A trial-based cost-effectiveness analysis of antibiotic prescription strategies for non-complicated respiratory tract infections in children.

BACKGROUND: Antibiotic prescription for respiratory tract infections (RTIs) in children attending primary care centres is almost double that predicted according to bacterial prevalence. Delayed antibiotic prescription (DAP) is designed to deploy a more rational use of antibiotics. While studies have evaluated DAP efficacy and safety for children with RTIs, little research has been conducted on the economic implications. METHODS: Our trial compared cost-effectiveness for DAP, immediate antibiotic prescription (IAP), and no antibiotic prescription (NAP) for children aged 2-14 years with acute uncomplicated RTIs attended to in 39 primary care centres in Spain. The main outcome was the incremental cost-effectiveness ratio (ICER), measured in euros per gained quality-adjusted life days (QALDs). Net monetary benefit (NMB) was also calculated as a tool for decision making. The analysis was performed from a societal perspective for a time horizon of 30 days, and included healthcare direct costs, non-healthcare direct and indirect costs, and the antimicrobial resistance (AMR) cost. RESULTS: DAP was the most cost-effective strategy, even when the cost of AMR was included. QALD values for the three strategies were very similar. IAP compared to DAP was more costly (109.68 vs 100.90 euros) and similarly effective (27.88 vs 27.94 QALDs). DAP compared to NAP was more costly (100.90 vs 97.48 euros) and more effective (27.94 vs. 27.82 QALDs). The ICER for DAP compared to NAP was 28.84 euros per QALD. The deterministic sensitivity analysis indicated that non-healthcare indirect costs had the greatest impact on the ICER. The cost-effectiveness acceptability curve showed that DAP was the preferred option in approximately 81.75% of Monte Carlo iterations, assuming a willingness-to-pay value of 82.2 euros per gained QALD. CONCLUSIONS: When clinicians are in doubt about whether an antibiotic is needed for children with RTIs attending PC centres, those treated with the DAP strategy will have slightly better efficiency outcomes than those treated with IAP because its costs are lower than those of IAP. DAP is also the most cost-effective strategy over a time horizon of 30 days if AMR is considered, despite higher short-term costs than NAP. However, if in the long term the costs of AMR are larger than estimated, NAP could also be an alternative strategy. TRIAL REGISTRATION: This trial has been registered at www. CLINICALTRIALS: gov (identifier NCT01800747; Date: 28/02/2013 (retrospectively registered).

The costs associated with stroke care continuum: a systematic review.

Stroke, a leading cause of death and long-term disability, has a considerable social and economic impact. It is imperative to investigate stroke-related costs. The main goal was to conduct a systematic literature review on the described costs associated with stroke care continuum to better understand the evolution of the economic burden and logistic challenges. This research used a systematic review method. We performed a search in PubMed/MEDLINE, ClinicalTrial.gov, Cochrane Reviews, and Google Scholar confined to publications from January 2012 to December 2021. Prices were adjusted using consumer price indices of the countries in the studies in the years the costs were incurred to 2021 Euros using the World Bank and purchasing power parity exchange rate in 2020 from the Organization for Economic Co-operation and Development with the XE Currency Data API. The inclusion criteria were all types of publications, including prospective cost studies, retrospective cost studies, database analyses, mathematical models, surveys, and cost-of-illness (COI) studies. Were excluded studies that (a) were not about stroke, (b) were editorials and commentaries, (c) were irrelevant after screening the title and abstract,(d) grey literature and non-academic studies, (e) reported cost indicators outside the scope of the review, (f) economic evaluations (i.e., cost-effectiveness or cost-benefit analyses); and (g) studies not meeting the population inclusion criteria. There may be risk of bias because the effects are dependent on the persons delivering the intervention. The results were synthetized by PRISMA method. A total of 724 potential abstracts were identified of which 25 articles were pulled for further investigation. The articles were classified into the following categories: 1)stroke primary prevention, 2) expenditures related to acute stroke care, 3) expenditures for post-acute strokes, and 4) global average stroke cost. The measured expenditures varied considerably among these studies with a global average cost from €610-€220,822.45. Given the great variability in the costs in different studies, we can conclude that we need to define a common system for assessing the costs of strokes. Possible limitations are related to clinical choices exposed to decision rules that trigger decisions alerts within stroke events in a clinical setting. This flowchart is based on the guidelines for acute ischemic stroke treatment but may not be applicable to all institutions.

