Integrated Health Care Delivery for Adolescents Living with and at Risk of HIV Infection: A Review of Models and Actions for Implementation.

Integrated service delivery, providing coordinated services in a convenient manner, is important in HIV prevention and treatment for adolescents as they have interconnected health care needs related to HIV care, sexual and reproductive health and disease prevention. This review aimed to (1) identify key components of adolescent-responsive integrated service delivery in low and middle-income countries, (2) describe projects that have implemented integrated models of HIV care for adolescents, and (3) develop action steps to support the implementation of sustainable integrated models. We developed an implementation science-informed conceptual framework for integrated delivery of HIV care to adolescents and applied the framework to summarize key data elements in ten studies or programs across seven countries. Key pillars of the framework included (1) the socioecological perspective, (2) community and health care system linkages, and (3) components of adolescent-focused care. The conceptual framework and action steps outlined can catalyze design, implementation, and optimization of HIV care for adolescents.

Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic.

COVID-19 caused significant declines in colorectal cancer (CRC) screening. Health systems and clinics, faced with a new rapidly spreading infectious disease, adapted to maintain patient safety and address the effects of the pandemic on healthcare delivery. This study aimed to understand how CDC-funded Colorectal Cancer Control Program recipients and their partner health systems and clinics may have modified evidence-based intervention (EBI) implementation to promote CRC screening during the COVID-19 pandemic; to identify barriers and facilitators to implementing modifications; and to extract lessons that can be applied to support CRC screening, chronic disease management, and clinic resilience in the face of future public health crises. Nine recipients were selected to reflect the diversity inherent among all CRCCP recipients. Recipient and clinic partner staff answered unique sets of pre-interview questions to inform tailoring of interview guides that were developed using constructs from the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) and Consolidated Framework for Implementation Research (CFIR). The study team then interviewed recipient, health system, and clinic partner staff incorporating pre-interview responses to focus each conversation. We employed a rapid qualitative analysis approach then conducted virtual focus groups with recipient representatives to validate emergent themes. Three modifications that emerged from thematic analysis include: (1) offering mailed fecal immunochemical test (FIT) kits for CRC screening with mail or drop off return; (2) increasing the use of patient education and engagement strategies; and (3) increasing the use of or improving automated patient messaging systems. With improved tracking and automated reminder systems, mailed FIT kits paired with tailored patient education and clear instructions for completing the test could help primary care clinics catch up on the backlog of missed screenings during COVID-19. Future research can assess the effectiveness and cost-effectiveness of offering mailed FIT kits on maintaining or improving CRC screening, especially among people who are medically underserved.

Mail-Based Self-Sampling to Complete Colorectal Cancer Screening: Accelerating Colorectal Cancer Screening and Follow-up Through Implementation Science.

Introduction: Leveraging cancer screening tests, such as the fecal immunochemical test (FIT), that allow for self-sampling and postal mail for screening invitations, test delivery, and return can increase participation in colorectal cancer (CRC) screening. The range of approaches that use self-sampling and mail for promoting CRC screening, including use of recommended best practices, has not been widely investigated. Methods: We characterized self-sampling and mail strategies used for implementing CRC screening across a consortium of 8 National Cancer Institute Cancer Moonshot Initiative Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) research projects. These projects serve diverse rural, urban, and tribal populations in the US. Results: All 8 ACCSIS projects leveraged self-sampling and mail to promote screening. Strategies included organized mailed FIT outreach with mailed invitations, including FIT kits, reminders, and mailed return (n = 7); organized FIT-DNA outreach with mailed kit return (n = 1); organized on-demand FIT outreach with mailed offers to request a kit for mailed return (n = 1); and opportunistic FIT-DNA with in-clinic offers to be mailed a test for mailed return (n = 2). We found differences in patient identification strategies, outreach delivery approaches, and test return options. We also observed consistent use of Centers for Disease Control and Prevention Summit consensus best practice recommendations by the 7 projects that used mailed FIT outreach. Conclusion: In research projects reaching diverse populations in the US, we observed multiple strategies that leverage self-sampling and mail to promote CRC screening. Mail and self-sampling, including mailed FIT outreach, could be more broadly leveraged to optimize cancer screening.

