Treatment of pre-invasive conditions during opportunistic screening and its effectiveness on cervical cancer incidence in one Norwegian county.

Norway had until recently no organized screening programme for cervical cancer, but opportunistic screening was common. This study focuses on the effectiveness of treatment of pre-malignant cervical conditions (CIN III) on cervical-cancer incidence in the county of Sør-Trøndelag in Norway, prior to the introduction of organized mass screening. The study is based on cervical-cancer incidence rates during the years 1965-92 and treatment data for CIN III. The expected number of cervical-cancer cases prevented due to early intervention was expressed in a regression model with 2 unknown parameters: the probability, p, of cancer development in case of CIN III, and the time lag, t, between treatment and when clinical cancer would otherwise have been diagnosed. The estimated probability that a patient treated for CIN III would have developed cervical cancer if not treated was found to be approximately 20%, and the mean time delay was around 16 years. In the last period of study (1988-92), the incidence was reduced by nearly 40% of what would have been expected without early intervention. Based on equal treatment rates as in 1990, parameter estimates were used to predict future incidence reduction. Maximum effectiveness will be achieved around the year 2005, with a nearly 70% reduction. Opportunistic screening and treatment of CIN III seems to have had considerable influence on cervical-cancer incidence. The costs, however, are substantial over-treatment, since our results indicate that 4 of 5 women treated for CIN III would not progress into the invasive state.

Use of pap-smears in a population without a mass screening program.

STUDY OBJECTIVE: To analyze the use of Pap-smears in a population where a screening program was not offered. DESIGN: Retrospective analysis of pathology registry data on women resident in two counties of Norway. SETTING: Evaluation of opportunistic screening by age and year of birth. Proportion of population tested during successive 3-year periods. MATERIAL: 353,665 smears from 88,048 women examined since 1973. For this purpose we concentrated on 257,951 smears from 77,431 women examined during the period 1981-90. RESULTS: Between 62 and 67% of women examined during each 3-year period were 20-39 years old, 14-16% were 50-69 years of age. Throughout the ten-year period the frequency of Pap-smear testing of women over 60 and under 20 increased slightly whereas it decreased for women 20-39 years old. Follow-up of positive or atypical smears comprised about 25% of all smears. The highest proportion of follow-ups was found among women 30-49 years old. About one third of women aged 20-59 years had more than one smear taken in a 3-year period, follow-up smears excluded. CONCLUSION: More than half of the women aged 50 and above have no smears or smears less than one every third year. This proportion increases with age. The use and distribution of smears by age is still far from the situation expected in an organized screening program although a slight amelioration was observed through the study period.

Societal costs of antenatal and obstetrical care.

Perinatal health care is an important part of a nation's health care system. In the Nordic countries this type of health care is provided by the national public health systems without cost for the women. The societal costs of the care provided have, however, not been known. The aim of the present study was to estimate societal costs of antenatal and obstetrical care in a Norwegian county during a twelve month period 1988-89. A total of 1908 women delivered during the registration period. The mean total cost was estimated to NOK 36.300 per woman. Primary care antenatal visits accounted for 8%, outpatient visits (inclusive ultrasound screening) 4%, and hospital care in connection with delivery represented 36% of the total cost. The major determinant of societal costs was sick leave during pregnancy, contributing 43% to the total cost. This underlines the importance of the ongoing debate about sick leave in pregnancy. The mean cost of primary care based antenatal care, averaging 10.8 visits per woman, was estimated to NOK 2.800. An important factor was use of patients' own time, accounting for 35% of this amount. The prevalence at the time of admission for delivery of five important complications or obstetrical conditions (pre-eclampsia, placenta previa, intrauterine growth retardation, twin pregnancy, and breech presentation) was recorded. The mean total societal cost for women with the indicator conditions was approximately one fifth greater than for women without any of the indicator conditions.

The feasibility of a public-private long-term care financing plan.

