Elsevier

Preventive Medicine

Volume 38, Issue 4, April 2004, Pages 403-411
Preventive Medicine

Cost-effectiveness of a tailored intervention to increase screening in HMO women overdue for Pap test and mammography services

https://doi.org/10.1016/j.ypmed.2003.11.024Get rights and content

Abstract

Background. Research has established the societal cost-effectiveness of providing breast and cervical cancer screening to women. Less is known about the cost of motivating women significantly overdue for services to receive screening.

Methods. In this intent-to-treat study, a total of 254 women, aged 52–69, who were overdue for both Pap test and mammography, were randomized to two groups, a tailored, motivational outreach or usual care. For effectiveness, we calculated the percent of women who received both services within 14 months of randomization. We used a comprehensive cost model to estimate total cost, per-participant cost, and the incremental cost-effectiveness of delivering the outreach intervention from the health plan perspective. We also conducted sensitivity analyses around two key parameters, target population size and level of effectiveness.

Results. Compared with usual care, outreach (P = 0.006) screened significantly more women. The intervention cost $167.62 (2,000 U.S. dollars) for each woman randomized to outreach, and incremental cost-effectiveness of outreach over usual care was $818 per additional woman screened. Sensitivity analyses estimated incremental cost-effectiveness between $19 and $90 per additional woman screened.

Conclusions. Larger health plans can likely increase Pap test and mammography services in this population for a relatively low cost using this outreach intervention.

Introduction

Although mammography and Pap screening rates have been increasing in the United States [1], [2], [3] and many managed care organizations have established programs to screen women, many women do not obtain screenings despite access to these services [1]. In some large managed care organizations that devoted resources to screening their age-eligible women, as many as 30% of the women failed to get breast or cervical cancer screening for 3 years [4]. A number of studies have examined the effectiveness of generic, group-targeted, and individually tailored prompts for cancer screening [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. Of these various interventions, prompts that are tailored to individual barriers have been found to be particularly effective [8], [9], [15]. Although tailored prompts have demonstrated success in bringing women to obtain screening, a substantial proportion of women do not respond even to multiple prompts. The women who do not respond to screening prompts are generally those who have gone the longest since their last screening or are women who have never been screened. This trend is of concern, since lack of regular mammogram and Pap screening relates to later-stage breast cancer once it is diagnosed [16], [17] and accounts for the majority of new cervical cancer in the United States [18]. Women not screened for 5 or more years have nearly 2/3 of the invasive cervical cancers [4], [19], and unscreened women are more likely to have other risk factors, such as cigarette smoking [15], [20].

Before health systems allocate additional resources to trying to reach at-risk women, they need an effective approach that they are able to implement and that is cost-effective. We recently conducted a randomized trial (using intent-to-treat design) comparing usual care and a tailored outreach intervention aimed at women, aged 50–69, overdue for both a mammogram and a Pap test. We found significantly improved screening rates over usual care for women who received a tailored outreach letter that addressed patient-specific barriers to obtaining Pap and mammogram screening, followed 6 months later by a tailored telephone call to women who still had not been screened for both services [21]. However, it is not clear that this or other specific interventions are worth the expenditures to health plans. Therefore, HMOs need the answer to the question, “How much additional cost is required to get these unscreened women in for needed cancer screening services?”

Past studies have shown that providing Pap smears and mammography to women in this age group [23], [24], [25] is reasonably cost-effective compared to other medical interventions. Some studies have evaluated cost-effectiveness of these services from the societal perspective. The Public Health Services guidelines on cost-effectiveness analysis [26] state that the societal perspective should include all of the costs of an intervention to all affected parties including direct costs of the intervention, all other health care costs, and patient costs. Societal cost-effectiveness information helps to establish priorities among recommended clinical services from a broad perspective, and our prior research indicates that published societal cost-effectiveness information is factored in some health plan managers' decisions about which clinical prevention services should receive additional health plan resources [22]. However, these cost-effectiveness data do not specifically address the costs to a health plan of discrete or alternative strategies to reach and motivate unscreened women to receive needed Pap and mammogram screening services. Our research indicates that more detailed cost information on specific intervention strategies could help health plan decision makers choose and successfully implement specific clinical prevention intervention strategies [22].

