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1.
Cancer Causes Control ; 30(9): 923-929, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31297693

RESUMO

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.


Assuntos
Neoplasias da Mama/diagnóstico , Neoplasias da Mama/economia , Detecção Precoce de Câncer/economia , Mamografia/economia , Programas de Rastreamento/economia , Navegação de Pacientes/economia , Adulto , Análise Custo-Benefício , Feminino , Humanos , Pessoa de Meia-Idade , Modelos Teóricos , Anos de Vida Ajustados por Qualidade de Vida
4.
PLoS One ; 14(5): e0217213, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31120970

RESUMO

OBJECTIVES: Risk stratification has so far been evaluated under the assumption that women fully adhere to screening recommendations. However, the participation in German cancer screening programs remains low at 54%. The question arises whether risk-stratified screening is economically efficient under the assumption that adherence is not perfect. METHOD: We have adapted a micro-simulation Markov model to the German context. Annual, biennial, and triennial routine screening are compared with five risk-adapted strategies using thresholds of relative risk to stratify screening frequencies. We used three outcome variables (mortality reduction, quality-adjusted life years, and false-positive results) under the assumption of full adherence vs. an adherence rate of 54%. Strategies are evaluated using efficiency frontiers and probabilistic sensitivity analysis (PSA). RESULTS: The reduced adherence rate affects both performance and cost; incremental cost-effectiveness ratios remain constant. The results of PSA show that risk-stratified screening strategies are more efficient than biennial routine screening under certain conditions. At any willingness-to-pay (WTP), there is a risk-stratified alternative with a higher likelihood of being the best choice. However, without explicit decision criteria and WTP, risk-stratified screening is not more efficient than biennial routine screening. Potential improvements in the adherence rates have significant health gains and budgetary implications. CONCLUSION: If the participation rate for mammographic screening is as low as in Germany, stratified screening is not clearly more efficient than routine screening but dependent on the WTP. A more promising design for future stratified strategies is the combination of risk stratification mechanisms with interventions to improve the low adherence in selected high-risk groups.


Assuntos
Neoplasias da Mama/economia , Carcinoma Intraductal não Infiltrante/economia , Análise Custo-Benefício , Detecção Precoce de Câncer/economia , Mamografia/economia , Cooperação do Paciente , Anos de Vida Ajustados por Qualidade de Vida , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/epidemiologia , Neoplasias da Mama/mortalidade , Carcinoma Intraductal não Infiltrante/diagnóstico , Carcinoma Intraductal não Infiltrante/epidemiologia , Carcinoma Intraductal não Infiltrante/mortalidade , Técnicas de Apoio para a Decisão , Detecção Precoce de Câncer/métodos , Feminino , Alemanha/epidemiologia , Humanos , Mamografia/métodos , Cadeias de Markov , Pessoa de Meia-Idade , Invasividade Neoplásica , Valor Preditivo dos Testes , Risco , Taxa de Sobrevida
5.
BMC Public Health ; 19(1): 370, 2019 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-30943933

RESUMO

BACKGROUND: The Affordable Care Act (ACA) required private insurers and Medicare to cover recommended preventive services without any cost sharing to improve utilization of these services. This study is an attempt to identify the impact of removing cost sharing on mammography and pap test utilization rates. METHODS: Counterfactual analysis was used to predict what would have been the screening rates in post-ACA if ACA was not there. This was done by estimating a model that examines determinants of dependent variable for the pre-ACA year (pre-ACA year is 2009). The estimated model was then used to predict the dependent variable for the post-ACA year using individual characteristics and other relevant variables unlikely to be affected by ACA (post-ACA year is 2016). Effect of ACA is defined as the difference between the values of dependent variables in post-ACA and the predicted values of dependent variables in the post-ACA year using counterfactual. RESULTS: The counterfactual analysis show that the utilization of mammogram and pap test did not improve following ACA. CONCLUSION: Removal of cost-sharing under the ACA did not improve mammography or pap test rates. Therefore, financial barrier may not be an important factor in affecting utilization of the screening tests and policy makers should focus on other non-financial barriers in order to improve coverage of the tests.