Organización y costes de la atención extrahospitalaria del ictus. Revisión sistemática de la literatura / Organization and costs of stroke care in outpatient settings: Systematic review

Objetivo: Revisar la bibliografía sobre costes del ictus (ICD-10 código I63) en el ámbito de la atención primaria. Diseño: Revisión sistemática. Fuentes de datos: PubMed/Medline, ClinicalTrials.gov, Cochrane Reviews, EconLit y Ovid/Embase entre el 1 de enero de 2012 y el 31 de diciembre de 2021 con descriptores incluidos en Medical Subject Heading (MeSH). Selección de estudios: Aquellos con descripción de costes de actividades realizadas en el ámbito extrahospitalario. Se incluyeron revisiones sistemáticas; estudios observacionales prospectivos y retrospectivos; análisis de bases de datos y de costes totales o parciales del ictus como enfermedad (COI). Se agregaron artículos utilizando el método de «bola de nieve». Se excluyeron los estudios: a) no relacionados concretamente con el ictus; b) en formato de editoriales o comentarios; c) irrelevantes después de examinar el título y el resumen; d) literatura gris y estudios no académicos. Extracción de datos: A los estudios se les asignó un nivel de evidencia según los niveles GRADE. Se recogieron datos de costes directos e indirectos. Resultados y conclusiones: Treinta estudios, de los que 14 (46,6%) eran relativos a costes postictus y 12 (40%) a costes en prevención cardiovascular. Los resultados muestran que la mayoría son análisis retrospectivos de diferentes bases de datos de atención hospitalaria a corto plazo, y no permiten realizar un análisis detallado de los costes por diferentes segmentos de servicios. Las posibilidades de mejora aparecen centradas en la prevención primaria y secundaria, selección y traslado prehospitalario, el alta precoz con soporte y la atención sociosanitaria.(AU)

Objective: To review the bibliography on stroke costs (ICD-10 code I63) in the field of primary care. Design: Systematic review. Data sources: PubMed/Medline, ClinicalTrials.gov, Cochrane Reviews, EconLit, and Ovid/Embase between 01/01/2012–12/31/2021 with descriptors included in Medical Subject Heading (MeSH). Selection of studies: Those with a description of the costs of activities carried out in the out-of-hospital setting. Systematic reviews were included; prospective and retrospective observational studies; analysis of databases and total or partial costs of stroke as a disease (COI). Articles were added using the snowball method. The studies were excluded because: a) not specifically related to stroke; b) in editorial or commentary format; c) irrelevant after review of the title and abstract; and d) gray literature and non-academic studies were excluded. Data extraction: They were assigned a level of evidence according to the GRADE levels. Direct and indirect cost data were collected. Results and conclusions: Thirty studies, of which 14 (46.6%) were related to post-stroke costs and 12 (40%) to cardiovascular prevention costs. The results show that most of them are retrospective analyzes of different databases of short-term hospital care, and do not allow a detailed analysis of the costs by different segments of services. The possibilities for improvement are centered on primary and secondary prevention, selection and pre-hospital transfer, early discharge with support, and social and health care.(AU)

Cost-effectiveness of a high-sensitivity cardiac troponin T systematic screening strategy compared with usual care to identify patients with peri-operative myocardial injury after major noncardiac surgery.

