sub-Saharan Africa. Studies examined established strategic areas, especially primary health care for women, prevention and treatment of infectious diseases, and workforce development. Studies have neglected the emerging areas of non-communicable diseases.
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Affiliation(s)
- Lauren Brown
- a Department of International Health , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Ting-Hsuan Lee
- b Department of International Health/Department of Health Policy and Management , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Manuela De Allegri
- c Institute of Public Health, Faculty of Medicine , Heidelberg University , Heidelberg , Germany
| | - Krishna Rao
- a Department of International Health , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - John Fp Bridges
- b Department of International Health/Department of Health Policy and Management , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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Broekhuizen H, Groothuis-Oudshoorn CGM, Vliegenthart R, Groen H, IJzerman MJ. Public Preferences for Lung Cancer Screening Policies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:961-968. [PMID: 28712626 DOI: 10.1016/j.jval.2017.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 02/11/2017] [Accepted: 04/02/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Because early detection of lung cancer can substantially improve survival, there is increasing attention for lung cancer screening. OBJECTIVES To estimate public preferences for lung cancer screening and to identify subgroups in preferences. METHODS Seven important attributes were selected using the literature, interviews, and a panel session. Preferences were elicited using a swing weighting questionnaire. The resulting attribute weights indicate the relative importance of swings from the worst to the best level between attributes. Hierarchical clustering was used to identify subgroups with different attribute weights. RESULTS One thousand thirty-four respondents from a representative Dutch panel aged between 40 and 80 years were included. The identified attributes were location of screening (weight = 0.18 ± 0.16), mode of screening (weight = 0.17 ± 0.14), sensitivity (weight = 0.16 ± 0.13) and specificity (weight = 0.13 ± 0.12) of the screening modality, waiting time until results (weight = 0.13 ± 0.12), radiation burden (weight = 0.13 ± 0.12), and duration of screening procedure (weight = 0.10 ± 0.09). Most respondents preferred breath analysis (45%) to giving blood samples (31%) or going through a scanner (24%) as screening modality; 59% preferred screening at the general practitioner's office instead of at the hospital. There was a significant difference in education between the five identified preference subgroups (P < 0.01). CONCLUSIONS There is considerable variation in how people value attributes of lung cancer screening. Different screening policies and implementation strategies may be appropriate for particular preference subgroups. Our results indicate that people prefer breath analysis and that they are more likely to attend screening modalities that can be used at a primary care facility.
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Affiliation(s)
- Henk Broekhuizen
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands.
| | | | | | - Harry Groen
- Department of Pulmonary Diseases, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten J IJzerman
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
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Mansfield C, Tangka FKL, Ekwueme DU, Smith JL, Guy GP, Li C, Hauber AB. Stated Preference for Cancer Screening: A Systematic Review of the Literature, 1990-2013. Prev Chronic Dis 2016; 13:E27. [PMID: 26916898 PMCID: PMC4768876 DOI: 10.5888/pcd13.150433] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction Stated-preference methods provide a systematic approach to quantitatively assess the relative preferences for features of cancer screening tests. We reviewed stated-preference studies for breast, cervical, and colorectal cancer screening to identify the types of attributes included, the use of questions to assess uptake, and whether gaps exist in these areas. The goal of our review is to inform research on the design and promotion of public health programs to increase cancer screening. Methods Using the PubMed and EconLit databases, we identified studies published in English from January 1990 through July 2013 that measured preferences for breast, cervical, and colorectal cancer screening test attributes using conjoint analysis or a discrete-choice experiment. We extracted data on study characteristics and results. We categorized studies by whether attributes evaluated included screening test, health care delivery characteristics, or both. Results Twenty-two studies met the search criteria. Colorectal cancer was the most commonly studied cancer of the 3. Fifteen studies examined only screening test attributes (efficacy, process, test characteristics, and cost). Two studies included only health care delivery attributes (information provided, staff characteristics, waiting time, and distance to facility). Five studies examined both screening test and health care delivery attributes. Overall, cancer screening test attributes had a significant effect on a patient’s selection of a cancer screening test, and health care delivery attributes had mixed effects on choice. Conclusion A growing number of studies examine preferences for cancer screening tests. These studies consistently find that screening test attributes, such as efficacy, process, and cost, are significant determinants of choice. Fewer studies have examined the effect of health care delivery attributes on choice, and the results from these studies are mixed. There is a need for additional studies on the barriers to cancer screening uptake, including health care delivery attributes, and the effect of education materials on preferences.
