A comparison of triage methods for Kenyan women who screen positive for cervical intraepithelial neoplasia by visual inspection of the cervix with acetic acid.

BACKGROUND: Only about one in seven visual inspection with acetic acid (VIA)-positive women has high-grade disease; further confirmatory testing could rule out false positives. OBJECTIVES: To determine if visual inspection with Lugol's iodine (VILI) or visual inspection with acetic acid and magnification (VIAM) can accurately confirm the presence of disease among rural Kenyan women referred to a district hospital because of a VIA-positive result at a primary health facility. METHODS: Referred women received cervical cytology and either VILI and/or VIAM as triage methods. All women were assessed by colposcopy and biopsied, if necessary. RESULTS: Of the 490 VIA-positive subjects referred, 332 (68%) attended the district hospital and received at least one of two triage tests and cervical cytology. The sensitivity and specificity for histologically-confirmed CIN 2 and 3 were 93% (14/15) and 32% (52/161) for VIAM; 100% (3/3) and 77% (49/64) for VILI; and 80% (16/20) and 48% (110/228) for cervical cytology. VILI reduced the number of false-positive screening results by 73%, without missing any true positives. CONCLUSIONS: VILI had comparable sensitivity and significantly higher specificity compared to VIAM and cervical cytology. VILI may be a promising triage test for screen-positive women in low-resource settings; additional research is required.

Report on a cryotherapy service for women with cervical intraepithelial neoplasia in a district hospital in western Kenya.

BACKGROUND: In low-resource settings, cryotherapy can be cost-effective, affordable, and a first-line treatment for cervical intraepithelial neplasia (CIN) of any grade. OBJECTIVES: To report the acceptability, safety and effectiveness of cryotherapy for women with cervical intraepithelial neoplasia (CIN) in Western Kenya. METHODS: Visual inspection with acetic acid (VIA)-positive women and those suspected of having cervical cancer based on an initial evaluation at a primary health facility were referred to the district hospital for colposcopy and additional evaluation using visual inspection with Lugol's iodine (VILI) and/or visual inspection with acetic acid and magnification (VIAM). Cryotherapy was offered immediately to women diagnosed with appropriate CIN lesions based on colposcopy or after waiting for a confirmatory cervical biopsy and a follow up visit occurred one year later. RESULTS: Ninety one 91 women 30 to 39 years of age had CIN appropriate for cryotherapy. Approximately 36% (24/67) were due for their 1 year follow up visit and 20 of 24 (83.3%) attended. Complete data were available for 18 of 20 (90%) and 13 (72.2%) had no sign of CIN. No serious adverse events were reported 1 to 3 months after cryotherapy. All respondents reported that the treatment experience was acceptable. CONCLUSIONS: Cryotherapy was acceptable, safe and effective.

Use of an expanded gold standard to estimate the accuracy of colposcopy and visual inspection with acetic acid.

We estimate the accuracy of colposcopy and visual inspection with acetic acid (VIA) while minimizing the effects of misclassification bias, and maximizing ascertainment of disease. VIA was performed by experienced physicians on a population-based sample of women aged 30 to 49 years in rural Shanxi province, China. Each woman received VIA, liquid-based cytology (LBC) and hybrid capture 2 (hc2, QIAGEN, Gaithersburg, MD; formerly Digene Corporation). Any woman who tested positive on any test had colposcopy, endocervical curettage (ECC) with directed biopsies as necessary and 4-quadrant random biopsies from normal-appearing areas of the cervix. A standard diagnosis based on colposcopy and directed biopsy, and an expanded diagnosis including ECC and 4-quadrant random biopsy were generated for each woman. In 1,839 women, use of the expanded versus the standard diagnostic criteria increased the prevalence of histologically confirmed high-grade cervical intraepithelial neoplasia and cancer (CIN2+) from 3.2% (59/1,839) to 4.2% (77/1,839) and decreased the sensitivity of VIA for CIN2+ from 69.5% (95% CI: 56.8-79.8) to 58.4% (95% CI: 47.3-68.8%) with little change in specificity of approximately 89%. Compared with the expanded diagnostic criterion, the sensitivity of a visual diagnosis of high-grade CIN or cancer by a colposcopist was 49.4% (95% CI: 38.2-60.5). The use of an expanded diagnostic criterion in this study yielded more conservative estimates of the sensitivity of VIA and colposcopy.