Preferences for Breast and Cervical Cancer Screening Among Women and Men in Kenya: Key Considerations for Designing Implementation Strategies to Increase Screening Uptake.

Breast and cervical cancer incidence rates and mortality rates in Kenya are high. Screening is globally accepted as a strategy for early detection and downstaging of these cancers for better outcomes, but despite the efforts established by the Kenyan government to provide these services to eligible populations, uptake has remained disproportionately low. Using data from a larger study aimed at understanding the implementation and scale-up of cervical cancer screening services, we analyzed data to compare the preferences for breast and cervical cancer screening services between men and women (25-49 years) in rural and urban communities in Kenya. Participants were recruited in concentric circles starting at the center of six subcounties. One woman and one man per household were enrolled for data collection on a continuous basis. More than 90% of both men and women had a monthly income of less than US $500. The top three preferred sources of information on screening for cancers affecting women were health care providers; community health volunteers; and media such as television, radio, newspapers, and magazines. More women (43.6%) than men (28.0%) trusted community health volunteers to provide health information on cancer screening. Printed materials and mobile phone messages were preferred by approximately 30% of both genders. Over 75% of both men and women preferred an integrated model of service delivery. These findings show that there are many similarities that can be leveraged when designing implementation strategies for population-wide breast and cervical cancer screening hence reducing the challenge of addressing diverse preferences of men and women which may not be easy to reconcile.

Factors That Support Sustainability of Health Systems Change to Increase Colorectal Cancer Screening in Primary Care Clinics: A Longitudinal Qualitative Study.

BACKGROUND: From 2015 to 2020, the Centers for Disease Control and Prevention's Colorectal Cancer Control Program (CRCCP) supported 30 awardees in partnering with primary care clinics to implement evidence-based interventions (EBIs) and supporting activities (SAs) to increase colorectal cancer (CRC) screening. This study identified factors that facilitated early implementation and sustainability within partner clinics. METHODS: We conducted longitudinal qualitative case studies of four CRCCP awardees and four of their partner clinics. We used the Consolidated Framework for Implementation Research (CFIR) to frame understanding of factors related to implementation and sustainability. A total of 41 semi-structured interviews were conducted with key staff and stakeholders exploring implementation practices and facilitators to sustainability. Qualitative thematic analysis of interview transcripts identified emerging themes across awardees and clinics. RESULTS: Qualitative themes related to six CFIR inner setting constructs-structural characteristics, readiness for implementation, networks and communication, culture, and implementation climate-were identified. Themes related to early implementation included conducting readiness assessments to tailor implementation, providing moderate funding to clinics, identifying clinic champions, and coordinating EBIs and SAs with existing clinic practices. Themes related to sustainability included the importance of ongoing electronic health record (EHR) support, clinic leadership support, team-based care, and EBI and SA integration with clinic policies, workflows, and procedures. IMPLICATIONS: Findings help to inform future scale-up of and decision-making within CRC screening programs and other chronic disease prevention programs implementing EBIs and SAs within primary care clinics and also highlight factors that maximize sustainability within these programs.

Health worker perceptions of stigma towards Zambian adolescent girls and young women: a qualitative study.

