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La valutazione dei costi del programma di screening mammografico nella citta di Firenze [Evaluation of the costs of mammographic screening programme in the city of Florence] |
Spagnolo G, Zappa M, Paci E, Giorgi D, Rosselli del Turco M |
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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 Screening programme for breast cancer detection.
Economic study type Cost-effectiveness analysis.
Study population The population under study included women resident in the city of Florence (Italy) aged between 50 and 69.
Setting Hospital. The economic study was performed in Florence, Italy.
Dates to which data relate The clinical data for the screening programme were collected between 1991 and 1993. The estimate of the number of cases under the alternative of no screening was based on observation of the incidence rate between 1985 and 1987. The data on costs related to the period 1990-1993.
Source of effectiveness data The evidence for the final outcomes was derived from a single study and an estimate based on historical data.
Link between effectiveness and cost data The costing was undertaken prospectively on the sample undergoing the screening programme and retrospectively for the hypothetical sample in the absence of the screening programme.
Study sample 54,750 women were invited to participate in the programme of screening between 1991 and 1992.53.9% underwent screening and 4.3% were recalled for further examinations. The control group included women who would have undergone a mammographic examination in the absence of a screening programme (9.5%) and 4.3% of them would have been recalled for further examinations. Power calculations were not used to determine the sample size.
Study design The study was a non-randomized trial with a historical control. 46.1% of the women invited did not undergo the screening. 4.3% underwent further examinations for cancer detection.
Analysis of effectiveness The analysis of the clinical study was based on treatment completers only. The health outcome used was the number of cancers detected by mammographic screening and further examinations. The two groups were comparable in age and location given that the estimate of the number of women undergoing screening without the implementation of the programme was based on the female population between 50 and 69 years of age resident in Florence.
Effectiveness results The number of cases of cancer detected under the screening programme was 117 whereas the number of cases in the absence of a screening programme was 30.
Clinical conclusions The implementation of a programme of screening for breast cancer detection increases the number of detected cases compared with the absence of the programme (117 and 30 respectively).
Modelling No modelling was applied.
Methods used to derive estimates of effectiveness The authors made some assumptions based on historical data provided by the same institution and published in 1994.
Estimates of effectiveness and key assumptions The authors assumed that 9.5% of the women invited to undertake the screening would have considered the test in the absence of the implementation of screening programme and 4.3% of them would have been recalled for further examinations.
Measure of benefits used in the economic analysis Since the analysis did not considered the benefits of the treatment following the results of the screening, the only health outcome used was the number of cancers detected by mammographic screening and further examinations.
Direct costs Costs and resources were separately estimated from a health service perspective and were not discounted at market prices. Costs included the invitations to undertake the screening, equipment for tests, hardware, furnishings, mobile facility, informative advertising, costs of maintenance, costs of management and personnel costs. The estimation of the costs and quantities was based on actual data. Equipment was evaluated by calculating the rate of mortgage for a period of 8-10 years on the cost of purchase - most was bought after 1990. Similar criteria were adopted for the other overhead costs. Personnel costs were calculated by referring to 1993 data. The average total cost per woman examined was reported in the study.
Statistical analysis of costs Costs were not treated in a stochastic way.
Sensitivity analysis The generalisability of the results was investigated by conducting a one-way sensitivity analysis on the rate of compliance, the rate of recall for further examinations (women whose screening was positive) and costs.
Estimated benefits used in the economic analysis 117 cases of cancer were diagnosed under the screening programme whereas 30 cases were estimated to be diagnosed in the absence of the screening programme.
Cost results The total cost per woman was L64,693 under the screening programme and L95,921 in the absence of screening.
Synthesis of costs and benefits Costs and benefits were combined by calculating the cost per case diagnosed. This was L8,158,629 under the screening programme and L5,665,756 in the absence of screening.
Authors' conclusions The authors did not compare the cost per case diagnosed under the two alternatives. Rather, since this represents only a first step in a more comprehensive study and the benefits of cancer detection were not considered, conclusions were based on the cost per woman examined under the screening programme and in its absence (L95,921 and L53,174 respectively). As expected, the former is higher since more costly investments are required in order to make the screening programme available.
CRD COMMENTARY - Selection of comparators The choice of comparator (no screening programme for cancer detection) is justified.
Validity of estimate of measure of benefit Benefits included the number of diagnosed cases, but did not take into account the specificity and sensitivity of the tests and the related benefits of treatment for patients with positive test results.
Validity of estimate of costs Direct costs were carefully estimated, however the estimate did not include indirect and intangible costs.
Other issues A large number of women between 50 and 69 years was included in the study, however the generalisability of the results is limited by the restricted area of investigation, including, as it did, only the city of Florence. The rate of incidence may differ in other areas. A sensitivity analysis on the estimated incidence of cancer was not conducted by the authors. It should be noted that, as stated above, this study represents only the first stage in a more comprehensive study aimed at evaluating the cost-effectiveness of a screening programme for breast cancer detection versus the alternative of no screening programme. An initial evaluation of the effectiveness of the programme is possible, given the analysis of the cost per case detected, however, the authors have not, as yet, considered the benefits of treatment for individuals with positive test results.
Implications of the study This first step in the study of the effectiveness of a screening programme for cancer detection needs to be validated by further analysis to include the benefits and costs deriving from a longer follow-up of the women tested.
Bibliographic details Spagnolo G, Zappa M, Paci E, Giorgi D, Rosselli del Turco M. La valutazione dei costi del programma di screening mammografico nella citta di Firenze. [Evaluation of the costs of mammographic screening programme in the city of Florence] Epidemiologia e Prevenzione 1995; 19(65): 330-337 Indexing Status Subject indexing assigned by NLM MeSH Breast Neoplasms /diagnosis; Female; Health Care Costs; Health Promotion; Humans; Italy; Mammography /economics /methods; Women's Health AccessionNumber 21997006254 Date bibliographic record published 31/03/1999 Date abstract record published 31/03/1999 |
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