Colposcopists' agreement on cervical biopsy site.

OBJECTIVE: To determine the inter-observer agreement among colposcopists on the most abnormal area of the cervix from which a biopsy would be obtained and whether any attributes predict agreement. MATERIAL AND METHODS: Fifty cervigrams were reviewed and 72 colposcopists from five countries indicated the site to biopsy and whether an ECC should be obtained. Prior to the study, six Canadian colposcopists met to achieve consensus on the most diseased area for biopsy. Consensus was also reached on whether an ECC was indicated. For each cervigram, percent agreement was determined between each study colposcopist and the consensus. Data were analyzed to determine the attributes associated with the consensus response. RESULTS: The percent overall agreement of the colposcopists with the consensus diagnoses had a mean of 0.70 (95% CI, 0.65-0.75). The use of ECC was most common in Canada (15% of cases). The following factors were assessed by multivariate analysis to determine their influence on individual agreement with the consensus recommendation for the site to biopsy: country, duration of practice (less than or greater than 1 year), professional group (nurse, family doctor, pathologist, gynecologist, gynecologic oncologist), expert status (recognized national/international expert vs colposcopist), and gender. No factor was significantly associated. CONCLUSION: This international study was feasible and the level of inter-observer agreement among colposcopists on the location of the most severe lesions in cervical images is good.

Vaginal self sampling versus physician cervical sampling for HPV among younger and older women.

OBJECTIVES: To estimate the agreement between self collected vaginal swabs and physician collected cervical brush samples for detection of oncogenic human papillomavirus infection (HPV) by the hybrid capture 2 (HC-2) test among women younger and older than 50 years, and to assess women's preference for sample collection method based on age. METHODS: Consecutive women aged 15-49 years due for a 1 year visit in a prevalence study of carcinogenic HPV and a new sample of women aged 50 years and older attending their family physicians for cervical screening, in Ontario, Canada, performed vaginal self sampling and underwent physician cervical sampling and cervical cytology. Women completed a self administered questionnaire on demographics and preference for sampling method. RESULTS: Among the 307 women aged 15-49 years, the prevalence of HPV was 20.8% (64/307) and 17.6% (54/307) in the vaginal and cervical specimens, respectively. Among the women aged 50 years and older, prevalence was 9.9% (15/152) and 8.6% (13/152), respectively. Kappa for agreement between sample collection methods was 0.54 for the younger and 0.37 for the older women (both p< 0.001). Nearly half of the women preferred self sampling or had no preference. CONCLUSIONS: There was fair agreement between self collected vaginal and physician collected cervical specimens for detecting carcinogenic HPV in younger and older women. Vaginal sampling for HPV appears to be promising as a primary screening strategy for cervical cancer prevention programmes in low resource settings in developed and developing countries.

Diagnostic accuracy of self collected vaginal specimens for human papillomavirus compared to clinician collected human papillomavirus specimens: a meta-analysis.