Assuntos
Custo Compartilhado de Seguro , Mamografia/economia , Programas de Rastreamento/economia , Teste de Papanicolaou/economia , Aceitação pelo Paciente de Cuidados de Saúde , Patient Protection and Affordable Care Act , Serviços Preventivos de Saúde/economia , Pessoal Administrativo , Feminino , Política de Saúde , Humanos , Cobertura do Seguro , Seguro Saúde , Medicare , Estados Unidos , Esfregaço Vaginal
7.
Breast ; 45: 82-88, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30904701

RESUMO

OBJECTIVES: This study aimed to investigate the cost-effectiveness of intensified breast cancer (BC) screening for women with a BRCA1/2 mutation aged 60-74. Simulated strategies were: (0) annual mammography as reference, (1) alternating annual mammography and MRI for women with dense breasts only; (2) addition of annual MRI for women with dense breasts only; (3) addition of annual MRI for all women. MATERIALS AND METHODS: A validated micro-simulation model of invasive BC was updated and validated for interval BC rates and tumor size distribution. Incremental cost-effectiveness ratios (ICER) of all three intensified strategies were compared to the next best strategy and stratified for BRCA1 and BRCA2. Discount rates for costs and life years gained (LYG) were 1.5% and 4% for the Dutch situation; 3% and 3% for international comparison. A threshold of €20,000 per LYG was applied. RESULTS: All intensified strategies showed more detected BCs and LYG, reduced BC deaths, and increased false positives. The Dutch discounted ICER of intensified strategy 1 compared to annual mammography was €38,000 per LYG in BRCA1 mutation carriers and €18,000 per LYG in BRCA2 mutation carriers. Further intensified strategies showed an ICER above the threshold when compared to this strategy. With international discount rate, the ICERs of all intensified strategies were above the threshold. CONCLUSION: Of the three alternative strategies, only alternating annual MRI and mammography for BRCA2 mutation carriers and dense breasts aged 60-75 is cost-effective compared to annual mammography. For BRCA1 mutation carriers, none of the alternative strategies is cost-effective compared to the next best strategy.


Assuntos
Neoplasias da Mama/diagnóstico , Neoplasias da Mama/economia , Detecção Precoce de Câncer/economia , Imagem por Ressonância Magnética/economia , Mamografia/economia , Idoso , Proteína BRCA1/genética , Proteína BRCA2/genética , Neoplasias da Mama/genética , Análise Custo-Benefício , Detecção Precoce de Câncer/métodos , Feminino , Predisposição Genética para Doença/genética , Humanos , Imagem por Ressonância Magnética/métodos , Mamografia/métodos , Pessoa de Meia-Idade , Mutação , Países Baixos , Anos de Vida Ajustados por Qualidade de Vida , Medição de Risco/economia
9.
Value Health ; 22(2): 185-193, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30711063

RESUMO

BACKGROUND: Several specialty societies have recently updated their breast cancer screening guidelines in late 2015/early 2016. OBJECTIVES: To evaluate the cost-effectiveness of US-based mammography screening guidelines. METHODS: We developed a microsimulation model to generate the natural history of invasive breast cancer and capture how screening and treatment modified the natural course of the disease. We used the model to assess the cost-effectiveness of screening strategies, including annual screening starting at the age of 40 years, biennial screening starting at the age of 50 years, and a hybrid strategy that begins screening at the age of 45 years and transitions to biennial screening at the age of 55 years, combined with three cessation ages: 75 years, 80 years, and no upper age limit. Findings were summarized as incremental cost-effectiveness ratio (cost per quality-adjusted life-year [QALY]) and cost-effectiveness acceptability frontier. RESULTS: The screening strategy that starts annual mammography at the age of 45 years and switches to biennial screening between the ages of 55 and 75 years was the most cost-effective, yielding an incremental cost-effectiveness ratio of $40,135/QALY. Probabilistic analysis showed that the hybrid strategy had the highest probability of being optimal when the societal willingness to pay was between $44,000/QALY and $103,500/QALY. Within the range of commonly accepted societal willingness to pay, no optimal strategy involved screening with a cessation age of 80 years or older. CONCLUSIONS: The screening strategy built on a hybrid design is the most cost-effective for average-risk women. By considering the balance between benefits and harms in forming its recommendations, this hybrid screening strategy has the potential to optimize the health care system's investment in the early detection and treatment of breast cancer.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/economia , Análise Custo-Benefício/métodos , Detecção Precoce de Câncer/economia , Mamografia/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Mamografia/métodos , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Fatores de Risco , Programa de SEER/economia
11.
Transl Behav Med ; 9(2): 328-335, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-29796649