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Affiliation(s)
- Carol Mansfield
- RTI Health Solutions, RTI International, Research Triangle Park, North Carolina
| | - Florence K L Tangka
- Centers for Disease Control and Prevention, 4770 Buford Hwy, NE, MS F-76, Atlanta, GA 30341.
| | | | | | - Gery P Guy
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Chunyu Li
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - A Brett Hauber
- RTI Health Solutions, RTI International, Research Triangle Park, North Carolina
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Boklage SH, Mangel AW, Ramamohan V, Mladsi D, Wang T. Impact of patient adherence on the cost-effectiveness of noninvasive tests for the initial diagnosis of Helicobacter pylori infection in the United States. Patient Prefer Adherence 2016; 10:45-55. [PMID: 26855566 PMCID: PMC4727507 DOI: 10.2147/ppa.s93320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Previous US-based economic models of noninvasive tests for diagnosis of Helicobacter pylori infection did not consider patient adherence or downstream costs of continuing infection. This analysis evaluated the long-term cost-effectiveness of the urea breath test (UBT), fecal antigen test (FAT), and serology for diagnosis of H. pylori infection after incorporating information regarding test adherence. MATERIALS AND METHODS A decision-analytic model incorporating adherence information evaluated the cost-effectiveness of the UBT, FAT, and serology for diagnosis of H. pylori infection. Positive test results led to first-line triple therapy; no further action was taken for nonadherence or negative results. Excess lifetime costs and reduced quality-adjusted life-years (QALYs) were estimated for patients with continuing H. pylori infection. RESULTS In the base-case scenario with estimated adherence rates of 86%, 48%, and 86% for the UBT, monoclonal FAT, and serology, respectively, corresponding expected total costs were US$424.99, $466.41, and $404.98/patient. Test costs were higher for the UBT, but were fully or partially offset by higher excess lifetime costs for the monoclonal FAT and serology. The QALYs gained/patient with the UBT vs monoclonal FAT and serology were 0.86 and 0.27, respectively. The UBT was dominant vs the monoclonal FAT, leading to lower costs and higher QALYs; the UBT was cost-effective vs serology (incremental cost/QALY gained $74). CONCLUSION Based on a comprehensive modeled analysis that included consideration of patient test adherence and long-term consequences resulting from continuing H. pylori infection, the UBT provided the greatest economic value among noninvasive tests for diagnosis of H. pylori infection, because of high patient adherence and excellent test performance.
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Affiliation(s)
| | | | | | | | - Tao Wang
- Otsuka America Pharmaceutical Inc, Princeton, NJ
- Correspondence: Tao Wang, Otsuka America Pharmaceutical Inc, 2440 Research Boulevard, Rockville, MD 20850, USA, Tel +1 240 683 3213, Fax +1 301 721 7213, Email
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WHAT IS THE ROLE OF COMMUNITY PREFERENCE INFORMATION IN HEALTH TECHNOLOGY ASSESSMENT DECISION MAKING? A CASE STUDY OF COLORECTAL CANCER SCREENING. Int J Technol Assess Health Care 2015; 31:241-8. [PMID: 26376934 DOI: 10.1017/s0266462315000367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The aim of this study was to determine the role of community preference information from discrete choice studies of colorectal cancer (CRC) screening in health technology assessment (HTA) reports and subsequent policy decisions. METHODS We undertook a systematic review of discrete choice studies of CRC screening. Included studies were reviewed to assess the policy context of the research. For those studies that cited a recent or pending review of CRC screening, further searches were undertaken to determine the extent to which community preference information was incorporated into the HTA decision-making process. RESULTS Eight discrete choice studies that evaluated preferences for CRC screening were identified. Four of these studies referred to a national or local review of CRC screening in three countries: Australia, Canada, and the Netherlands. Our review of subsequently released health policy documents showed that while consideration was given to community views on CRC, policy was not informed by discrete choice evidence. CONCLUSIONS Preferences and values of patients are increasingly being considered "evidence" to be incorporated into HTA reports. Discrete choice methodology is a rigorous quantitative method for eliciting preferences and while as a methodology it is growing in profile, it would appear that the results of such research are not being systematically translated or integrated into HTA reports. A formalized approach is needed to incorporate preference literature into the HTA decision-making process.
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Assessing stated preferences for colorectal cancer screening: a critical systematic review of discrete choice experiments. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2014; 7:271-82. [PMID: 24652475 DOI: 10.1007/s40271-014-0054-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND It is well established that screening is effective in reducing the incidence and mortality associated with colorectal cancer (CRC). National screening programs have been implemented in many countries; however, uptake remains an issue. Understanding patient preferences may assist in shaping screening programs and tailoring information about screening tests. OBJECTIVE Our objective was to undertake a systematic review of discrete choice experiments (DCEs) of CRC screening. METHODS A systematic review of DCEs of CRC screening was undertaken in an average-risk general population. The methodological qualities of the studies were assessed using a standard checklist outlining best practice for conjoint studies. RESULTS Nine studies met the selection criteria. Meta-analysis was not possible due to the heterogeneity of the data and methods. However, in eight studies, attributes describing accuracy and/or clinical effectiveness were reported to be statistically significant. We also found that individuals were willing to trade-off other attributes such as an increased risk of complications to gain greater clinical benefits. Screening was also preferred to non-screening by the majority of respondents, regardless of the test used. CONCLUSIONS Understanding and incorporating individuals' preferences in decision making is increasingly considered essential in the health field. Data from DCEs can provide valuable insights into the trade-offs individuals are willing to undertake in respect to CRC screening. Such insights can be used by decision makers to identify screening tests that could maximize informed uptake. It is likely that, with better reporting and evolving methodology, the contribution that DCEs can make to such debates will increase.