BACKGROUND/OBJECTIVES: Providing summary recommendations regarding self collection of vaginal specimens for human papillomavirus (HPV) testing is difficult owing to the wide range of published estimates for the diagnostic accuracy of this approach. To determine summary estimates from analyses of reported findings of the sensitivity, specificity and summary receiver operating characteristic curves (SROC) for self collected vaginal specimens for HPV testing compared to the reference standard, clinician collected HPV specimens. METHODS: Standard search criteria for a diagnostic systematic review were employed. Eligible studies were combined using a random effects model and summary ROC curves were derived for overall and for specific subgroups. RESULTS: Summary measures were determined from 12 studies. Six studies where patients used Dacron or cotton swabs or cytobrushes to obtain samples were pooled and had an overall sensitivity of 0.74 (95% CI 0.61 to 0.84) and specificity of 0.88 (95% CI 0.83 to 0.92), with diagnostic odds ratio of 22.3 and an area under the curve of 0.91. Self specimens using Dacron or cotton swabs or cytobrushes collected by women enrolled at referral clinics had an overall sensitivity of 0.81 (95% CI 0.65 to 0.91) and specificity of 0.90 (95% CI 0.80 to 0.95). Sensitivity and specificity of tampons ranged from 0.67-0.94 and 0.80-0.85 respectively. CONCLUSIONS: Our findings indicate that the combined sensitivity for HPV-DNA is more than 70% when patients use Dacron swabs, cotton swabs, or cytobrushes to obtain their own vaginal specimens for HPV-DNA evaluation. Self collected HPV-DNA swabs may be an appropriate alternative for low resource settings or in patients reluctant to undergo pelvic examinations.

Training for cervical cancer prevention programs in low-resource settings: focus on visual inspection with acetic acid and cryotherapy.

The modern approach to cervical cancer prevention, characterized by use of cytology and multiple visits for diagnosis and treatment, has frequently proven challenging and unworkable in low-resource settings. Because of this, the Alliance for Cervical Cancer Prevention (ACCP) has made it a priority to investigate and assess alternative approaches, particularly the use of visual screening methods, such as visual inspection with acetic acid (VIA) and visual inspection with Lugol's iodine (VILI), for precancer and cancer detection and the use of cryotherapy as a precancer treatment method. As a result of ACCP experience in providing training to nurses and doctors in these techniques, it is now widely agreed that training should be competency based, combining both didactic and hands-on approaches, and should be done in a clinical setting that resembles the service-delivery conditions at the program site. This article reviews ACCP experiences and perceptions about the essentials of training in visual inspection and cryotherapy and presents some lessons learned with regard to training in these techniques in low-resource settings.

Confirmation of cervical neoplasia using a hand-held, lighted magnification device.

OBJECTIVES: The objective of this study was to estimate the sensitivity and specificity of visual inspection with acetic acid and magnification (VIAM) using the AviScope device to confirm high-grade cervical intraepithelial neoplasia or carcinoma. METHODS: VIAM was performed on 142 women aged 18-50 years referred to three colposcopy clinics because of abnormal cervical cytology. Each woman then had a colposcopic examination with cervical biopsy when indicated. RESULTS: The AviScope device identified 24 of the 40 women who had CIN 2, 3, or carcinoma, yielding a sensitivity of 60.0% (95% CI 43.4, 74.7). The AviScope correctly identified 60 of 87 women negative for dysplasia or cancer, yielding a specificity of 69.0% (95% CI 58.0, 78.2) compared with colposcopy and cervical histology. CONCLUSION: VIAM using the AviScope device was moderately sensitive and specific for the confirmation of high-grade cervical lesions in women referred with abnormal cervical cytology.

Assessment of the cervix after acetic acid wash: inter-rater agreement using photographs.

OBJECTIVE: To estimate the inter-rater agreement on the assessment of cervical photographs after acetic acid wash, using visual inspection with acetic acid categories. METHODS: Three raters individually assessed 144 photographs as negative, positive, or suspicious for cancer. The inter-rater agreement was analyzed using the unweighted and weighted kappa coefficient. To explore the reasons for concordancy and discordancy, photographs were compared on histologic evidence of cervical intraepithelial neoplasia and on testing for oncogenic types of human papillomavirus. RESULTS: Overall raw agreement among the three raters was 66.7% (96 of 144) with a kappa of 0.57 (95% confidence interval 0.48, 0.66). Pair-wise agreement using unweighted and weighted kappa was moderate to substantial: 0.54-0.60 and 0.56-0.63, respectively. There was concordance on negative in 25.7% (37 of 144) and on positive or suspicious for cancer in 41.0% (59 of 144). Cervical intraepithelial neoplasia II or III was not present on biopsy if photographs were concordant-negative, and the human papillomavirus test was less likely to be positive (relative risk 0.3; 95% confidence interval 0.2, 0.6) in concordant-negatives compared with concordant-positives, including suspicious for cancer. Cervical intraepithelial neoplasia II or III was more common in photographs that were concordant-positive, including suspicious for cancer, compared with discordants (relative risk 3.4, 95% confidence interval 1.5, 7.6). CONCLUSION: Based on photographs of the cervix taken after acetic acid wash, the level of agreement among raters using visual inspection with acetic acid categories was moderate to substantial, consistent with other commonly used tests.

