Heterogeneous Preferences for Colorectal Cancer Screening in Germany: Results of a Discrete Choice Experiment.

OBJECTIVES: Colorectal cancer (CRC) screening tests differ in benefits, harms, and processes, making individual informed decisions preference based. The objective was to analyze the preferences of insurees in Germany for characteristics of CRC screening modalities. METHODS: A generic discrete choice experiment with 2-alternative choice sets and 6 attributes (CRC mortality, CRC incidence, complications, preparation, need for transportation, and follow-up; 3 levels each) depicting characteristics of fecal testing, sigmoidoscopy, and colonoscopy was generated. Participants completed 8 choice tasks. Internal validity was tested using a within-set dominated pair. Between June and October 2020, written questionnaires were sent to a stratified random sample (n = 5000) of 50-, 55-, and 60-year-old insurees of the AOK (Allgemeine Ortskrankenkasse) Lower Saxony, who had previously received an invitation to participate in the organized screening program including evidence-based information. Preferences were analyzed using conditional logit, mixed logit, and latent-class model. RESULTS: From 1282 questionnaires received (26% [1282 of 4945]), 1142 were included in the analysis. Approximately 42% of the respondents chose the dominated alternative in the internal validity test. Three heterogeneous preference classes were identified. Most important attributes were preparation (class 1; n = 505, 44%), CRC mortality (class 2; n = 347, 30%), and CRC incidence (class 3; n = 290, 25%). Contrary to a priori expectations, a higher effort was preferred for bowel cleansing (class 1) and accompaniment home (classes 1 and 2). CONCLUSION: Internal validity issues of choice data need further research and warrant attention in future discrete choice experiment surveys. The observed preference heterogeneity suggests different informational needs, although the underlying reasons remained unclear.

[Telematics in ambulatory care: Exploring the nurses' perspective]. / Telematische Anwendungen in der ambulanten Pflege: Die Perspektive von Pflegekräften.

Telematics in ambulatory care: Exploring the nurses' perspective Abstract. BACKGROUND: In the context of demographic change, the use of information and communications technology in home care has the aim of ensuring the quality of nursing care in the future. The acceptance of telematic applications by all users is crucial in this regard. AIM: The aim of this study was to assess the subjective attitudes and intentions of nursing staff on telematic applications in home care. METHODS: Based on the "Unified Theory of Acceptance and Use of Technology" (UTAUT), an online survey was conducted in which nursing staff as well as nursing students throughout Germany were surveyed. 371 questionnaires have been included in the analysis. RESULTS: Nursing students as well as nurses stated inadequate information and insufficient technical competence. Referring to performance expectations, both groups hope for improving care process transparency and communication inside and outside sectors. For effort expectancy, higher costs, training efforts and technology dependency were named. CONCLUSIONS: The results show the relevance of the attitudes and demands of users for a successful implementation. In the future, training and further education should increasingly promote the technological competence of nursing staff.

Is there a place for sigmoidoscopy in colorectal cancer screening? A systematic review and critical appraisal of cost-effectiveness models.

INTRODUCTION: Screening for colorectal cancer (CRC) is effective in reducing both incidence and mortality. Colonoscopy and stool tests are most frequently used for this purpose. Sigmoidoscopy is an alternative screening measure with a strong evidence base. Due to its distinct characteristics, it might be preferred by subgroups. The aim of this systematic review is to analyze the cost-effectiveness of sigmoidoscopy for CRC screening compared to other screening methods and to identify influencing parameters. METHODS: A systematic literature search for the time frame 01/2010-01/2023 was conducted using the databases MEDLINE, Embase, EconLit, Web of Science, NHS EED, as well as the Cost-Effectiveness Registry. Full economic analyses examining sigmoidoscopy as a screening measure for the general population at average risk for CRC were included. Incremental cost-effectiveness ratios were calculated. All included studies were critically assessed based on a questionnaire for modelling studies. RESULTS: Twenty-five studies are included in the review. Compared to no screening, sigmoidoscopy is a cost-effective screening strategy for CRC. When modelled as a single measure strategy, sigmoidoscopy is mostly dominated by colonoscopy or modern stool tests. When combined with annual stool testing, sigmoidoscopy in 5-year intervals is more effective and less costly than the respective strategies alone. The results of the studies are influenced by varying assumptions on adherence, costs, and test characteristics. CONCLUSION: The combination of sigmoidoscopy and stool testing represents a cost-effective screening strategy that has not received much attention in current guidelines. Further research is needed that goes beyond a narrow focus on screening technology and models different, preference-based participation behavior in subgroups.