BACKGROUND: About 300 million surgeries are performed worldwide annually and this figure is increasing constantly. Peri-operative myocardial injury (PMI), detected by cardiac troponin (cTn) elevation, is a common cardiac complication of noncardiac surgery, strongly associated with short- and long-term mortality. Without systematic peri-operative cTn screening, most cases of PMI may go undetected. However, little is known about cost effectiveness of a systematic PMI screening strategy with high-sensitivity cardiac troponin T (hs-cTnT) after noncardiac surgery. OBJECTIVE: To assess, in patients with high cardiovascular risk, the cost-effectiveness of a systematic screening strategy using a hs-cTnT assay, to identify patients with PMI after major noncardiac surgery, compared with usual care. DESIGN: Cost-effectiveness analysis; single centre prospective cohort study. SETTING: Spanish University Hospital. PATIENTS: From July 2016 to March 2019, we included 1477 consecutive surgical patients aged ≥65 or if <65, with documented history of cardiovascular disease or impaired renal function, who underwent major noncardiac surgery and required at least an overnight hospital stay. We excluded patients aged <65 years without cardiovascular disease, undergoing minor surgery, or with an expected <24 h hospital stays. INTERVENTIONS: We conducted a decision-tree analysis, comparing a systematic screening strategy measuring hs-cTnT before surgery, and at the 2nd and 3rd days after surgery vs. a usual care strategy. We considered a third-party payer perspective and the outcomes of both strategies in the short-term (30 days follow-up). Information about costs was expressed in Euros-2021. We calculated the incremental cost-effectiveness ratio (ICER) of the systematic hs-cTnT strategy, defined as the expected cost per any additional PMI detected, and explored the robustness of the model using deterministic and probabilistic sensitivity analysis. MAIN OUTCOME MEASURES: ICER of the systematic hs-cTnT screening strategy. RESULTS: The ICER was €425 per any additionally detected PMI. The deterministic sensitivity analysis showed that a 15% variation in costs, and a 1% variation in the predictive values, had a minor impact over the ICER, except in case of the negative predictive value of the systematic hs-cTnT screening strategy. Monte Carlo simulations (probabilistic sensitivity analysis) showed that systematic hs-cTnT screening would be cost-effective in 100% of cases with a 'willingness to pay' of €780. CONCLUSIONS: Our results suggest that systematic peri-operative PMI screening with hs-cTnT may be cost-effective in the short-term in patients undergoing major noncardiac surgery. Economic evaluations, with a long-term horizon, are still needed. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03438448.

Factors influencing intention to participate in breast cancer screening. An exploratory structural model.

OBJECTIVES: The paper has two objectives. The first one examines whether informing women about the benefits and adverse effects of breast cancer screening could have an effect on three variables: their knowledge, the importance women attach to the future consequences of their current decisions (time perspective), and the degree to which women are worried about developing breast cancer (worry). The second one examines whether these three variables affect their intention to participate in the screening, either directly or indirectly through their feeling of regret if they do not attend the screening (anticipated regret); through their values and the support they receive in making their decisions (decisional conflict); and, through the perceived acceptability and benefits of the screening programme (attitude). METHODS: Partial least squares-structural equation modelling (PLS-SEM) is used to analyse both objectives and to differentiate between direct, indirect, and moderating effects, due to the incorporation in the model of the three mediating variables (anticipated regret, decisional conflict, and attitude) and a moderating variable (educational level). RESULTS: Information affects knowledge (objective variable), but not the behavioural variables (time perspective and worry). On the other hand, the level of knowledge has no direct or indirect effect on intention, but behavioural variables do affect it through the mediating variables. CONCLUSIONS: The variables of the planned behaviour theory are relevant to understand women's decisions and to be able to take appropriate health policy measures. Doing so, the processes of personalised screening would improve, or there would be the incorporation of shared decision-making in this context; these being demands associated with the most recent goals achieved in health programmes in many countries.

[Organization and costs of stroke care in outpatient settings: Systematic review]. / Organización y costes de la atención extrahospitalaria del ictus. Revisión sistemática de la literatura.