RESUMO

As population health has become a focus of health care payers and providers, interest has grown in mail, phone, and other forms of outreach for improving population rates of cancer screening. Translational research is needed to compare the effectiveness and cost of low- and high-intensity behavioral outreach interventions for promoting cancer screening. The purpose of the article is to compare the effectiveness in promoting biannual mammograms of three interventions delivered over 4 years to a primary care population with a high baseline mammography adherence of 83.3%. We randomized women aged 40-84 to reminder letter only (LO arm), letter + reminder call (RC arm), and two letters + counseling call (CC arm) involving tailored education and motivational interviewing. Mammography adherence (≥1 mammogram in the previous 24 months) at four time points was determined from insurance claims records. Over 4 years, 30,162 women were randomized. At the end of 4 years, adherence was highest in the RC arm (83.0%) compared with CC (80.8%) and LO (80.8%) arms (p = .03). Only 23.5% of women in the CC arm were reached and accepted full counseling. The incremental cost per additional mammogram for RC arm women was $30.45 over the LO arm cost. A simple reminder call can increase screening mammogram adherence even when baseline adherence is high. Some more complex behavioral interventions delivered by mail and phone as in this study may be less effective, due to limited participation of patients, a focus on ambivalence, lack of follow-up, and other factors.


Assuntos
Aconselhamento , Detecção Precoce de Câncer , Mamografia , Sistemas de Alerta , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/economia , Análise Custo-Benefício , Aconselhamento/economia , Detecção Precoce de Câncer/economia , Detecção Precoce de Câncer/métodos , Feminino , Custos de Cuidados de Saúde , Humanos , Mamografia/economia , Mamografia/métodos , Pessoa de Meia-Idade , Cooperação do Paciente , Sistemas de Alerta/economia , Telemedicina/economia , Telemedicina/métodos , Telefone , Terapia Assistida por Computador/economia , Terapia Assistida por Computador/métodos , Resultado do Tratamento
12.
Cad. Saúde Pública (Online) ; 35(6): e00099817, 2019. tab, graf
Artigo em Inglês | LILACS | ID: biblio-1011692

RESUMO

Abstract: Our objectives with this study were to describe the spatial distribution of mammographic screening coverage across small geographical areas (micro-regions) in Brazil, and to analyze whether the observed differences were associated with spatial inequities in socioeconomic conditions, provision of health care, and healthcare services utilization. We performed an area-based ecological study on mammographic screening coverage in the period of 2010-2011 regarding socioeconomic and healthcare variables. The units of analysis were the 438 health micro-regions in Brazil. Spatial regression models were used to study these relationships. There was marked variability in mammographic coverage across micro-regions (median = 21.6%; interquartile range: 8.1%-37.9%). Multivariable analyses identified high household income inequality, low number of radiologists/100,000 inhabitants, low number of mammography machines/10,000 inhabitants, and low number of mammograms performed by each machine as independent correlates of poor mammographic coverage at the micro-region level. There was evidence of strong spatial dependence of these associations, with changes in one micro-region affecting neighboring micro-regions, and also of geographical heterogeneities. There were substantial inequities in access to mammographic screening across micro-regions in Brazil, in 2010-2011, with coverage being higher in those with smaller wealth inequities and better access to health care.


Resumo: O estudo teve como objetivos descrever a distribuição espacial do rastreamento por mamografia entre áreas geográficas pequenas (microrregiões) no Brasil, além de investigar se as diferenças observadas estavam associadas a inequidades espaciais nas condições socioeconômicas, na prestação de assistência à saúde e no uso de serviços de saúde. Este foi um estudo ecológico de base territorial, comparando a cobertura do rastreamento por mamografia em 2010-2011 com fatores socioeconômicos e de cuidados de saúde. O estudo usou 438 microrregiões sanitárias brasileiras como as unidades analíticas. Foram utilizados modelos de regressão espacial para estudar as associações. Houve uma importante variabilidade na cobertura por mamografia entre microrregiões (mediana = 21,6%; variação interquartil: 8,1%-37,9%). A análise multivariada identificou: forte desigualdade na renda familiar, número baixo de radiologistas/100 mil habitantes, número baixo de aparelhos de mamografia/10 mil habitantes e número baixo de mamografias realizadas com cada aparelho enquanto correlatos independentes da baixa cobertura mamográfica no nível microrregional. Houve evidência de forte dependência espacial nessas associações, em que as mudanças em uma microrregião afetavam as microrregiões vizinhas, além de heterogeneidade geográfica. O estudo revelou importantes inequidades no acesso ao exame de mamografia entre microrregiões brasileiras em 2010-2011, com cobertura mais alta nas microrregiões com menor desigualdade de renda e melhor acesso geral aos cuidados de saúde.