Imiquimod 5% cream is a safe and effective self-applied treatment for anogenital warts--results of an open-label, multicentre Phase IIIB trial.

Our objective was to determine the efficacy and safety of imiquimod 5% cream in the treatment of external genital/perianal warts in an open-label Phase IIIB trial. Patients applied imiquimod 5% cream 3 times per week, for up to 16 weeks. Those who cleared their warts were monitored during a 6-month follow-up period. If their warts recurred, or new warts developed during this time, patients could be re-treated for up to 16 additional weeks. Patients who experienced partial clearance during the initial treatment period entered an extended treatment period of up to an additional 16 weeks. A total of 943 patients from 114 clinic sites in 20 countries participated in this study. Complete clinical clearance was observed in 451/943 (47.8%) patients (intent-to-treat (ITT) analysis) during the initial treatment period, with clearance in an additional 52 (5.5%) patients during the extended treatment period beyond 16 weeks. The overall clearance rate for the combined treatment periods was 53.3%. In a treatment failure analysis, the overall clearance rate was 65.5%; a greater proportion of female patients (75.5%) experienced complete clearance than male patients (56.9%). Low recurrence rates, of 8.8% and 23.0%, were observed at the end of the 3- and 6-month follow-up periods, respectively. The sustained clearance rates (patients who cleared during treatment and remained clear at the end of the follow-up period) after 3 and 6 months were 41.6% and 33.0% (ITT analysis), respectively. Local erythema occurred in 67% of patients. In the majority of patients local skin reactions were of mild to moderate severity. In conclusion, imiquimod 5% cream is an effective self-applied treatment for external genital/perianal warts when applied for up to 16 weeks and is well tolerated for up to 32 weeks.

Comparison of human papillomavirus DNA testing and repeat Papanicolaou test in women with low-grade cervical cytologic abnormalities: a randomized trial. HPV Effectiveness in Lowgrade Paps (HELP) Study No. 1 Group.

BACKGROUND: Results of cervical cytology screening showing atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesions (LSIL) indicate risk for high-grade cervical intraepithelial neoplasia (CIN 2 or 3). In a community-based randomized trial we compared the test performance of human papillomavirus (HPV) DNA testing with that of 6-month repeat Papanicolaou (Pap) test in detecting histologically confirmed CIN 2 or 3. METHODS: We randomly assigned 212 women aged 16-50 years with ASCUS or LSIL on cervical cytology screening to undergo either immediate HPV DNA testing or a repeat Pap test in 6 months. Cervical swabs for the HPV DNA testing and the Pap smears were obtained by their family physicians. We tested the swabs for oncogenic HPV using the Hybrid Capture II assay (Digene Corp., Beltsville, Md.). Community-based pathologists examined the Pap smears. All women were referred for colposcopy by their family physicians. Two gynecological pathologists assessed the histology findings. We calculated test performance in women who completed the trial using CIN 2 or 3 as the reference standard. RESULTS: A total of 159 women completed the study. Compared with HPV DNA testing, which detected 87.5% (7/8) of the cases of CIN 2 or 3, repeat Pap smear showing high-grade intraepithelial neoplasia (HSIL) detected 11.1% (1/9) of cases (p = 0.004), and repeat Pap smear showing ASCUS, LSIL or HSIL detected 55.6% (5/9) (p = 0.16). Corresponding specificities were 50.6%, 95.2% (p = 0.002) and 55.6% (p = 0.61). Loss to follow-up was 17.1% in the HPV test group and 32.7% in the repeat Pap group (p = 0.009). Given the 7 cases of CIN 2 or 3 detected by HPV testing and the 5 cases detected by the repeat Pap smear, the incremental cost of HPV testing was calculated to be $3003 per additional case of CIN identified. INTERPRETATION: HPV DNA testing was more costly but was associated with significantly less loss to follow-up. It may detect more cases of CIN 2 or 3 in women with low-grade cytologic abnormalities.