OBJECTIVE: To review the bibliography on stroke costs (ICD-10 code I63) in the field of primary care. DESIGN: Systematic review. DATA SOURCES: PubMed/Medline, ClinicalTrials.gov, Cochrane Reviews, EconLit, and Ovid/Embase between 01/01/2012-12/31/2021 with descriptors included in Medical Subject Heading (MeSH). SELECTION OF STUDIES: Those with a description of the costs of activities carried out in the out-of-hospital setting. Systematic reviews were included; prospective and retrospective observational studies; analysis of databases and total or partial costs of stroke as a disease (COI). Articles were added using the snowball method. The studies were excluded because: a) not specifically related to stroke; b) in editorial or commentary format; c) irrelevant after review of the title and abstract; and d) gray literature and non-academic studies were excluded. DATA EXTRACTION: They were assigned a level of evidence according to the GRADE levels. Direct and indirect cost data were collected. RESULTS AND CONCLUSIONS: Thirty studies, of which 14 (46.6%) were related to post-stroke costs and 12 (40%) to cardiovascular prevention costs. The results show that most of them are retrospective analyzes of different databases of short-term hospital care, and do not allow a detailed analysis of the costs by different segments of services. The possibilities for improvement are centered on primary and secondary prevention, selection and pre-hospital transfer, early discharge with support, and social and health care.

European national health plans and the monitoring of online searches for information on diabetes mellitus in different European healthcare systems.

Diabetes mellitus (DM) is a serious non-communicable disease (NCD) and relies on the patient being aware of their condition, proactive, and having adequate medical care. European countries healthcare models are aware of the impact of these variables. This study evaluates the impact of online health information seeking behavior (OHISB) during World Diabetes Mellitus Day (WDMD) in European countries from 2014 to 2019 by grouping countries according to the changes in citizens' search behavior, diabetes mellitus prevalence, the existence of National Health Plans (NHP), and their respective healthcare systems. We extracted data from Global Burden of Disease, Google Trends (GT), Public Health European Commission, European Coalition for Diabetes, and the Spanish Ministry of Health. First, we used the broken-line models to analyze significant changes in search trends (GT) in European Union member countries in the 30-day intervals before and after the WDMD (November 14) from 2014 to 2019. Then the results obtained were used in the second phase to group these countries by factor analysis of mixed data (FAMD) using the prevalence of DM, the existence of NHP, and health models in each country. The calculations were processed using R software (gtrendsR, segmented, Factoextra, and FactoMineR). We established changes in search trends before and after WDMD, highlighting unevenness among European countries. However, significant changes were mostly observed among countries with NHP. These changes in search trends, in addition to being significant, were reiterated over time and occurred especially in countries belonging to the Beveridge Model (Portugal, Spain, and Sweden) and with NHPs in place. Greater awareness of diabetes mellitus among the population and continuous improvements in NHP can improve the patients' quality of life, thus impacting in disease management and healthcare expenditure.

Women's preference to apply shared decision-making in breast cancer screening: a discrete choice experiment.

OBJECTIVE: To analyse women's stated preferences for establishing the relative importance of each attribute of shared decision-making (SDM) and their willingness to pay (WTP) for more participatory care in breast cancer screening programmes (BCSP). DESIGN: A discrete choice experiment was designed with 12 questions (choice tasks). It included three attributes: 'How the information is obtained', regarding benefits and harms; whether there is a 'Dialogue for scheduled mammography' between the healthcare professional and the woman; and, 'Who makes the decision', regarding participation in BCSP. Data were obtained using a survey that included 12 choice tasks, 1 question on WTP and 7 socioeconomic-related questions. The analysis was performed using conditional mixed-effect logit regression and stratification according to WTP. SETTING: Data collection related to BCSP was conducted between June and November 2021 in Catalonia, Spain. PARTICIPANTS: Sixty-five women aged between 50 and 60. MAIN OUTCOME MEASURES: Women's perceived utility of each attribute, trade-off on these attributes and WTP for SDM in BCSP. RESULT: The only significant attribute was 'Who makes the decision'. The decision made alone (coefficient=2.879; 95% CI=2.297 to 3.461) and the decision made together with a healthcare professional (2.375; 95% CI=1.573 to 3.177) were the options preferred by women. The former contributes 21% more utility than the latter. Moreover, 52.3% of the women stated a WTP of €10 or more for SDM. Women's preferences regarding attributes did not influence their WTP. CONCLUSIONS: The participant women refused a current paternalistic model and preferred either SDM or informed decision-making in BCSP.

