Health Technology Assessment (HTA) Report: Interventions to increase participation to organised cancer

screening programs

Ministry of Health Grant for Applied Research

Giorgi Rossi P, Camilloni L, Ferroni E, Jimenez B, Furnari G, Guasticchi G, Borgia P.

Laziosanità – Agenzia di Sanità Pubblica

della Regione Lazio

HTAi 2012- Bilbao

Background

• The most important barrier reducing the effectiveness of oncological screening program is low participation of the target population.

• High participation rates are necessary to obtain a significant impact on population health.

• Compliance to invitation should be achieved by encouraging “informed” participation by individuals who are aware of the benefits, limitations and disadvantages of the screening program.

Objective

To synthesize the scientific evidence produced by International research on the efficacy of interventions to increase participation in screening programs.

Methods: the HTA process

• Identification of a multi-discipliner working group including all the principal investigators who conducted studies with public funding on screening participation in Italy

• Scope definition

• Stakeholder consultation

• Assessment and draft of the report

• Stakeholder consultation

• Final report

Methods: PICOS

We updated the systematic review by Jepson et al 2000.

Population: breast 49-69; cervix 25-64;

colorectal 50-74

Intervention: any type of intervention or strategy aimed at increasing participation

Comparison: standard invitation letter (with or without recall)

Outcome: participation to screening program;

Study: RCT, cRCT, controlled non-randomised, before/after studies.

Methods: assessment domains

1.Efficacy

2.Cost-effectiveness

3.Organizational impact

4.Social (inequalities), ethic (informed participation) and legal (privacy) issues

Study selection Flow chart

Potentially relevant citations (titles) identified and screened (n=5879)

Potentially relevant abstracts identified and

screened (n=958)

Retrieve full text for critical appraisal (n=145)

QT Studies full field inclusion criteria (n=52)

Excluded irrelevant citations

(n=4821)

Excluded QT irrelevant abstracts but useful for

QL Review (n=813)

Excluded irrelevant QT studies but useful for QL Review (n=93)

Studies from Jepson Review (n=70) Final set (n=122)

Classification of the interventions, according to the target

•To the target population: •the individual: invitations, reminders, etc.•the population: health education, information campaigns by the mass-media.

•Screening tests: new tests or new procedures; self-administered tests; etc. •Health professionals: training; stimuli for physicians, audit and feedback, etc.•Health service organization: removing financial or economic barriers, involving more providers, fixed or open appointments, etc.

Interventions targeted to individuals

•There is strong evidence of a positive effect of mail recall

Interventions targeted to individuals

•And phone recall

Interventions targeted to individuals

•Heterogenous results for face to face recall

Interventions targeted to individuals

•Thre is consistent evidence of a modest positive effect of the GP’s sign on the invitation letter

Interventions targeted to individuals

•Informational matherial mailed with the letter has no effect on participation

Interventions targeted to the population

Few studies evaluated the effect of mass media campaigns and there are several methodological problems

Other studies evaluating multi-facetted interventions, including mass media campaigns, showed non consistent results

Interventions that make screening tests easier or more acceptable

•Diet restrictions have a negative effect on FOBT compliance

•Higher number of evacuations have a negative effect on Guaiac FOBT compliance

Interventions that make screening tests easier or more acceptable

Self-sampling for HPV increases participation in non-responders compared to recall letter

Study or Subgroup

Giorgi Rossi 2010Gok 2010

Total (95% CI)

Total eventsHeterogeneity: Chi² = 0.73, df = 1 (P = 0.39); I² = 0%Test for overall effect: Z = 4.59 (P < 0.00001)

Events

1217404

7525

Total

61626920

27536

Events

8646

132

Total

619277

896

Weight

48.5%51.5%

100.0%

M-H, Fixed, 95% CI

1.41 [1.10, 1.82]1.66 [1.27, 2.16]

1.54 [1.28, 1.85]

self-sampling direct mail standard recall Risk Ratio Risk RatioM-H, Fixed, 95% CI

0.1 0.2 0.5 1 2 5 10standard self sampling

Interevtions targeted to health service organization

Fixed appointment has higher participation than open invitation

Interevtions targeted to health service organization

Remainder addressed to the GP flagging not screened people have a a modest consistent positive effect

Direct mailing of the FOBT vs piking up at the clinc showed heterogenous mostly positve results

Direct mailing has better results than on demand mailing

Interevtions targeted to health service organization

Cost-effectiveness

Given the low cost per QALY of the three cancer screening, we might spend up to 40€ to gain an unscreened woman to Pap test, 130€ for mammography, 80€ an individual to FOBT and 800€ for sygmoidoscopy.

We found economic evaluations only for few interventions and results are often context dependent:•Recall letters are consistently cost effective •Results for reminders to GPs are more heterogeneous

Social issues

•Some interventions have effects on inequalities:

•Longer and more detailed letters increase differneces in access.

•GP involvement is effective in increasing participation specifically of more disadvantaged people.

•Phone recalls are more effective in women with low educational level.

Conclusions

Many interventions have been implemented to increase patrticipation to screening, but only few of them have been evaluated

Effectiveness of these interventions may be context dependent.

Some interventions showed consistent positive results in many context and can be implemented with few resources:

•Mail recall

•GP’s sign

•Fixed appointment

Thank you!

HTA report available at:

Epiprev.it