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Contrasting costs of a prostate cancer educational program by income |
Weinrich S P, Weinrich M, Ellison G, Hudson J, Reeder G, Weissbecker I |
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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 The use of two alternative educational interventions, oriented to inform the risks and benefits of prostate cancer screening. There were followed by screening, using a digital rectal examination (DRE) and/or drawing of blood for a prostate-specific antigen (PSA) test, and a biopsy for those men with abnormal results. The core of the educational interventions included a slide-tape presentation and a handout on prostate cancer. Four types of educational programmes were categorised in two groups of interventions, non-client navigation (NCN) and client-navigation (CN) methods.
NCN methods included either the presentation of the core content alone, or with the addition of a peer-educational method where men treated for prostate cancer gave testimony about the advantages of prostate cancer screening.
CN methods included the core content plus a call to the participants (1 week after the educational programme), to overcome barriers to screening, and three reminders (a calendar, a key ring and a refrigerator magnet). They also included a combination method with the additional intervention of a peer-educator.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised both African American men aged 40 to 70 years old and white men aged 50 to 70 years old, who had no history of prostate cancer. The men were not currently or recently under evaluation for prostate cancer (i.e. during the 12 months before the study), and were mentally orientated as to the date and place. Three income groups were considered, low income ($9,600 or less), middle income ($9,601 - $25,020) and higher income ($25,021 or more).
Setting The setting appears to have been the community for the educational programmes, and secondary or tertiary care for the screening evaluation. The study was performed in South Carolina, USA.
Dates to which data relate The dates to which the effectiveness and resource use data related were not reported. The price year was 1995.
Source of effectiveness data The effectiveness data were derived from a single study.
Link between effectiveness and cost data The costing appears to have been performed prospectively on the same sample population as that used in the effectiveness analysis.
Study sample No power calculations to assure a certain power were performed during the planning phase of the study. Among 1,172 men from 86 work sites participating in the educational programmes, 1,086 met the inclusion criteria. To be considered in the analysis, the majority of employees in the work sites had to earn the minimum wage, and at least 50% of them had to be African American. In total, 178 low-income men, 488 middle-income men, and 420 higher-income men were included in the study, although the authors did not report the total number who received either the NCN or the CN methods. A total of 104 men were excluded, either because they did not meet the inclusion criteria, or because they did not complete an initial questionnaire on the baseline characteristics of the participants. The authors did not show evidence that the study sample was representative of the study population.
Study design This appears to have been a randomised controlled study, although the authors did not report the method used to randomly allocate the educational programmes to each of the participating sites. The study was multi-centred since men from 86 work sites were included. The authors did not report any loss to follow-up. No blinding method appears to have been used.
Analysis of effectiveness All the participants in the study appear to have been considered for the analysis of the results. The primary health outcomes reported were:
the percentage of men screened over the total men that attended each educational method, overall and by income group;
the percentage of men that did not undergo either DRE or PSA by income group; and
the number and percentage of men with prostate cancer detected over the total number of men screened by income groups.
The low-income group was shown to be significantly younger, with more African American and less educated men than the higher income groups.
Effectiveness results The percentages of men screened over the total who attended the NCN method were 64.2% overall, 50% among the low-income men, 62.8% among the middle-income men, and 72.7% among the higher-income men.
The percentages of men screened over the total men who attended the CN method were 77.1% overall, 70.3% among the low-income men, 78.6% among the middle-income men, and 77.9% among the higher-income men. The authors stated that those receiving the CN method were more likely to obtain screening than those receiving the NCN method, (p=0.001).
The percentage of men who did not undergo either DRE or PSA was 41.6% in the low-income group, 29.5% in the middle-income group, and 24.8% in the higher-income group.
In total, 7 men in the low-income group, 6 in the middle-income group and 4 in the higher-income group were detected with prostate cancer.
The percentage of men with prostate cancer detected over the total number of men screened was significantly higher among the low-income group (6.7%) than the middle-income group, (1.7%; p=0.014), and the higher-income group, (1.3%; p=0.007).
Clinical conclusions The participation rates for screening were lower among the low-income group, although men in this group showed higher detection rates of prostate cancer. The participation rates were higher with the CN methods than with the NCN methods.
Measure of benefits used in the economic analysis The summary measure of benefit used in the economic analysis was the percentage of men detected with prostate cancer according to income level. This measure was obtained directly from the effectiveness analysis.
Direct costs The resource quantities and the costs were not reported separately. The direct costs considered in the study appear to have been those of the health service. These were the organisational costs for providing the educational programme, screening (visits to the physician to have a DRE and/or a PSA) and check-up reminders (in the case of the combined CN method). The organisation costs included personnel and travel, recruitment of sites, charges for telephone calls, and so on. The direct costs appear to have been taken from a study by Weinrich et al. (see Other Publications of Related Interest). Moreover, the authors seem to have made some assumptions to estimate costs that were comparable across sites, according to the number of attendees per site (6, 12 or 24; average number of men per site was 12.4) and the distance of the site (local versus long distance, depending on the telephone toll charges applied). Discounting was not performed, which was appropriate as the costs seem to have been incurred during less than one year. The study reported the average cost per attendee. The price year was 1995.
Statistical analysis of costs The authors stated that the costs were computed as averages, thus inferential statistics were not appropriate.
Indirect Costs No indirect costs were reported.
Sensitivity analysis No sensitivity analysis was performed.
Estimated benefits used in the economic analysis See the 'Effectiveness Results' section.
Cost results The costs per man screened varied according to the number of men screened by site and the distance of the site.
