Problema General

Both the interventions above aimed at improving CRC uptake by African Americans targeted patients and neither study considered cost-effectiveness. A number of US studies have assessed the cost-effectiveness of clinician reminders to improve CRC screening rates, although they do not specifically focus on the impact on ethnic minorities. These are described briefly below, and referenced at the end of the chapter rather than the bibliographic register or Table 2.3.3 since they do not specify the population studied.

Frame et al (1994) have assessed the relative cost-effectiveness of computer-based vs manual health maintenance tracking systems to improve provider (clinician) compliance with health maintenance protocols, including FOBt, mammography, clinical breast examination, and cervical smears. A randomised controlled trial was conducted in a sample of 1,665 patients in a rural, multiple-office, non-profit, fee for service US family practice. Overall provider compliance increased by 15% in the computer-based tracking group, and by 4% in the manual paper group, compared to the control group. Patient concordance was also significantly higher with changes in overall compliance of 27.1% in the computer-based trial group, as opposed to 13.5% in the control group (p=0.02). The average cost of maintaining the computer system, generating reminders, and mailing patient reminders was calculated to be $US0.78 per patient per year. Although no attempt was made to assess the cost of the manual system, this might be expected to be higher, and therefore the computerised reminder intervention would be more cost-effective.

Bird et al (1990) report an RCT of 62 US internal medicine residents to evaluate the use of three strategies to improve the performance of cancer screening tests (FOBt, digital rectal examination, sigmoidoscopy, pap smear, pelvic examination, clinical breast examination, and mammography). Two of the strategies, medical audit with monthly feedback and computerised cancer screening reminders (patient's screening status when visiting the practice), were targeted at physicians. The third was a patient education strategy (reminder letter with appointment and postcard reminder if overdue). Implementation costs were respectively $US9.63 per patient, $US12.93, and $US3.11. Including any additional downstream costs (i.e. the cost of subsequent tests), the net cost per additional test performed was: $US50.40 for audit with feedback, $US18.19 for computerised cancer

screening reminders, and $US51.20 for patient education. Thus the computerised cancer screening reminder intervention was similarly judged to be the most cost-effective.

A further study demonstrates the cost-effectiveness of a reminder combined with a financial incentive. Morrissey et al (1995) evaluated a combined financial incentive and reminder intervention to increase uptake of preventative care in physicians’ offices for those aged 65 years or more. Overall 1,914 patients from 10 primary care medical practices were randomised either to a usual care control or intervention group (i.e. full MEDICARE reimbursement for physicians, making these services free to patients plus manual paper reminders to physicians to schedule preventative care visits). The ‘preventative care’ package included FOBt, digital rectum examination, and (for women) smear test and breast examination. At 2 years, the performance of screening tests was higher in the intervention group than the control group (P<0.001). The 3-year average Medicare costs were also lower in this group due to significantly lower hospital utilisation (P<0.02), and therefore the intervention was judged cost-effective.

One study indicates that a patient letter may be more cost-effective than a physician reminder (Belcher 1990). A randomised-controlled trial was conducted of 3 different models of delivery of preventive services to 1,224 male outpatients. These included: a) use of a physician-orientated paper reminder involving education and motivation and chart flow sheets, listing recommended activities together with periodic feedback to physicians on their performance; b) use of a patient education model whereby patients were posted an information brochure designed to encourage them to ask for preventive services which were outlined in a patient-held pocket guide; c) use of a patient invitation letter to attend a health promotion clinic. The 3 means of delivering preventative medicine were compared with a control group. The study findings indicated that only reminder intervention c) resulted in measurable improvements relative to the control group. Rates for faecal occult blood testing increased from 22% to 78% during the first year, were sustained for 5 years, and were statistically significant. Costs were also measured and demonstrate that a letter invitation to attend a health promotion clinic will be cost-effective.

2.7

UK cancer screening intervention studies (see Table A4.4 in Appendix

A4)

• UK intervention studies almost exclusively focus on South Asian women; research on Chinese, African- Caribbean and other minority women is largely lacking. Almost all studies use the meta-category 'South Asian' rather than considering Asian sub-groups.

• There is limited UK research on interventions to improve cervical cancer screening uptake by Asian women. The only trial identified that home visits are more effective than a postal leaflet. International studies provide some evidence of the greater effectiveness of a linkworker versus a patient reminder letter for improving uptake by ethnic minority women.

• For breast cancer screening, a large number of UK studies have evaluated letter/ telephone follow up, linkworkers and 'multi-strategy' interventions. The use of a reminder letter appears to have a limited role in improving uptake by ethnic minorities. Unlike cervical cancer screening, there also appears to be no evidence that home visits by a linkworker are effective in improving uptake.

• The only UK study to examine the cost-effectiveness of interventions to improve breast screening uptake by ethnic minority women reports that a GP letter is more cost-effective than a flag in patient notes;

linkworkers were not included in the trial.

• There is evidence from studies in London, Cardiff, Bradford and Berkshire that a multifaceted strategy can lead to a relatively high ethnic uptake of breast (and cervical) screening. The cost-effectiveness of such an intervention has not been assessed.

The literature on evaluation of interventions to improve cervical/ breast screening uptake by ethnic minority populations in the UK is much more extensive than the US literature on CRC screening interventions. Most studies focus on South Asian women and, once again, research on African-Caribbean women is largely missing.

Studies do not normally consider Asian sub-groups and instead report findings for the meta-category 'South Asian'. Only one paper considers cervical cancer screening and one both breast and cervical cancer screening; the remainder report on intervention to improve uptake of breast screening.