Additional offer of sigmoidoscopy in colorectal cancer screening in Germany: rationale and protocol of the decision-analytic modelling approach in the SIGMO study.

INTRODUCTION: In Germany, statutory insured persons are entitled to a stool test (faecal immunochemical test (FIT)) or colonoscopy for colorectal cancer (CRC) screening, depending on age and sex, yet participation rates are rather low. Sigmoidoscopy is a currently not available screening measure that has a strong evidence base for incidence and mortality reduction. Due to its distinct characteristics, it might be preferred by some, who now reject colonoscopy. The objective of this study is to estimate the economic consequences of the additional offer of sigmoidoscopy for CRC screening in Germany compared with the present screening practice while considering the preferences of the general population. METHODS AND ANALYSIS: A decision-analytic modelling approach will be developed that compares the present CRC screening programme in Germany (FIT, colonoscopy) with a programme extended by sigmoidoscopy from a societal perspective. A decision tree and Markov model will be combined to assess both short-term and long-term effects, such as CRC and adenoma detection rates, the number of CRC cases, CRC mortality as well as complications. The incremental cost per quality-adjusted life year gained for each alternative will be calculated. The model will incorporate the general population's preferences based on a discrete choice experiment. Further, input parameters will be taken from the literature, the German cancer registry and health insurance claims data. ETHICS AND DISSEMINATION: Ethical approval for the study was obtained from the Ethics Committee of Hannover Medical School (ID: 8671_BO_K_2019). The findings of the study will be published in peer-reviewed journals and presented at national and/or international conferences. TRIAL REGISTRATION NUMBER: DRKS00019010.

Attributes Characterizing Colorectal Cancer Screening Tests That Influence Preferences of Individuals Eligible for Screening in Germany: A Qualitative Study.

Purpose: This qualitative study is part of the SIGMO study, which evaluates general populations' preferences for colorectal cancer (CRC) screening in Germany using a discrete choice experiment. Attribute identification and selection are essential in the construction of choice tasks and should be evidence-based ensuring that attributes are relevant to potential beneficiaries and contribute to overall utility. Therefore, this qualitative study aims to identify relevant attributes characterizing CRC screening tests from the perspective of those eligible for screening in Germany. Patients and Methods: Individuals aged 50 to 60 were purposively selected. A questioning route was developed and piloted. Four focus groups (FG) (n=20) were conducted (November 2019) with two moderators and one observer each. FGs were audio recorded, transcribed, and analyzed using qualitative content analysis. Attributes were deductively assigned based on a priori identified attribute categories, and inductively derived. Results: Across FGs, 24 attributes (n=293 codes) were discussed, five of which (sedation, inability to work, transportation home, predictive values, waiting time for screening colonoscopy) were inductively derived (n=76 codes). Four attributes identified a priori were not addressed in any FG. The most frequently discussed attribute category was procedural characteristics, followed by measures of screening test validity, benefits, harms, and structural characteristics of health care. The most commonly addressed attributes were preprocedural bowel cleansing, kind of procedure, and predictive values. Conclusion: Newly identified attributes characterizing CRC screening tests from an individual's perspective, and a priori identified attributes not addressed by any FG stress the added value of qualitative research and thereby the importance of applying a mix of methods in identifying and selecting attributes for the construction of choice tasks. This study meets the requirements for a transparent and detailed presentation of the qualitative methods used in this process, which has rarely been the case before.

Attributes in stated preference elicitation studies on colorectal cancer screening and their relative importance for decision-making among screenees: a systematic review.