Prevalence and predictors of human papillomavirus infection in women in Ontario, Canada. Survey of HPV in Ontario Women (SHOW) Group.

BACKGROUND: Human papillomavirus (HPV) is thought to be the primary cause of cervical intraepithelial neoplasia and cervical cancer. We determined the age-specific prevalence of HPV infection and its risk factors in Ontario women. METHODS: We obtained 2 cervical specimens from randomly selected women (in 5-year age categories, from 15 to 49 years) who were being seen in 32 family practices for cytologic screening. The specimens were tested for carcinogenic HPV by the hybrid capture II assay (Digene Corp., Silver Spring, Md.) and by polymerase chain reaction (PCR) and genotyping. RESULTS: Of 1004 women eligible to participate, samples were obtained from 955 (95.1%). The prevalence of HPV (as determined by the hybrid capture II method) was highest, at 24.0% (95% confidence interval [CI] 16.5% to 31.5%), among women 20 to 24 years of age and was progressively lower in older age groups, reaching 3.4% (95% CI 0.1% to 6.7%) in women 45 to 49 years old. The prevalence of HPV (any type) as determined by PCR showed a similar pattern but was significantly higher (p = 0.01) among women 45 to 49 years old than among those 40 to 44 years old (13.0% [95% CI 6.4% to 19.6%] v. 3.3% [95% CI 0.1% to 6.5%]). Risk factors for positivity with the hybrid capture II method were never-married status, divorced or separated status, more than 3 lifetime partners, more than 1 partner in the preceding year, cigarette smoking and current use of oral contraceptives. The presence of squamous intraepithelial lesions on cytologic examination was strongly associated with positivity with the hybrid capture II assay (odds ratio 96.0, 95% CI 22.3 to 413.4; p < 0.01). INTERPRETATION: The highest prevalence of HPV was 24.0%, in women 20 to 24 years old. Risk factors supported a sexual mode of transmission, and there was a strong association between HPV and abnormal cervical cytologic results.

Comparison of self-collected vaginal, vulvar and urine samples with physician-collected cervical samples for human papillomavirus testing to detect high-grade squamous intraepithelial lesions.

