|Costs and cost-effectiveness of a church-based intervention to promote mammography screening
|Stockdale S E, Keeler E, Duan N, Derose K P, Fox S A
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.
The use of a church-based mammography promotion intervention, comprising telephone counselling supplemented with mailed materials.
Type of intervention
Primary prevention promotion.
Economic study type
The study population comprised women aged 50 to 70 years who attended church services at least once per month.
The setting was the community. The study was carried out in 45 churches in the southern Los Angeles county area, USA.
Dates to which data relate
The effectiveness evidence and data on resource use were derived from studies published in 1995 and 2000. The price year was 1997.
Source of effectiveness data
The effectiveness evidence was derived from a review of published studies.
Outcomes assessed in the review
The outcomes assessed from the literature were the increase in mammography maintenance in adherent women (those who had already undergone mammography) and the increase in mammography use in nonadherent women receiving the promotion intervention, compared with no intervention. The increase in days of life per woman screened with mammography was also assessed.
Study designs and other criteria for inclusion in the review
Sources searched to identify primary studies
Criteria used to ensure the validity of primary studies
Methods used to judge relevance and validity, and for extracting data
Number of primary studies included
The effectiveness evidence was obtained from two primary studies.
Methods of combining primary studies
The primary studies were combined in the narrative.
Investigation of differences between primary studies
Results of the review
Compared with no intervention, the increase in mammography maintenance was 7.5% for adherent women participating in the programme, (p=0.029).
Compared with no intervention, the increase in mammography use was 2.6% for nonadherent women participating in the programme, (p=0.323).
The increase in days of life was 9.8 days per woman screened with mammography.
Measure of benefits used in the economic analysis
The benefit measure used in the economic analysis was the number of life-years saved with the mammography promotion programme, compared with no intervention. The number of additional screenings due to the promotion programme was also calculated.
No discounting was carried out since the costs were incurred over a period of 2 years. The unit costs and the quantities of resources were reported separately. The cost/resource boundary adopted reflected the different perspectives from which the study was conducted (see 'Hypothesis/Study Question' section). The cost items included in the analysis referred to recruitment, training and meetings, phone counselling, and mailed supplemental materials. The personnel costs were calculated according to each specific perspective. The costs were classified as direct and indirect, but this referred to a sub-classification of the cost items included in the study. Precise details of the costing analyses were provided. The quantities were estimated from published studies, while the costs were estimated using both official data and published studies. The authors made several assumptions. The price year was 1997.
Statistical analysis of costs
No statistical analysis of the costs was carried out.
The indirect costs do not appear to have been included in the analysis.
Sensitivity analyses were carried out to assess the robustness of the estimated cost per additional screening of model 1 to variations in the effectiveness of the intervention among adherent and nonadherent participants. The costs of the materials alone were also calculated for both patient groups
Estimated benefits used in the economic analysis
The number of extra screenings due to the intervention was 3.24.
The life-years saved with the mammography promotion programme, compared with no intervention, were not reported.
The total costs per church and participant were $609.98 and $10.89 in model 1, $1,579.04 and $28.20 in model 2, and $2,927.07 and $52.27 in model 3.
Synthesis of costs and benefits
Several incremental cost-effectiveness analyses were carried out to combine the costs and the benefits of comparing mammography promotion and no intervention.
The cost per additional screening was $188.27 in model 1, $487.38 in model 2, and $903.42 in model 3.
The total cost per life-year saved was calculated by summing the additional cost of outreach per life-year saved with the intervention ($7,002 in model 1, $18,138 in model 2, and $33,632 in model 3) and the cost per life-year saved by mammography (estimated from the literature as $12,676). Consequently, the total cost per life-year saved by mammography promotion was $19,678 in model 1, $30,814 in model 2, and $46,308 in model 3.
In the worst-case scenario, the cost per additional screening was $1,089 for all adherent participants and less than zero for all nonadherent participants. In the best-case scenario, the cost per additional screening was $75 for all adherent participants and $100 for all nonadherent participants.
The costs of materials alone were $70 for adherent women and $202 for nonadherent women.
For an average church congregation with approximately 200 to 400 active members, the church-based mammography promotion intervention proved to be a feasible and cost-effective programme, especially with the use of volunteer labour and resources.
CRD COMMENTARY - Selection of comparators
The rationale for the choice of the comparator was clear. No intervention was selected since no screening promotion was actually conducted in the study setting, and the aim of this study was to assess the active value of the intervention. You should assess whether a screening promotion intervention is carried out in your own setting.
Validity of estimate of measure of effectiveness
The effective analysis used limited data derived from published studies. However, a formal review of the literature was not performed. The effectiveness estimates were not combined as the authors used data from the available studies selectively. Some sensitivity analyses were carried out on the effectiveness estimates, due to the uncertainty of the data. These may partially address the limitations of the effectiveness data.
Validity of estimate of measure of benefit
The benefit measure used in the economic analysis was the number of life-years gained with the screening promotion intervention. It appears to have been appropriate and comparable with other interventions. However, the actual number of life-years gained was not reported and the estimation was partially based on a published study. Therefore, the benefits of the programme need to be treated with caution.
Validity of estimate of costs
The authors stated that the study was carried out from three different perspectives, but it was unclear which types of indirect costs were included. In terms of the direct programme costs, precise details of the costing analyses were provided. In addition, the unit costs and the quantities of resources were reported separately. The price year was stated implicitly. However, the costs were treated deterministically and sensitivity analyses were not carried out, thus limiting the generalisability of the cost results.
The authors made some comparisons of their findings with those from other studies. The issue of the generalisability of the study results to other settings was not explicitly addressed. However, sensitivity analyses were carried out and the costs and the quantities were reported separately. These enhance the generalisability of the findings. The population comprised women aged 50 to 70 years who regularly attended church services, and this was reflected in the authors' conclusions.
Implications of the study
The authors noted that there was no evidence that the effects of the intervention would be long lasting. It was suggested that the implementation of the programme using a network of churches or private or government partners could reduce the fixed costs, thus enhancing the cost-effectiveness of the intervention. Finally, it should be noted that some religious groups may not be willing to implement such an intervention in their community.
Source of funding
Supported by the National Institutes of Health, National Cancer Institute, award 1 R0/1 CA65880.
Stockdale S E, Keeler E, Duan N, Derose K P, Fox S A. Costs and cost-effectiveness of a church-based intervention to promote mammography screening. Health Services Research 2000; 35(5 Part 1): 1037-1057
Other publications of related interest
Comment: Health Services Research 2000;35(5 Pt 1):905-9.
Subject indexing assigned by NLM
Aged; Aged, 80 and over; Christianity; Community-Institutional Relations /economics; Cost-Benefit Analysis; Feasibility Studies; Female; Health Care Costs /statistics & Health Promotion /economics; Health Services Research; Humans; Los Angeles; Mammography /economics /utilization; Mass Screening /economics; Middle Aged; Minority Groups; Models, Econometric; Poverty; Program Evaluation; Sensitivity and Specificity; Surveys and Questionnaires; Women's Health Services /economics /utilization; numerical data
Date bibliographic record published
Date abstract record published