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Cost-effectiveness of interventions to promote cervical screening in general practice |
Hyndman J C, Straton J A, Pritchard D A, Le Sueur H |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Interventions to extend the take-up of cervical screening in general practice.
Economic study type Cost-effectiveness analysis.
Study population Women, aged 36 to 69 years, who were eligible for a Pap smear.
Setting General practice. The study was set in Perth, Australia.
Dates to which data relate Effectiveness, resource use, and cost data were collected in 1991. The price year was 1991.
Source of effectiveness data The effectiveness evidence was derived from a single study.
Link between effectiveness and cost data The costing, which was carried out retrospectively after the effectiveness results were known, was undertaken on the same patient sample as that used in the effectiveness analysis.
Study sample 757 women who required smear tests were randomly allocated to one of the four intervention groups: control group (n=185), tagged group (n=198), letter group (n=206), and appointment group (n=168). Four women who had attended a special clinic were excluded. No power calculations were reported.
Study design This was a prospective randomised controlled trial carried out at multiple centres. Patients were followed up for one year. No patients were lost to follow-up.
Analysis of effectiveness The analysis of the clinical study was based on intention to treat. The primary health outcome was the proportion of women presenting for screening. The authors did not report whether, at analysis, groups were comparable in terms of patient characteristics.
Effectiveness results The number of women actually screened was 30 in the control group, 39 in the tagged group, 53 in the letter group, and 51 in the appointment group. If a base number of 100 recruited women was taken for each intervention, the expected number screened was 16.2 in the control group, 19.7 in the tagged group, 25.7 in the letter group, and 30.4 in the appointment group.
Clinical conclusions An education programme for doctors at the practice could, by itself, nearly double the rate of screening for attending women.
Measure of benefits used in the economic analysis The proportion of women presenting for screening was used as the measure of benefits.
Direct costs Direct costs were discounted at an annual rate of 5%. Quantities and costs were reported separately. Direct costs related to the costs of contacting patients, reminding patients to keep appointments, costs related to taking smears, and the costs of floor space, telephone and furniture. The quantity/cost boundary adopted was that of the health service. The estimation of quantities and costs was based on actual data. The price year was 1991.
Statistical analysis of costs No statistical analysis of costs was reported.
Indirect Costs Indirect costs were discussed but were not included.
Currency Australian dollars (Aus$).
Sensitivity analysis Sensitivity analyses were conducted on the time a doctor spent taking a smear and on practice attendance.
Estimated benefits used in the economic analysis 30 women were screened in the control group, 39 in the tagged group, 53 in the letter group, and 51 in the appointment group. If a base number of 100 recruited women was taken for each intervention, the expected number screened was 16.2 in the control group, 19.7 in the tagged group, 25.7 in the letter group, and 30.4 in the appointment group.
Cost results The total costs for 100 randomised women were Aus$236.80 in the control group, Aus$290.60 in the tagged group, Aus$1,165.50 in the letter group, and Aus$1,465.60 in the appointment group.
Synthesis of costs and benefits The incremental cost per additional screen over the control group was Aus$15.40 for the tagged group, Aus$97.75 for the letter group, and Aus$86.50 for the appointment group.
Authors' conclusions The tagging of notes, although more expensive than providing opportunistic screening, is a more economic option than either the letter or appointment strategies.
CRD COMMENTARY - Selection of comparators A justification was given for the comparator used, namely currently available interventions. You, as a user of the database, should decide if these health technologies are relevant to your own setting.
Validity of estimate of measure of benefit The analysis was based on a randomised controlled trial, which was appropriate for the study question and is likely to have high validity. The study sample was representative of the study population. The authors did not report whether patient groups were comparable at analysis, which could have influenced the results through selection bias. The analysis of effectiveness was handled credibly. The estimation of benefits was obtained directly from the effectiveness analysis.
Validity of estimate of costs Good features of the cost analysis were that all relevant direct cost categories were included, costs were used to proxy prices, the price year was reported, and quantities and costs were reported separately. However, no sensitivity or statistical analyses were reported on quantities or costs. Travel costs to patients attending the general practice, time lost from work by women attending for a smear and external costs borne by governments were not considered, although a rationale for this decision was given.
Other issues The authors made appropriate comparisons of their findings with those from other studies and did address the issue of generalisability to other settings. The authors' statement that tagging notes is the optimal strategy is based on the finding that it has the lowest incremental cost-effectiveness ratio. However, the other two interventions were both more effective and more costly than tagging, and therefore the decision as to which strategy to choose should be based on the provider's willingness to pay. The study considered women eligible for a smear and this was reflected in the authors' conclusions. The authors noted that the incremental cost-effectiveness ratios may be affected by the socio-economic profiles of the population.
Implications of the study The tagging of notes, although more expensive than providing opportunistic screening, is a more economic option than either the letter or appointment strategies.
Source of funding Funded by a Health, Housing and Community Services Research and Development Grant.
Bibliographic details Hyndman J C, Straton J A, Pritchard D A, Le Sueur H. Cost-effectiveness of interventions to promote cervical screening in general practice. Australian and New Zealand Journal of Public Health 1996; 20(3): 272-277 Indexing Status Subject indexing assigned by NLM MeSH Adult; Aged; Cost-Benefit Analysis; Family Practice /economics; Female; Health Promotion /economics; Humans; Mass Screening /economics; Middle Aged; Papanicolaou Test; Vaginal Smears /economics AccessionNumber 21996001781 Date bibliographic record published 30/06/2001 Date abstract record published 30/06/2001 |
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