BACKGROUND: Certain types of human papillomavirus (HPV) in cervical samples are strongly associated with squamous intraepithelial lesions (SIL) and invasive cervical carcinoma. We determined and compared the test characteristics of testing for HPV with samples obtained by patients and with samples obtained by their physicians. METHODS: In a consecutive series of women referred to a colposcopy clinic at a teaching hospital because of abnormalities on cervical cytologic screening, 200 agreed to collect vulvar, vaginal and urine samples for HPV testing. The physician then collected cervical samples for HPV testing, and colposcopy, with biopsy as indicated, was performed. Presence of HPV was evaluated using the hybrid capture II assay (Digene Corp., Silver Spring, Md.) with a probe cocktail for 13 carcinogenic types. Cervical specimens were also tested for HPV by polymerase chain reaction and hybridization with type-specific probes. Cervical smears for cytologic examination were obtained from all women. RESULTS: High-grade lesions (high-grade squamous intraepithelial lesions [HSIL], equivalent to cervical intraepithelial neoplasia [CIN] grade 2 or 3, and adenocarcinoma) were found in 58 (29.0%) of the 200 women. Carcinogenic types of HPV were detected in the self-collected vaginal samples of 50 (86.2%) of these 58 women, in the self-collected vulvar samples of 36 (62.1%) and in the self-collected urine samples of 26 (44.8%). Carcinogenic types of HPV were detected in the cervical samples collected by physicians for 57 (98.3%) of these 58 women. The remaining 142 women (71.0%) had normal findings or low-grade squamous intraepithelial lesions (LSIL, CIN grade 1). Test results were negative or noncarcinogenic types of HPV were detected in the self-collected vaginal samples of 76 (53.5%) of these 142 women, in the self-collected vulvar samples of 89 (62.7%) and in the self-collected urine samples of 99 (69.7%). The sensitivity for self-collected samples ranged from 44.8% to 86.2%, and the specificity from 53.5% to 69.7%. For the samples collected by physicians, the sensitivity was 98.3% and the specificity 52.1%. The self-sampling methods were generally acceptable to the women: 98.4% of respondents (126/128) deemed urine sampling acceptable, 92.9% (118/127) found vulvar sampling acceptable, and 88.2% (112/127) found vaginal sampling acceptable. INTERPRETATION: Self-collection of samples for HPV testing was acceptable to women attending a colposcopy clinic for investigation of suspected cervical lesions and shows sufficient sensitivity to warrant further evaluation as a screening test for cervical cancer prevention programs.

A new visual indicator of chlamydial cervicitis?

OBJECTIVES: To determine the usefulness of endocervical discharge opacity as a risk indicator for chlamydial infection in relation to two acknowledged visual indicators--yellow endocervical discharge and easily induced mucosal bleeding of the cervix. METHODS: Women from two family planning clinics, a therapeutic abortion clinic, and a university student health clinic (n = 1418 total) consented to a pelvic examination and chlamydia testing, and completed a questionnaire on socio-demographics, sexual behaviour, medical history, and symptoms. A case of chlamydia was defined as positive by culture or blocked enzyme immunoassay in an endocervical swab. RESULTS: The prevalence of chlamydial infection in the clinics was 6.3%. All three of the visual indicators--yellow endocervical discharge, easily induced bleeding, and opaque cervical discharge--were statistically significantly and independently associated with chlamydial infection (odds ratios 2.8, 2.3, and 2.9 respectively), independent of clinic type. Adjustment for the other visual indicators made little difference to the odds ratios. CONCLUSION: Opacity of endocervical discharge was at least as important as the other two commonly acknowledged indicators of chlamydial cervicitis--yellow endocervical discharge and easily induced mucosal bleeding of the cervix.

Effect of preventive home visits by a nurse on the outcomes of frail elderly people in the community: a randomized controlled trial.

BACKGROUND: Timely recognition and prevention of health problems among elderly people have been shown to improve their health. In this randomized controlled trial the authors examined the impact of preventive home visits by a nurse compared with usual care on the outcomes of frail elderly people living in the community. METHODS: A screening questionnaire identified eligible participants (those aged 70 years or more at risk of sudden deterioration in health). Those randomly assigned to the visiting nurse group were assessed and followed up in their homes for 14 months. The primary outcome measure was the combined rate of deaths and admissions to an institution, and the secondary outcome measure the rate of health services utilization, during the 14 months; these rates were determined through a medical chart audit by a research nurse who was blind to group allocation. RESULTS: The questionnaire was mailed to 415 elderly people, of whom 369 (88.9%) responded. Of these, 198 (53.7%) were eligible, and 142 consented to participate and were randomly assigned to either the visiting nurse group (73) or the usual care group (69). The combined rate of deaths and admissions to an institution was 10.0% in the visiting nurse group and 5.8% in the usual care group (p = 0.52). The rate of health services utilization did not differ significantly between the 2 groups. Influenza and pneumonia vaccination rates were significantly higher in the visiting nurse group (90.1% and 81.9%) than in the usual care group (53.0% and 0%) (p < 0.001). INTERPRETATION: The trial failed to show any effect of a visiting nurse other than vastly improved vaccination coverage.