Views of health professionals on risk-based breast cancer screening and its implementation in the Spanish National Health System: A qualitative discussion group study.

BACKGROUND: With the aim of increasing benefits and decreasing harms, risk-based breast cancer screening has been proposed as an alternative to age-based screening. This study explores barriers and facilitators to implementing a risk-based breast cancer screening program from the perspective of health professionals, in the context of a National Health Service. METHODS: Socio-constructivist qualitative research carried out in Catalonia (Spain), in the year 2019. Four discussion groups were conducted, with a total of 29 health professionals from primary care, breast cancer screening programs, hospital breast units, epidemiology units, and clinical specialties. A descriptive-interpretive thematic analysis was performed. RESULTS: Identified barriers included resistance to reducing the number of screening exams for low-risk women; resistance to change for health professionals; difficulties in risk communication; lack of conclusive evidence of the benefits of risk-based screening; limited economic resources; and organizational transformation. Facilitators include benefits of risk-based strategies for high and low-risk women; women's active role in their health care; proximity of women and primary care professionals; experience of health professionals in other screening programs; and greater efficiency of a risk-based screening program. Organizational and administrative changes in the health system, commitment by policy makers, training of health professionals, and educational interventions addressed to the general population will be required. CONCLUSIONS: Despite the expressed difficulties, participants supported the implementation of risk-based screening. They highlighted its benefits, especially for women at high risk of breast cancer and those under 50 years of age, and assumed a greater efficiency of the risk-based program compared to the aged-based one. Future studies should assess the efficiency and feasibility of risk-based breast cancer screening for its transfer to clinical practice.

Development of support material for health professionals who are implementing Shared Decision-making in breast cancer screening: validation using the Delphi technique.

BACKGROUND: The Literature is no report support material on Shared Decision-making applied to breast cancer screening that is intended for Spanish health professionals. The researcher created both a handbook and a guide for this topic using an adaption of the Three-talk model. OBJECTIVE: A Delphi method will be used to reach an agreement among experts on the contents and design of a manual and guide, designed by the research team, and to be used by health professionals in the application of SDM in breast cancer screening. DESIGN: A qualitative study. The content and design of the handbook and the guide was discussed by 20 experts. The Delphi techniques was in an online mode between July and October 2020 and researchers used Google forms in three rounds with open and closed questions. The criterion established for consensus was a coefficient of concordance (Cc) above 75, for questions using a Likert scale of 1-6-in which 1 meant 'completely disagree' and 6 'completely agree'-with a cut-off point equal to or higher than 4. RESULTS: Participants considered the Three-talk model suitable for the screening context. The handbook sections and level of detail were considered satisfactory (Cc=90). The summary provided by the clinical practice guide was considered necessary (Cc=75), as it was the self-assessment tool for professionals (Cc=85). Content was added: addressing the limitations of the SDM model; extending the number of sample dialogues for health professionals; providing supplementary resources on using Patient Decisions aids and adding references on communication skills. CONCLUSIONS AND APPLICATIONS: The first handbook and clinical practice guide providing unique SDM support material for health professionals have been developed. The handbook and guide are useful and innovative as supporting material for health professionals, but training strategies for SDM and a piloting plan for the use of materials are requested, in order to facilitate its implementation.

Barriers and Facilitators to the Implementation of a Personalized Breast Cancer Screening Program: Views of Spanish Health Professionals.