BACKGROUND: The high prevalence of HIV among adolescent girls and young women aged 15-24 in Eastern and Southern Africa indicates a substantial need for accessible HIV prevention and treatment services in this population. Amidst this need, Zambia has yet to meet global testing and treatment targets among adolescent girls and young women living with HIV. Increasing access to timely, high-quality HIV services in this population requires addressing the intensified anticipated and experienced stigma that adolescent girls and young women often face when seeking HIV care, particularly stigma in the health facility setting. To better understand the multi-level drivers and manifestations of health facility stigma, we explored health workers' perceptions of clinic- and community-level stigma against adolescent girls and young women seeking sexual and reproductive health, including HIV, services in Lusaka, Zambia. METHODS: We conducted 18 in-depth interviews in August 2020 with clinical and non-clinical health workers across six health facilities in urban and peri-urban Lusaka. Data were coded in Dedoose and thematically analyzed. RESULTS: Health workers reported observing manifestations of stigma driven by attitudes, awareness, and institutional environment. Clinic-level stigma often mirrored community-level stigma. Health workers clearly described the negative impacts of stigma for adolescent girls and young women and seemed to generally express a desire to avoid stigmatization. Despite this lack of intent to stigmatize, results suggest that community influence perpetuates a lingering presence of stigma, although often unrecognized and unintended, in health workers and clinics. CONCLUSIONS: These findings demonstrate the overlap in health workers' clinic and community roles and suggest the need for multi-level stigma-reduction approaches that address the influence of community norms on health facility stigma. Stigma-reduction interventions should aim to move beyond fostering basic knowledge about stigma to encouraging critical thinking about internal beliefs and community influence and how these may manifest, often unconsciously, in service delivery to adolescent girls and young women.

Acceptability, Utility, and Cost of a Mobile Health Cancer Screening Education Application for Training Primary Care Physicians in India.

PURPOSE: Mobile health (mHealth)-based oncology education can be a powerful tool for providing cancer screening knowledge to physicians, as mobile technology is widely available and inexpensive. We developed a mobile application (M-OncoED) to educate physicians on cancer screening and tested the acceptability, utility, and cost of two different approaches to recruit physicians. METHODS: M-OncoED was designed to perform pre- and postlearning assessments through the in-built quizzes; present case studies and educational materials for cervical, breast, and oral cancer screening; collect responses to interactive queries; document module completion; send reminders and alerts; and track user metrics, including number of sessions to complete each module and time spent per session. We tested two recruitment approaches: a broad-scale recruitment group, for which we relied on e-mails, messaging apps (e.g., WhatsApp), and phone calls, and the targeted recruitment group, for which we conducted a face-to-face meeting for the initial invitation. RESULTS: Overall, about 35% of those invited in the targeted group completed the course compared with about 3% in the broad-based recruitment group. The targeted recruitment approach was more cost-efficient ($55.33 vs. $109.43 per person). Cervical cancer screening knowledge increased by about 30 percentage points, and breast cancer screening knowledge increased by 10 percentage points. There was no change in knowledge for oral cancer scorings. CONCLUSION: This study has demonstrated the feasibility and utility of using an mHealth app to educate physicians. A more intensive hands-on recruitment approach is likely required to engage physicians to download and complete the app. Future studies should assess the impact of mHealth tools on physician behavior and patient outcomes. IMPLICATIONS FOR PRACTICE: Mobile health (mHealth)-based oncology education can be a powerful tool for providing cancer screening knowledge to physicians, as mobile technology is widely available and inexpensive. This study has demonstrated the feasibility and utility of using an mHealth app to educate physicians and illustrates the type of recruitment approach (face-to-face) that is likely required to incentivize physicians to download the app and complete the training.

The Effectiveness of mHealth and eHealth Tools in Improving Provider Knowledge, Confidence, and Behaviors Related to Cancer Detection, Treatment, and Survivorship Care: a Systematic Review.

Mobile health (mHealth) and eHealth interventions have demonstrated potential to improve cancer care delivery and disease management by increasing access to health information and health management skills. However, there is a need to better understand the overall impact of these interventions in improving cancer care and to identify best practices to support intervention adoption. Overall, this review intended to systematically catalogue the recent body of cancer-based mHealth and eHealth education and training interventions and assess the effectiveness of these interventions in increasing health care professionals' knowledge, confidence, and behaviors related to the delivery of care along the cancer continuum. Our initial search yielded 135 articles, and our full review included 23 articles. We abstracted descriptive data for each of the 23 studies, including an overview of interventions (i.e., intended intervention recipients, location of delivery, topic of focus), study methods (i.e., design, sampling approach, sample size), and outcome measures. Almost all the studies reported knowledge gain as an outcome of the education interventions, whereas only half assessed provider confidence or behavior change. We conclude that there is some evidence that mHealth and eHealth interventions lead to improvements in cancer care delivery, but this is not a consistent finding across the studies reviewed. Our findings also identify gaps that should be addressed in future research, offer guidance on the utility of mHealth and eHealth interventions, and provide a roadmap for addressing these gaps.