In this study, the feasibility of a public-private long-term care (LTC) financing plan that would combine private LTC insurance with special Medicaid eligibility requirements was assessed. The plan would also raise the Medicaid asset limit from the current $2,000 to the value of an individual's insurance benefits. After using benefits the individual could enroll in Medicaid. Thus, insurance would substitute for asset spend-down, protecting individuals against catastrophic costs. This financing plan was analyzed through a computer model that simulated lifetime LTC use for a middle-income age cohort beginning at 65 years of age. LTC payments from Medicaid, personal income and assets, Medicare, and insurance were projected by the model. Assuming that LTC use and costs would not grow beyond current projections, the proposed plan would provide asset protection for the cohort without increasing Medicaid expenditures. In contrast, private insurance alone, with no change in Medicaid eligibility, would offer only limited asset protection. The results must be qualified, however, because even a modest increase in LTC cost growth or use of care (beyond current projections) could result in substantially higher Medicaid expenditures. Also, private insurance might increase personal LTC expenditures because of the added cost of insuring.

Problems and prospects in the economic evaluation of antenatal care.

Economic evaluations can be used to compare alternative antenatal care programs in terms of cost and outcome. The cost of routine antenatal care is small compared to the total cost associated with pregnancy and childbirth. The main problem in economic evaluations is related to outcome measurement.

Medicaid spenddown among nursing home residents in Wisconsin.

We examined Medicaid spenddown among nursing home residents from 72 facilities in Wisconsin during 1988. Results indicate that only a small proportion (12%) of discharges from these facilities had spent down to Medicaid eligibility. This represents about one-fourth (23%) of persons who had been admitted private pay. Moreover, we estimated that over 40% of those who spent down to Medicaid did so within 6 months, 58% spent down within a year, and 76% spent down within 2 years. Even though a relatively small percentage of residents spent down, this group had very long stays (median stay greater than 3 years) and thus contributed quite heavily to nursing home days.

Should asymptomatic patients be tested for Chlamydia trachomatis in general practice?

Routine testing for Chlamydia trachomatis during gynaecological examinations has been suggested as a preventive measure against pelvic inflammatory disease and other health risks associated with chlamydial genital infections. This study examined the cost and effectiveness of routine testing for C trachomatis in general practice. An epidemiological model was used to predict how routine testing and treatment of positive cases would affect the future number of cases of pelvic inflammatory disease, infertility and ectopic pregnancy in a general practice population. The cost of routine test and treatment, and savings resulting from prevented future morbidity, were also estimated. For the population under study, a routine test for chlamydial infections in asymptomatic 18-24 year old women during gynaecological examinations was found to be cost effective but this was not the case for older women. At least two years should elapse between repeated tests.

Cost effectiveness of testing for chlamydial infections in asymptomatic women.

Routine testing for Chlamydia trachomatis during gynecological visits, as well as treatment of those found positive, has been suggested as a preventive measure against the serious consequences of chlamydial genital infections, e.g., pelvic inflammatory disease (PID), infertility, and ectopic pregnancy. This article examines the cost and effectiveness of this practice. The study is based on a model that predicts how routine testing and treatment will affect the future number of cases of PID, infertility, and ectopic pregnancy. The costs of test and treatment are estimated, as are the savings resulting from prevention. Results indicate that although routine testing was not effective in reducing the overall morbidity caused by chlamydial infections, for women 18-22 years of age routine testing during regular gynecologic sessions can be a cost-effective personal health service.

Induced abortion: Chlamydia trachomatis and postabortal complications. A cost benefit analysis.

The overall prevalence of Chlamydia trachomatis among 873 abortion-seeking women was 9.3% during 1985. Significantly higher age-specific prevalences of C. trachomatis occurred among younger women (p less than 0.001). None of 17 women treated for C. trachomatis before the abortion was carried out, was readmitted to the hospital. Of 64 Chlamydia-positive women, who commenced treatment within the first 2 weeks after the abortion was carried out, 14.1% were readmitted to the hospital, compared with 5.7% of Chlamydia-negative women (p less than 0.02). Postabortal salpingitis was verified at readmission among 10.9% of Chlamydia-positive women and 3.2% of Chlamydia-negative women (p less than 0.01). An analysis of screening of all abortion-seeking women is estimated to be worthwhile when the prevalence of C. trachomatis exceeds 4.3%. We recommend screening for Chlamydia trachomatis of all abortion-seeking women, 30 years or younger, at the pre-abortion visit, provided that treatment can be completed before the abortion is carried out.