This study explored the barriers and facilitators to the implementation of a risk-based breast cancer screening program from the point of view of Spanish health professionals. A cross-sectional study with 220 Spanish health professionals was designed. Data were collected in 2020 via a web-based survey and included the advantages and disadvantages of risk-based screening and barriers and facilitators for the implementation of the program. Descriptive statistics and Likert scale responses analyzed as category-ordered data were obtained. The risk-based screening was considered important or very important to reduce breast cancer mortality and promote a more proactive role for women in breast cancer prevention, to increase coverage for women under 50 years, to promote a breast cancer prevention strategy for women at high risk, and to increase efficiency and effectiveness. Switching to a risk-based program from an age-based program was rated as important or very important by 85% of participants. As barriers for implementation, risk communication, the workload of health professionals, and limited human and financial resources were mentioned. Despite the barriers, there is good acceptance, and it seems feasible, from the perspective of health professionals, to implement a risk-based breast cancer screening program in Spain. However, this poses a number of organizational and resource challenges.

Diabetes mellitus and inequalities in the equipment and use of information technologies as a socioeconomic determinant of health in Spain.

Inequalities in the equipment and use of information and communications technology (ICT) in Spanish households can lead to users being unable to access certain information or to carry out certain procedures. Accessibility to ICT is considered a social determinant of health (SDOH) because it can generate inequalities in access to information and in managing access to health services. In the face of a chronic illness such as diabetes mellitus (DM)-for which a comprehensive approach is complex and its complications have a direct impact on current healthcare systems-all the resources that patients may have are welcome. We aimed to analyze hospitalizations and amputations as direct consequences of DM among the autonomous communities of Spain (ACS) in 2019, along with socioeconomic factors related to health, including inequalities in access to ICT between territories, as well as citizens' interest in online information searches about DM. We used different databases such as that of the Ministerio de Sanidad (Spain's health ministry), Ministerio de Asuntos Económicos y transformación (Ministry of Economic Affairs and Digital Transformation), Google Trends (GT), and the Instituto Nacional de Estadística (Spain's national institute of statistics). We examined the data with R software. We employed a geolocation approach and performed multivariate analysis (specifically factor analysis of mixed data [FAMD]) to evaluate the aggregate interest in health information related to DM in different regions of Spain grounded in online search behavior. The use of FAMD allowed us to adjust the techniques of principal component analysis (PCA) and multiple correspondence analysis (MCA) to detect differences between the direct consequences of DM, citizen's interest in this non-communicable disease, and socioeconomic factors and inequalities in access to ICT in aggregate form between the country's different ACS. The results show how SDOH, such as poverty and education level, are related to the ACS with the highest number of homes that cite the cost of connection or equipment as the reason for not having ICT at home. These regions also have a greater number of hospitalizations due to DM. Given that in Spain, there are certain differences in accessibility in terms of the cost to households, in the case of DM, we take this issue into account from the standpoint of an integral approach by health policies.

Healthcare professionals' behaviour regarding the implementation of shared decision-making in screening programmes: A systematic review.

OBJECTIVE: To explore the barriers to and facilitators of healthcare professionals' implementation of SDM regarding screening programmes. METHOD: A systematic review was conducted in PubMed, Cochrane Library, CINHAL, and PsyscInfo. The barriers and facilitators identified were classified into three factors based on their origin: patients, healthcare system performance, and healthcare professionals themselves. RESULTS: Eight studies were selected: seven related to cancer screening. The most significant facilitators were literacy and interest in active participation, both of which have their origins in patients. The most significant barriers identified for the first time in a systematic review were legal conflict, lack of remuneration and lack of flexibility in clinical guidelines in screening programmes. CONCLUSION: The results of this study show that there are differences between barriers and facilitators for SDM when it is applied in the context of healthy people who perform preventive activities, particularly screening, in contrast to general medical consultation contexts. PRACTICAL IMPLICATIONS: The authors suggest that to advance in the practice of SDM, we need to develop and disseminate training documents. Further, SDM should be incorporated into clinical guidelines. There should be more studies focusing on healthcare professionals' behaviour within the context of the uncertainty of screening programmes.

Effect of information about the benefits and harms of mammography on women's decision making: The InforMa randomised controlled trial.