Treatment cost and access to care: experiences of young women diagnosed with breast cancer.

PURPOSE: Breast cancer is the leading cause of cancer-related deaths in women younger than 40 years. We aim to evaluate cost as a barrier to care among female breast cancer patients diagnosed between 18 to 39 years. METHODS: In early 2017, we distributed a survey to women diagnosed with breast cancer between the ages of 18 and 39 years, as identified by the central cancer registries of California, Georgia, North Carolina, and Florida. We used multivariable statistics to explore cost-related barriers to receiving breast cancer care for the 830 women that completed the survey. RESULTS: About half of the women (47.4%) reported spending more on breast cancer care than expected, and almost two-thirds (65.3%) had not discussed costs with their care team. A third of the patients (31.8%) indicated forgoing care due to cost. Factors associated with not receiving anticipated care due to cost included age less than35 years at diagnosis, self-insurance, comorbid conditions, and late-stage diagnosis. CONCLUSION: Previous studies using breast cancer registry data have not included detailed insurance information and care received by young women. Young women with breast cancer frequently forgo breast cancer care due to cost. Our results highlight the potential for policies that facilitate optimal care for young breast cancer patients which could include the provision of comprehensive insurance coverage.

Role of an Implementation Economics Analysis in Providing the Evidence Base for Increasing Colorectal Cancer Screening.

PURPOSE AND OBJECTIVES: Since 2005 the Centers for Disease Control and Prevention (CDC) has funded organizations across the United States to promote screening for colorectal cancer (CRC) to detect early CRC or precancerous polyps that can be treated to avoid disease progression and death. The objective of this study was to describe how findings from economic evaluation approaches of a subset of these awardees and their implementation sites (n = 9) can drive decision making and improve program implementation and diffusion. INTERVENTION APPROACH: We described the framework for the implementation economics evaluation used since 2016 for the Colorectal Cancer Control Program (CRCCP) Learning Collaborative. EVALUATION METHODS: We compared CRC interventions implemented across health systems, changes in screening uptake, and the incremental cost per person of implementing an intervention. We also analyzed data on how implementation costs changed over time for a CRC program that conducted interventions in a series of rounds. RESULTS: Implementation of the interventions, which included provider and patient reminders, provider assessment and feedback, and incentives, resulted in increases in screening uptake ranging from 4.9 to 26.7 percentage points. Across the health systems, the incremental cost per person screened ranged from $18.76 to $144.55. One awardee's costs decreased because of a reduction in intervention development and start-up costs. IMPLICATIONS FOR PUBLIC HEALTH: Health systems, CRCCP awardees, and CDC can use these findings for quality improvement activities, incorporation of information into trainings and support activities, and future program design.

Economic Evaluation of Interventions to Increase Colorectal Cancer Screening at Federally Qualified Health Centers.

The Centers for Disease Control and Prevention (CDC) has a long-standing commitment to increase colorectal cancer (CRC) screening for vulnerable populations. In 2005, the CDC began a demonstration in five states and, with lessons learned, launched a national program, the Colorectal Cancer Control Program (CRCCP), in 2009. The CRCCP continues today and its current emphasis is the implementation of evidence-based interventions to promote CRC screening. The purpose of this article is to provide an overview of four CRCCP awardees and their federally qualified health center partners as an introduction to the accompanying series of research briefs where we present individual findings on impacts of evidence-based interventions on CRC screening uptake for each awardee. We also include in this article the conceptual framework used to guide our research. Our findings contribute to the evidence base and guide future program implementation to improve sustainability, increase CRC screening, and address disparities in screening uptake.