Screening seniors for risk of functional decline: results of a survey in family practice.

OBJECTIVE: To measure functional status, determine risk of functional decline and assess consistency between responses and standardized instruments. DESIGN: A mailed survey which measured functional impairment, recent hospitalization and bereavement. A positive response on at least one of these factors indicated that the individual was "at risk" for functional decline. A random sample (n = 73) of "at risk" subjects (specifically, family practice patients aged 70 and older) were assessed by a nurse. RESULTS: The response rate was 89% (369/415), 59% of seniors were female and the mean age was 77.1 (SD = 5.5) years. Self-reported risk, based on activities of daily living (ADLs), was associated with impairment in at least one basic ADL (p < 0.0005) using a standardized instrument. The positive predictive value of the survey for ADL impairment was 65%. CONCLUSION: Response to a mailed survey was high and self-reported ADL risks were consistent with findings from standardized assessment tools.

Restructuring health services delivery research: a community-based model.

As management of acute illness shifts to the community from tertiary care centres, there is a need for community-based research into the delivery of health services. One author is the coordinator of a health services delivery research unit located in a community health centre as well as the director of research in the Department of Family Medicine at McMaster University. The other author is a member of the administration of the sponsoring institution. The research unit, created in 1994, has close links with the sponsoring hospital, a research centre and the faculty of health sciences at a nearby university. Its staff has grown from 2 to 12 members, mainly as a result of grant support. Its aim is to improve the delivery of community-based health services, and to this end it conducts research in collaboration with programs at the health centre, stakeholder groups, communities and institutions. Research projects have been undertaken in clinical guidelines, women's health, mature adults' health, medication use and new technologies for screening. As an example, concern about chlamydial infections in women in the community led to research into burden of illness, diagnosis, screening methods, test technologies, validation of guidelines and provider behaviors. In the future, funding will be a major concern. The authors contend that more funding from such agencies as the Medical Research Council of Canada should flow to community-based research.

Consumer health information services: preliminary findings about who is using them.

Focus groups and in-depth telephone interviews were used to develop a telephone questionnaire later completed by people 55 years and older about their use of a Health Information Support Telephone Service (HISTS). Preliminary findings identified an equal number of well educated male and female callers, who called for information for themselves. The confidentially of the service was very important to respondents and may have impacted the time to recruit people for the focus groups. The second study described is a pilot test completed by three Consumer Health Information/Resource Centres (CHIRC). An Info Script was used by health professionals to direct people to information centres. Preliminary results indicate that over half of the participants stated they visited the information centre because they were given an Info Script and that they would not have gone without the Info Script.

Economic evaluation of hybrid capture human papillomavirus testing in women with low-grade papanicolaou smear abnormalities.

OBJECTIVES: Our aim was to determine the cost-effectiveness of three strategies for detecting cervical intraepithelial neoplasia 2 and 3 after a determination of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion on screening Papanicolaou (Pap) smear. METHODS: Single repeat Pap smear. Hybrid Capture testing for human papillomavirus, and immediate colposcopy were compared. A theoretical decision analysis model was constructed with 10,000 women in each group. Costs and outcomes are those of diagnosis and treatment of cervical intraepithelial neoplasia (CIN) 2 or 3. Outcome probabilities and utilization data were obtained from a literature review and expert opinion. RESULTS: Repeat smear detected 1,125 cases, Hybrid Capture, 1,350 cases, and colposcopy, 1,482 cases of CIN2 or CIN3, costing $1,490,000, $1,980,000, and $2,420,000, respectively. Incremental cost per high-grade dysplasia was $2,178 for Hybrid Capture and $3,333 for colposcopy. Sensitivity analyses that test management efficiencies are reported. CONCLUSIONS: More effective strategies are more costly. However, if costs saved by preventing invasive cancers are included, all three strategies may be cost-saving.