BACKGROUND: In Spain, women invited to breast screening are not usually informed about potential harms of screening. The objective of the InforMa study is to assess the effect of receiving information about the benefits and harms of breast screening on informed choice and other decision-making outcomes, in women approaching the age of invitation to mammography screening. METHODS: Two-stage randomised controlled trial. In the first stage, 40 elementary territorial units of the public healthcare system were selected and randomised to intervention or control. In the second stage, women aged 49-50 years were randomly selected. The target sample size was 400 women. Women in the intervention arm received a decision aid (DA) with detailed information on the benefits and harms of screening. Women in the control arm received a standard leaflet that did not mention harms and recommended accepting the invitation to participate in the Breast Cancer Screening Program (BCSP). The primary outcome was informed choice, defined as adequate knowledge and intentions consistent with attitudes. Secondary outcomes included decisional conflict, worry about breast cancer, time perspective, opinions about the DA or the leaflet, and participation in the BCSP. RESULTS: In the intervention group, 23.2% of 203 women made an informed choice compared to only 0.5% of 197 women in the control group (p < 0.001). Attitudes and intentions were similar in both study groups with a high frequency of women intending to be screened, 82.8% vs 82.2% (p = 0.893). Decisional conflict was significantly lower in the intervention group. No differences were observed in confidence in the decision, anxiety, and participation in BCSP. CONCLUSIONS: Women in Spain lack knowledge on the benefits and harms of breast screening. Providing quantitative information on benefits and harms has produced a considerable increase in knowledge and informed choice, with a high acceptance of the informative materials. TRIAL REGISTRATION: Trial identifier NCT03046004 at ClinicalTrials.gov registry. Registered on February 4 2017. Trial name: InforMa study.

Assessment of the effects of decision aids about breast cancer screening: a systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review and meta-analysis of randomised controlled trials (RCTs) and observational studies is to assess the effect of decision aids (DAs) in women aged 50 and below facing the decision to be screened for breast cancer. SETTING: Screening for breast cancer. INTERVENTION: DAs aimed to help women make a deliberative choice regarding participation in mammography screening by providing information on the options and outcomes. ELIGIBLE STUDIES: We included published original, non-pilot, studies that assess the effect of DAs for breast cancer screening. We excluded the studies that evaluated only participation intention or actual uptake. The studies' risk of bias was assessed with the Cochrane Collaboration's tool for RCTs and the National Institutes of Health Quality Assessment Tool for non-RCTs. PRIMARY AND SECONDARY OUTCOMES: The main outcome measures were informed choice, decisional conflict and/or confidence, and knowledge. Secondary outcomes were values, attitudes, uncertainty and intention to be screened. RESULTS: A total of 607 studies were identified, but only 3 RCTs and 1 before-after study were selected. The use of DAs increased the proportion of women making an informed decision by 14%, 95% CI (2% to 27%) and the proportion of women with adequate knowledge by 12%, 95% CI (7% to 16%). We observed heterogeneity among the studies in confidence in the decision. The meta-analysis of the RCTs showed a significant decrease in confidence in the decision and in intention to be screened. CONCLUSIONS: Tools to aid decision making in screening for breast cancer improve knowledge and promote informed decision; however, we found divergent results on decisional conflict and confidence in the decision. Under the current paradigm change, which favours informed choice rather than maximising uptake, more research is necessary for the improvement of DAs.

Evolución de la mortalidad por cáncer de mama y diseminación de la mamografía de cribado en Cataluña. Un análisis por regiones sanitarias / The evolution of breast cancer mortality and the dissemination of mammography in Catalonia. An analysis by health region