Cost and Effectiveness of Reminders to Promote Colorectal Cancer Screening Uptake in Rural Federally Qualified Health Centers in West Virginia.

The purpose of this study is to evaluate the effectiveness of the West Virginia Program to Increase Colorectal Cancer Screening in implementing patient reminders to increase fecal immunochemical test (FIT) kit return rates in nine federally qualified health centers (FQHCs). Using process measures and cost data collected, the authors examined the differences in the intensity of the phone calls across FQHCs and compared them with the return rates achieved. They also reported the cost per kit successfully returned as a result of the intervention. Across all FQHCs, 5,041 FIT kits were ordered, and the initial return rate (without a reminder) was 41.1%. A total of 2,201 patients received reminder phone calls; on average, patients received 1.61 reminder calls each. The reminder interventions increased the average FIT kit return rate to 60.7%. The average total cost per FIT kit returned across all FQHCs was $60.18, and the average cost of only the reminders was $11.20 per FIT kit returned. FQHCs achieved an average increase of 19.6 percentage points in FIT kit return rates, and costs across clinics varied. Clinics with high-quality health information systems that enabled tracking of patients with minimal effort were able to implement lower cost reminder interventions.

The Effectiveness and Cost to Improve Colorectal Cancer Screening in a Federally Qualified Homeless Clinic in Eastern Kentucky.

The objective of this study was to analyze the effectiveness and cost of patient incentives, together with patient navigation and patient reminders, to increase fecal immunochemical test (FIT) kit return rates and colorectal cancer screening uptake in one federally qualified health center (FQHC) in Appalachia. This FQHC is a designated homeless clinic, as 79.7% of its patient population are homeless. We collected process, outcome, and cost data from the FQHC for two time periods: usual care (September 2016-August 2017) and implementation (September 2017-September 2018). We reported the FIT kit return rate, the increase in return rate, and the additional number of individual screens. We also calculated the incremental cost per additional screen. The patient incentive program, with patient navigation and patient reminders, increased the number of FIT kits returned from the usual care period to the implementation period. The return rate increased by 25.9 percentage points (from 21.7% to 47.6%) with an additional 91 people screened at an incremental cost of $134.61 per screen. A patient incentive program, together with the assistance of patient navigators and supplemented with patient reminders, can help improve CRC screening uptake among vulnerable and homeless populations.

Effectiveness and Cost of Implementing Evidence-Based Interventions to Increase Colorectal Cancer Screening Among an Underserved Population in Chicago.

With funding from the Centers for Disease Control and Prevention's Colorectal Cancer Control Program, The University of Chicago Center for Asian Health Equity partnered with a federally qualified health center (FQHC) to implement multiple evidence-based interventions (EBIs) in order to improve colorectal cancer (CRC) screening uptake. The purpose of this study is to determine the effectiveness and cost of implementing a provider reminder system entered manually and supplemented with patient reminders and provider assessment and feedback. The FQHC collected demographic characteristics of the FQHC and outcome data from January 2015 through December 2015 (preimplementation period) and cost from January 2016 through September 2017 (implementation period). Cost data were collected for the implementation period. We report on the demographics of the eligible population, CRC screening order, completion rates by sociodemographic characteristics, and, overall, the effectiveness and cost of implementation. From the preimplementation phase to the implementation phase, there was a 21.2 percentage point increase in CRC screens completed. The total cost of implementing EBIs was $40908.97. We estimated that an additional 283 screens were completed because of the interventions, and the implementation cost of the interventions was $144.65 per additional screen. With the interventions, CRC screening uptake in Chicago increased for all race/ethnicity and demographic backgrounds at the FQHC, particularly for patients aged 50 to 64 years and for Asian, Hispanic, and uninsured patients.

Examining the Effectiveness of Provider Incentives to Increase CRC Screening Uptake in Neighborhood Healthcare: A California Federally Qualified Health Center.