Other studies have examined the cost-effectiveness of discrete strategies for encouraging mammography screening [27], [28], [29], [35]. Some interventions were tested in nonmedical settings such as churches [35]. Other interventions, such as those analyzed by Saywell et al., differ in several other respects from the Valanis et al. interventions. Valanis et al. targeted a population that was harder to reach than in previously published studies. The Valanis et al. criteria were women overdue for both Pap test and mammography screening for at least 24 months, most of whom were 5 or more years past due. Prior studies examined women overdue for just mammography for significantly fewer months [21], [28], [29]. In addition, prior studies required “buy-in to counseling as part of the consent process,” while Valanis et al. recruited using electronic databases and questionnaires. Finally, prior studies used interviews to gather barriers information, while Valanis et al. generated individual barriers information from questionnaires. This analysis aims to provide HMOs and other large health plans that are particularly interested in focusing on women at increased risk for advanced disease with information about the cost-effectiveness of a new strategy to increase participation in two key preventive screening programs.

Section snippets

Overview

We present the estimated incremental cost-effectiveness of an outreach intervention to increase Pap test and mammography used in women age 52–69, who are overdue for both these services. Our effectiveness data are based on a recent randomized trial conducted at Kaiser Permanente Northwest. The primary outcome is the incremental cost per additional woman screened with both Pap testing and mammography in the outreach intervention compared to the usual-care-only control condition.

Setting

We analyzed this

Results

Over the course of the intervention 127 women were randomized to the usual care plus outreach intervention. Of these, 50 (39%) received both Pap test and mammography screening services within 14 months of the intervention. The usual-care-only control group also had 127 women, and 24 (19%) received both Pap test and mammography screening services within the study period [21]. These rates of receipt of services were used in the base-case, cost-effectiveness analysis.

Discussion

We analyzed the cost and effectiveness of a tailored outreach intervention for increasing the number of women receiving both Pap test and mammography screening in a population overdue for both these services. We examined the actual cost-effectiveness associated with delivering the intervention in the randomized clinical research trial, and we conducted sensitivity analyses to examine how the cost-effectiveness of providing the intervention would vary for three typically sized target

Acknowledgements

This study was funded by a program project grant from the National Cancer Institute, PO1 CA72085. The authors would like to thank Cacie Cunningham for excellent research assistance and Jen Coury for excellent editorial support.

References (37)

  • Self-reported use of mammography among women aged greater than or equal to 40 years—United States, 1989 and 1995

    MMWR Morb. Mortal. Wkly. Rep.

    (1997)
  • L.M. Anderson et al.

    Has the use of cervical, breast, and colorectal cancer screening increased in the United States?

    Am. J. Public Health

    (1995)
  • J.D. Allen et al.

    Intention to have a mammogram in the future among women who have underused mammography in the past

    Health Educ. Behav.

    (1998)
  • S.J. Curry et al.

    Theoretical models for predicting and improving compliance with breast cancer screening

    Ann. Behav. Med.

    (1994)
  • J.S. Mandelblatt et al.

    Effectiveness of interventions designed to increase mammography use: a meta-analysis of provider-targeted strategies

    Cancer Epidemiol. Biomarkers Prev.

    (1999)
  • R.K. Yabroff et al.

    Interventions targeted toward patients to increase mammography use

    Cancer Epidemiol. Biomarkers Prev.

    (1999)
  • C.S. Skinner et al.

    How effective is tailored print communication?

    Ann. Behav. Med.

    (1999)
  • V.L. Champion et al.

    Comparisons of tailored mammography interventions at two months postintervention

    Ann. Behav. Med.

    (2002)
  • Cited by (21)

    • Cost-effectiveness of targeted versus tailored interventions to promote mammography screening among women military veterans in the United States

      2011, Evaluation and Program Planning
      Citation Excerpt :

      Comparing the interventions to the no cost control group, yields a cost per additional woman screened of between $39 and $56. Another HMO in-reach study found that compared to usual care, a tailored intervention increased mammography screening rates by 20% at a cost of $818 per additional woman screened (Lynch, Whitlock, Valanis, & Smith, 2004). While these “in-reach” interventions were very effective, a recent meta-analysis reported significant heterogeneity in the effect sizes of published health-plan based intervention studies for repeat mammography (i.e., some studies reported null effects compared with control groups) (Vernon, McQueen, Tiro, & del Junco, 2010).

    • Cost-Effectiveness of Guided Self-Help Treatment for Recurrent Binge Eating

      2010, Journal of Consulting and Clinical Psychology
    • Patient-mediated interventions to improve professional practice

      2018, Cochrane Database of Systematic Reviews
    View all citing articles on Scopus
    View full text