With the NCN method, the costs per attendee in a local site were $26.98 (6 attendees per site), $13.49 (12 attendees per site) and $6.79 (24 attendees per site), depending on the number of attendees per site. The corresponding costs in a long distance site were $34.67 (6 attendees), $17.34 (12 attendees) and $8.68 (24 attendees), respectively.
With the CN method, the costs per attendee in a local site were $33.80 (6 attendees per site), $20.69 (12 attendees per site) and $14.15 (24 attendees per site), depending on the number of attendees per site. The corresponding costs in a long distance site were $44.41 (6 attendees), $28.11 (12 attendees) and $19.95 (12 attendees), respectively.
For both types of methods (NCN and CN), the costs per attendee were higher for low-income men in comparison with higher-income men.
Synthesis of costs and benefits Cost-effectiveness ratios were calculated as the cost per cancer detected by the educational programme and income level.
Depending on the number of attendees per site and the type of site, the cost per cancer detected among the low-income men varied from $129 (for a local site with 24 attendees) to $664 (for a long distance site with 6 attendees) with the NCN method. With the CN method, this cost varied from $232 (for a local site with 24 attendees) to $727 (for a long distance site with 6 attendees).
The cost per cancer detected among the middle-income men varied from $406 (local site with 24 attendees) to $2,085 (long distance site with 6 attendees) with the NCN method. With the CN method, this costs varied from $816 (local site with 24 attendees) to $2,562 (long distance site with 6 attendees).
The cost per cancer detected among the higher-income men varied from $458 (local site with 24 attendees) to $2,355 (long distance site with 6 attendees) with the NCN method. With the CN method, this cost varied from $1,077 (local site with 24 attendees) to $3,381 (long distance site with 6 attendees).
No incremental cost-effectiveness analysis was performed.
Authors' conclusions Targeting lower-income men for prostate cancer screening was cost-effective due to the higher prostate cancer rate found among this group. This led to a greater reduction in the cost per cancer detected for lower-income men than for middle- or higher- income men.
CRD COMMENTARY - Selection of comparators No justification was given for the comparators used in the study, and none of the educational methods was explicitly stated as the comparator. You should decide whether these are widely used health technologies in your own setting.
Validity of estimate of measure of effectiveness The study appears to have been a randomised controlled study, as reported by the authors, although the method of randomisation used was not stated and it is not known whether it was appropriate. Moreover, the authors did not report how many men were assigned to each educational method, as only percentages were reported. Some effectiveness estimators were given according to the income group, some by educational method, and some for both. Nevertheless, there was a lack of reporting. This meant that it was not possible to link some data by income with data by educational method, which would appear relevant in this study. As may be expected, the income groups were shown to be significantly different, although the authors did not report any information that would have allowed the comparison of groups receiving different educational methods. The study sample was not shown to have been representative of the study population, although the fact that men from 86 different work sites were included increases the likelihood that it was. The period to which the effectiveness data related was not reported. There is, therefore, some uncertainty surrounding the validity of the effectiveness results.
Validity of estimate of measure of benefit The estimation of benefits (detection rates for prostate cancer by income groups) was obtained directly from the effectiveness analysis. This choice of estimate appeared to be implicitly justified because of the objective of the study. The use of an alternative measure of benefit, such as the life-years gained or the quality-adjusted life-years, did not appear possible within the framework of this study (i.e. a primary study with a very limited follow-up).
Validity of estimate of costs It is not possible to say whether all the costs relevant to the perspective adopted were considered, as a detailed list of the costs included was not provided. The costs and the quantities were not reported separately and statistical analyses of the resource quantities were not performed. These factors introduce uncertainty into the reliability of the cost results. The price year was given. Discounting was not performed, which was appropriate since the costs were incurred during a short time. The authors justified the lack of statistical analyses of the costs. Sensitivity analyses were also not performed. Therefore, there is uncertainty surrounding the cost results.
Other issues The authors did not make appropriate comparisons of their findings with those from other studies. This may, however, have been due to the lack of existing studies comparing the cost-effectiveness of prostate cancer educational interventions by income. The issue of generalisability of the results to other settings was not addressed. The lack of reporting of some relevant data may imply that the results were presented selectively.
Implications of the study The authors highlighted the relevance of targeting lower-income men, to increase their participation in prostate cancer screening programmes, given the higher detection rates of prostate cancer that these men have. They recommended further research to identify the most cost-effective educational interventions to inform this group. They also drew attention to the need for providing financial assistance to this more needy group.
Source of funding Supported by the National Cancer Institute, grant number RO1 CA60561.
Bibliographic details Weinrich S P, Weinrich M, Ellison G, Hudson J, Reeder G, Weissbecker I. Contrasting costs of a prostate cancer educational program by income. American Journal of Health Behavior 2000; 24(6): 422-433 Other publications of related interest von Eschenbach AC, Ho R, Murphy GP, Cunningham M, Lins N. American Cancer Society guideline for the early detection of prostate cancer: update 1997. CA: a Cancer Journal for Clinicians. 1997;47:261-4.
Weinrich SP, Weinrich M, Atwood J, Cobb M. Cost for prostate cancer educational programs by race and educational programmes by race and educational intervention. American Journal of Health Behavior 1999;23:144-56.
Indexing Status Subject indexing assigned by CRD MeSH African Americans; African Continental Ancestry Group; Aged; Cost-Benefit Analysis; European Continental Ancestry Group; Income; Male; Middle Aged; Occupational Health Services; Program Evaluation; Prostate-Specific Antigen /analysis; Prostatic Neoplasms /education /diagnosis /prevention & Socioeconomic Factors; United States; control AccessionNumber 22001007598 Date bibliographic record published 31/05/2004 Date abstract record published 31/05/2004 |
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