As an awardee of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program, the California Department of Public Health partnered with Neighborhood Healthcare to implement evidence-based interventions and provider incentives (incentives offered to support staff, e.g., medical assistants, phlebotomists, front office staff, lab technicians) to improve colorectal cancer screening uptake. The objective of this study was to evaluate the effectiveness and cost of the provider incentive intervention implemented by Neighborhood Healthcare to increase colorectal cancer screening uptake. We collected and analyzed process and cost data to assess fecal immunochemical test (FIT) kit return rates to the health centers and the number of completed FIT kits. We estimated the costs of the preexisting interventions and the new interventions. Analyses were conducted for two time periods: preimplementation and implementation. Most Neighborhood Healthcare health centers experienced an increase in the percentage of FIT kit returns (average of 3.6 percentage points) and individuals screened (an average increase of 111 FIT kits per month) from the baseline period through the implementation period. The cost of the incentive intervention for each additional screen was $66.79. In conclusion, the results indicate that incentive programs can have an overall positive impact on both the percentage of FIT kits returned and the number of individuals screened.

Identifying Barriers and Facilitators to Breast Cancer Early Detection and Subsequent Treatment Engagement in Kenya: A Qualitative Approach.

BACKGROUND: Early detection and prompt access to quality treatment and palliative care are critical for good breast cancer outcomes. Interventions require understanding of identified barriers and facilitators to care. A hermeneutic phenomenological approach, whose purpose is to describe feelings and lived experiences of participants, can expand the existing scope of understanding of barriers and facilitators in accessing breast cancer care in Kenya. METHODS: This is qualitative research applying focus groups and a hermeneutic phenomenological approach to identify barriers and facilitators to breast cancer care from the knowledge, perceptions, and lived experiences of women with and without a diagnosis of breast cancer in Kenya. We conducted four focus group discussions with 6-11 women aged 30-60 years in each. Groups were classified according to breast cancer diagnosis and socioeconomic status. The transcribed discussions were coded independently by two investigators. Together they reviewed the codes and identified themes. RESULTS: The key barriers were costs, inadequate knowledge, distance to health facilities, communication with health providers, medicines stockouts, long waiting periods, limited or no counseling at diagnosis, patient vulnerability, and limited access to rehabilitation items. Facilitators were dependable social support, periodical access to subsidized awareness, and early detection services and friendly caregivers. We found no marked differences in perceptions between groups by socioeconomic status. CONCLUSION: There is need for targeted awareness and education for health providers and the public, early detection services with onsite counseling and cost mitigation. Support from the society and religious organizations and persons may be leveraged as adjuncts to conventional management. Further interpretations are encouraged. IMPLICATIONS FOR PRACTICE: Continuing cancer education for health providers in technical skills for early detection, treatment, and survivorship care, as well as nontechnical skills like communication, and an understanding of their patients' preferences and socioeconomic status may guide individualized management plans and positively affect patient experiences. Patients and the general public also need education on cancer to avoid misconceptions and inaccuracies that perpetuate fear, confusion, delayed presentation for treatment, and stigma. Critical analysis of the cancer care value chain and processes, development, and implementation of interventions to reduce costs while streamlining processes may improve client experiences.

The effect of delivery structure on costs, screening and health promotional services in state level National Breast and Cervical Cancer Early Detection Programs.

PURPOSE: We estimated the costs and effectiveness of state programs in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) based on the type of delivery structure. METHODS: Programs were classified into three delivery structures: (1) centralized, (2) decentralized, and (3) mixed. Centralized programs offer clinical services in satellite offices, but all other program activities are performed centrally. Decentralized programs contract with other entities to fully manage and provide screening and diagnostic services and other program activities. Programs with mixed service delivery structures have both centralized and decentralized features. Programmatic costs were averaged over a 3 year period (2006-2007, 2008-2009, and 2009-2010). Effectiveness was defined in terms of the average number of women served over the 3 years. We report costs per woman served by program activity and delivery structure and incremental cost effectiveness by program structure and by breast/cervical services. RESULTS: Average costs per woman served were lowest for mixed program structures (breast = $225, cervical = $216) compared to decentralized (breast = cervical = $276) and centralized program structures (breast = $259, cervical = $251). Compared with decentralized programs, for each additional woman served, centralized programs saved costs of $281 (breast) and $284 (cervical). Compared with decentralized programs, for each additional woman served, mixed programs added an additional $109 cost for breast but saved $1,777 for cervical cancer. CONCLUSIONS: Mixed program structures were associated with the lowest screening and diagnostic costs per woman served and had generally favorable incremental costs relative to the other program structures.