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Tsunematsu M, Kawasaki H, Masuoka Y, Kakehashi M. Factors affecting breast cancer screening behavior in Japan--assessment using the health belief model and conjoint analysis. Asian Pac J Cancer Prev 2014; 14:6041-8. [PMID: 24289622 DOI: 10.7314/apjcp.2013.14.10.6041] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Japanese women in their 40s or older have been encouraged to attend breast cancer screening. However, the breast cancer screening rate in Japan is not as high as in Europe and the United States. The aim of this study was to identify psychological and personal characteristics of women concerning their participation in breast cancer screening using the Health Belief Model (HBM). In addition, the attributes of screening more easily accepted by participants were analyzed by conjoint analysis. MATERIALS AND METHODS In this cross sectional study of 3,200 age 20-69 women, data were collected by an anonymous questionnaire. Questions were based on HBM and personal characteristics, and included attitudes on hypothetical screening attributes. Data of women aged 40-69 were analyzed by logistic regression and conjoint analysis to clarify the factors affecting their participation in breast cancer screening. RESULTS Among responses collected from 1,280 women of age 20-69, the replies of 993 women of age 40-69 were used in the analysis. Regarding the psychological characteristics based on HBM, the odds ratios were significantly higher in "importance of cancer screening" (95%CI: 1.21-2.47) and "benefits of cancer screening" (95%CI: 1.09-2.49), whereas the odds ratio was significantly lower in "barriers to participation before cancer screening" (95%CI: 0.27-0.51). Conjoint analysis revealed that the respondents, overall, preferred screening to be low cost and by female staff members. Furthermore, it was also clarified that attributes of screening dominant in decision-making were influenced by the employment status and the type of medical insurance of the women. CONCLUSIONS In order to increase participation in breast cancer screening, it is necessary to disseminate accurate knowledge on cancer screening and to reduce barriers to participation. In addition, the attributes of screening more easily accepted were inexpensive, provided by female staff, executed in a hospital and finished in a short time.
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Affiliation(s)
- Miwako Tsunematsu
- Department of Health Informatics, Graduate School of Biomedical and Health Sciences Hiroshima University, Hiroshima, Japan E-mail :
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Ghanouni A, Halligan S, Taylor SA, Boone D, Plumb A, Stoffel S, Morris S, Yao GL, Zhu S, Lilford R, Wardle J, von Wagner C. Quantifying public preferences for different bowel preparation options prior to screening CT colonography: a discrete choice experiment. BMJ Open 2014; 4:e004327. [PMID: 24699460 PMCID: PMC3987721 DOI: 10.1136/bmjopen-2013-004327] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES CT colonography (CTC) may be an acceptable test for colorectal cancer screening but bowel preparation can be a barrier to uptake. This study tested the hypothesis that prospective screening invitees would prefer full-laxative preparation with higher sensitivity and specificity for polyps, despite greater burden, over less burdensome reduced-laxative or non-laxative alternatives with lower sensitivity and specificity. DESIGN Discrete choice experiment. SETTING Online, web-based survey. PARTICIPANTS 2819 adults (45-54 years) from the UK responded to an online invitation to take part in a cancer screening study. Quota sampling ensured that the sample reflected key demographics of the target population and had no relevant bowel disease or medical qualifications. The analysis comprised 607 participants. INTERVENTIONS After receiving information about screening and CTC, participants completed 3-4 choice scenarios. Scenarios showed two hypothetical forms of CTC with different permutations of three attributes: preparation, sensitivity and specificity for polyps. PRIMARY OUTCOME MEASURES Participants considered the trade-offs in each scenario and stated their preferred test (or chose neither). RESULTS Preparation and sensitivity for polyps were both significant predictors of preferences (coefficients: -3.834 to -6.346 for preparation, 0.207-0.257 for sensitivity; p<0.0005). These attributes predicted preferences to a similar extent. Realistic specificity values were non-significant (-0.002 to 0.025; p=0.953). Contrary to our hypothesis, probabilities of selecting tests were similar for realistic forms of full-laxative, reduced-laxative and non-laxative preparations (0.362-0.421). However, they were substantially higher for hypothetical improved forms of reduced-laxative or non-laxative preparations with better sensitivity for polyps (0.584-0.837). CONCLUSIONS Uptake of CTC following non-laxative or reduced-laxative preparations is unlikely to be greater than following full-laxative preparation as perceived gains from reduced burden may be diminished by reduced sensitivity. However, both attributes are important so a more sensitive form of reduced-laxative or non-laxative preparation might improve uptake substantially.
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Affiliation(s)
- Alex Ghanouni
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Darren Boone
- Centre for Medical Imaging, University College London, London, UK
| | - Andrew Plumb
- Centre for Medical Imaging, University College London, London, UK
| | - Sandro Stoffel
- Institute for Health and Consumer Protection, European Commission, Joint Research Centre, Ispra, Italy
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Guiqing Lily Yao
- Department of Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, UK
| | - Shihua Zhu
- Department of Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, UK
| | - Richard Lilford
- Department of Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, UK
| | - Jane Wardle
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Christian von Wagner
- Department of Epidemiology and Public Health, University College London, London, UK
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