Fundamento: El descenso de las tasas de mortalidad por cáncer de mama (CM) se ha atribuido a la implantación de programas de cribado y a avances terapéuticos. El objetivo de este trabajo es comparar la evolución de su mortalidad en las regiones sanitarias de Cataluña en el periodo 1993-2007. Paralelamente, se ha analizado la diseminación de la mamografía periódica en las regiones sanitarias. Métodos: Se analizaron los datos del registro de mortalidad y encuestas de salud. Se utilizaron regresiones de Poisson y «joinpoint» para comparar las tasas de mortalidad por CM y analizar su evolución temporal. Se utilizaron modelos de efectos mixtos para comparar el nivel y la evolución de la mortalidad por regiones. Resultados. La tasa de mortalidad por CM descendió un 3% anual en Cataluña. Entre 1993 y 2007, la tasa estandarizada varió de 34,8 a 23,3 por 100.000 mujeres. Barcelona ciutat presentó unas tasas de mortalidad más elevadas que las regiones Centre (ratio de tasas (RT)=0,87), Costa de Ponent (RT=0,89), Tarragona (RT=0,9) y Lleida (RT=0,915), pero estas diferencias tendieron a desaparecer. No se observaron cambios de tendencia en la evolución de la mortalidad de las regiones, excepto en la región Centre. Durante los años 1990 Barcelona ciutat presentó unos porcentajes de utilización de mamografía periódica del 36,1% de las mujeres de 40-74 años, en la encuesta de 1994, la región Centre (23,7%) y Costa de Ponent (25,2%). Conclusiones: La progresiva utilización de mamografía periódica y la disminución de la mortalidad por CM fueron similares en las regiones sanitarias de Cataluña(AU)

Background: The decrease of breast cancer (BC) mortality rates has been attributed to early detection programs and therapeutic advances. The objective is to compare BC mortality trend in health regions of Catalonia during the period 1993-2007. In parallel, dissemination of periodic mammography in the health regions has been analyzed. Methods: Mortality and health surveys data were used. Poisson and «joinpoint» regression analyses were used to compare regional BC mortality rates and quantify their temporal evolution. Mixed effects models were used to compare the rates and their evolution by region. Results: The BC mortality rate decreased 3% annually in Cataluña. Between 1993 and 2007, the standard mortality rate changed from 34.8 to 23.3 per 100,000 women. Barcelona ciutat showed higher mortality rates than the Centre (rate ratio (RR)=0.873), Costa de Ponent (RR=0.885), Tarragona (RR=0.9) and Lleida regions (RR=0.915), but these differences tend to disappear over time. There were no observed trend changes in the evolution of the regional mortality rates, except in the Centre region. The use of periodic mammography was similar across health regions. During the 90s, Barcelona ciutat had a 36.1% utilization of periodic mammography in women aged 40-74, in the 1994 survey, the Centre 23.7 and Costa de Ponent 25.2%. Conclusions: The progressive increase in the use of periodic mammography and the decrease of BC mortality were similar in the eight health regions of Catalonia(AU)

[The evolution of breast cancer mortality and the dissemination of mammography in Catalonia: an analysis by health region]. / Evolución de la mortalidad por cáncer de mama y diseminación de la mamografía de cribado en Cataluña: Un análisis por regiones sanitarias.

BACKGROUND: The decrease of breast cancer (BC) mortality rates has been attributed to early detection programs and therapeutic advances. The objective is to compare BC mortality trend in health regions of Catalonia during the period 1993-2007. In parallel, dissemination of periodic mammography in the health regions has been analyzed. METHODS: Mortality and health surveys data were used. Poisson and «joinpoint¼ regression analyses were used to compare regional BC mortality rates and quantify their temporal evolution. Mixed effects models were used to compare the rates and their evolution by region. RESULTS: The BC mortality rate decreased 3% annually in Cataluña. Between 1993 and 2007, the standard mortality rate changed from 34.8 to 23.3 per 100,000 women. Barcelona ciutat showed higher mortality rates than the Centre (rate ratio (RR)=0.873), Costa de Ponent (RR=0.885), Tarragona (RR=0.9) and Lleida regions (RR=0.915), but these differences tend to disappear over time. There were no observed trend changes in the evolution of the regional mortality rates, except in the Centre region. The use of periodic mammography was similar across health regions. During the 90s, Barcelona ciutat had a 36.1% utilization of periodic mammography in women aged 40-74, in the 1994 survey, the Centre 23.7 and Costa de Ponent 25.2%. CONCLUSIONS: The progressive increase in the use of periodic mammography and the decrease of BC mortality were similar in the eight health regions of Catalonia.