INTRODUCTION: The SIGMO study (Sigmoidoscopy as an evidence-based colorectal cancer screening test - a possible option?) examines screening eligible populations' preferences for colorectal cancer (CRC) screening in Germany using a discrete choice experiment (DCE). Attribute identification and selection are essential for the construction of choice tasks and should be evidence-based. As a part of the SIGMO study this systematic review provides an overview of attributes included in studies eliciting stated preferences for CRC screening tests and their relative importance for decision-making. METHODS: Systematic search (November 2021) for English-language studies published since January 2000 in PubMed, Embase, Web of Science, Biomedical Reference Collection: Corporate Edition, LIVIVO and PsycINFO. DCEs and conjoint analysis ranking or rating tasks on screening eligible populations' preferences for stool testing, sigmoidoscopy, and/or colonoscopy were included. Attributes were extracted and their relative importance was calculated and ranked. Risk of bias (RoB) of included studies was assessed using a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Study selection and RoB rating were carried out independently by two reviewers. Data were extracted by one reviewer and checked by another one. RESULTS: A total of 23 publications on 22 studies were included. Overall RoB was rated as serious/critical for 21 studies and as moderate for 2 studies. Main reasons for high RoB were non-random sampling, low response rates, lack of non-responder analyses, and, to a lesser extent, weaknesses in the measurement instrument and data analysis. Extracted attributes (n = 120) referred to procedure-related characteristics (n = 42; 35%), structural characteristics of health care (n = 24; 20%), test characteristics (n = 23; 19%), harms (n = 16; 13%), benefits (n = 13; 11%), and level of evidence (n = 2; 2%). Most important attributes were reduction in CRC mortality (and incidence) (n = 7), test sensitivity (n = 7), out-of-pocket costs (n = 4), procedure (n = 3), and frequency (n = 2). CONCLUSIONS: Health preference studies on CRC were found to have a high RoB. The composition of choice tasks revealed a lack of attributes on patient-important outcomes (like incidence reduction), while attributes not considered relevant for individual screening decisions (like sensitivity) were frequently used. Future studies eliciting stated preferences in cancer screening should apply the principles of informed decision-making in attribute identification and selection.

Video-based teleconsultations in pharmaceutical care - A systematic review.

BACKGROUND: In recent years, telemedicine has gained increasing importance in the delivery of pharmaceutical care. The use of video technologies for remote communication between different parties offers the potential to meet the future challenges which arise from the increase in elderly and chronically ill patients. However, the influence of these technologies on patient-related outcomes in pharmaceutical care is not yet sufficiently known. METHOD: In December 2018 a systematic literature search was conducted in the databases Medline, Cochrane Library and PubPharm. Randomized controlled trials were considered, which investigate real-time video conferencing between pharmacists on the one hand and patients or other healthcare providers on the other hand. The influence on patient related outcomes compared to standard care was assessed. The bias potential was evaluated using the Cochrane Risk-of-Bias instrument. A total of 4 randomized controlled trials could be included. RESULTS: The studies describe partly complex intervention settings with adults and adolescents suffering from asthma, chronic renal failure, HIV infection, hyperlipidemia, hypertension and/or diabetes. None of the studies considers the interprofessional communication of pharmacists with other service providers. No influence on clinical or psychological endpoints was found. In some cases, an increase in adherence and correct medication use is evident. Healthcare utilization is not influenced. In all studies there is an increased risk of systematic bias. DISCUSSION: Teleconsultations with pharmacists can rather be used to ensure the general provision of pharmaceutical care than to improve patient-related outcomes. Further studies are necessary to fully depict the influence of telemedical interventions in pharmaceutical care.

General populations' preferences for colorectal cancer screening: rationale and protocol for the discrete choice experiment in the SIGMO study.

INTRODUCTION: In Germany, the organised colorectal cancer (CRC) screening programme includes the immunologic faecal occult blood test and colonoscopy. The sigmoidoscopy is recommended for individuals rejecting colonoscopy but is not included into the screening programme. To examine whether the evidence based sigmoidoscopy should be additionally offered, the first objective of this study is to evaluate the demand for sigmoidoscopy by analysing the German general populations' preferences for CRC screening. METHODS AND ANALYSIS: Preference data will be collected using a discrete choice experiment (DCE). Identification and selection of the attributes and their levels will be supported by evidence resulting from a systematic literature search and focus groups. An efficient, fractional factorial choice design will be generated. In a cross-sectional study, the DCE will be administered as a written questionnaire to a random sample of 4000 members of the statutory health insurance company in Lower Saxony (AOK Lower Saxony). Insured persons 50-60 years of age without CRC or a chronic inflammatory bowel disease will be eligible. The collected choice data will be analysed by conducting a conditional logit regression model and latent class models. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the Ethics Committee of Hannover Medical School (reference number 8671_BO_K_2019). The study results will be disseminated via conference presentations, publications in peer-reviewed journals and, to participants, the membership magazine of the AOK Lower Saxony. TRIAL REGISTRATION NUMBER: DRKS00019010.