Cost-effectiveness of patient navigation for breast cancer screening in the National Breast and Cervical Cancer Early Detection Program.

OBJECTIVES: Patient navigation (PN) services have been shown to improve cancer screening in disparate populations. This study estimates the cost-effectiveness of implementing PN services within the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: We adapted a breast cancer simulation model to estimate a population cohort of women aged 40-64 years from the NBCCEDP through their lifetime. We incorporated their screening frequency and screening and diagnostic costs. RESULTS: Within the NBCCEDP, Program with PN (vs. No PN) resulted in a greater number of mammograms per woman (4.23 vs. 4.14), lower lifetime mortality from breast cancer (3.53% vs. 3.61%), and fewer missed diagnostic resolution per woman (0.017 vs. 0.025). The estimated incremental cost-effectiveness ratios for a Program with PN was $32,531 per quality-adjusted life-years relative to Program with No PN. CONCLUSIONS: Incorporating PN services within the NBCCEDP may be a cost-effective way of improving adherence to screening and diagnostic resolution for women who have abnormal results from screening mammography. Our study highlights the value of supportive services such as PN in improving the quality of care offered within the NBCCEDP.

Awardee-specific economic costs of providing cancer screening and health promotional services to medically underserved women eligible in the National Breast and Cervical Cancer Early Detection Program.

OBJECTIVES: To estimate awardee-specific costs of delivering breast and cervical cancer screening services in their jurisdiction and to assess potential variation in the cost of key activities across awardees. METHODS: We developed the cost assessment tool to collect resource use and cost data from the National Breast and Cervical Cancer Early Detection Program awardees for 3 years between 2006 and 2010 and generated activity-based cost estimates. We estimated awardee-specific cost per woman served for all activities, clinical screening delivery services, screening promotion interventions, and overarching program support activities. RESULTS: The total cost per woman served by the awardees varied greatly from $205 (10th percentile) to $499 (90th percentile). Differences in the average (median) cost per person served for clinical services, health promotion interventions, and overarching support activities ranged from $51 to $125. CONCLUSIONS: The cost per woman served varied across awardee and likely reflected underlying differences across awardees in terms of screening infrastructure, population served, and barriers to screening uptake. Collecting information on contextual factors at the awardee, health system, provider, and individual levels may assist in understanding this variation in cost.

Cost-effectiveness of breast cancer screening in the National Breast and Cervical Cancer Early Detection Program.

PURPOSE: To estimate the cost-effectiveness of breast cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: Using a modified CISNET breast cancer simulation model, we estimated outcomes for women aged 40-64 years associated with three scenarios: breast cancer screening within the NBCCEDP, screening in the absence of the NBCCEDP (no program), and no screening through any program. We report screening outcomes, cost, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and sensitivity analyses results. RESULTS: Compared with no program and no screening, the NBCCEDP lowers breast cancer mortality and improves QALYs, but raises health care costs. Base-case ICER for the program was $51,754/QALY versus no program and $50,223/QALY versus no screening. Probabilistic sensitivity analysis ICER for the program was $56,615/QALY [95% CI $24,069, $134,230/QALY] versus no program and $51,096/QALY gained [95% CI $26,423, $97,315/QALY] versus no screening. CONCLUSIONS: On average, breast cancer screening in the NBCCEDP was cost-effective compared with no program or no screening.