Resumen: Los objetivos de este estudio fueron describir la distribución espacial de la cobertura del cribado mamográfico, a través de pequeñas áreas geográficas (microrregiones) en Brasil, y examinar si las diferencias observadas estuvieron asociadas con inequidades espaciales, en términos de condiciones socioeconómicas, sistema de atención de salud, y utilización de servicios de salud. Se trata de un estudio ecológico, basado en áreas incluidas en la cobertura de cribado mamográfico durante 2010-2011 y relacionadas con variables socioeconómicas y de salud. Las unidades de análisis fueron 438 microrregiones de salud en Brasil. Se utilizaron modelos de regresión espacial para estudiar estas relaciones existentes. Hubo una variabilidad marcada en relación con la cobertura mamográfica a través de las microrregiones (media = 21.6%; rango intercuartílico: 8,1%-37,9%). Los análisis multivariables identificaron una alta inequidad en los ingresos por hogar, bajo número de radiólogos/100,000 habitantes, bajo número de máquinas de mamografía/10.000 habitantes, y un bajo número de mamografías realizadas por cada máquina, lo que está independiente correlacionado con la baja cobertura de mamografías en el nivel de microrregión. Hubo evidencias de una dependencia espacial fuerte de estas asociaciones, con cambios en una microrregión afectando a microrregiones vecinas, y también de heterogeneidades geográficas. Hubo inequidades sustanciales en el acceso al cribado mamográfico a través de las microrregiones en Brasil, en 2010-2011, con una cobertura superior en aquellas con pequeñas inequidades respecto a la riqueza y mejor acceso a los servicios de salud.


Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Idoso , Neoplasias da Mama/diagnóstico por imagem , Mamografia/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Fatores Socioeconômicos , Brasil , Mamografia/economia , Características de Residência , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Detecção Precoce de Câncer , Análise Espacial , Acesso aos Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos
14.
Breast ; 42: 50-53, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30172804

RESUMO

BACKGROUND: There is currently no clear consensus recommendation for the use of short-interval follow-up mammography after a benign-concordant breast biopsy (BCBB), and practice patterns vary widely. The objectives of this study were to evaluate whether a short-interval follow-up mammogram provided clinical utility after stereotactic BCBB and to examine the costs associated with this surveillance strategy. METHODS: A retrospective review of women who underwent a stereotactic breast biopsy yielding benign-concordant results between January 2005 and October 2014 was performed to evaluate findings on subsequent imaging, to calculate compliance with recommended short-interval imaging, and to examine whether subsequent imaging revealed an abnormality at the site of the initial stereotactic BCBB. A cost analysis was performed utilizing Medicare reimbursement rates to calculate projected and actual costs of short-interval follow-up imaging after stereotactic BCBB. RESULTS: Of the 470 stereotactic BCBB performed, a short-interval mammogram was completed in 207 (44.0%), 9 (4.3%) of which had suspicious mammographic findings at the initial biopsy site, and 6 subsequently underwent biopsy, with none resulting in malignant or high-risk pathology. The cost of short-interval mammographic follow-up (n = 207) was calculated at $28,541.16. CONCLUSIONS: This study provides evidence that 6-month follow-up mammography has low clinical utility and unnecessarily increases costs after stereotactic BCBB. A safe and more cost-effective strategy may be resumption of routine mammography at 12 months post-biopsy.


Assuntos
Neoplasias da Mama/patologia , Detecção Precoce de Câncer/estatística & dados numéricos , Biópsia Guiada por Imagem/estatística & dados numéricos , Mamografia/estatística & dados numéricos , Adulto , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/economia , Neoplasias da Mama/cirurgia , Detecção Precoce de Câncer/economia , Feminino , Seguimentos , Humanos , Biópsia Guiada por Imagem/economia , Mamografia/economia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Estudos Retrospectivos
15.
Appl Health Econ Health Policy ; 16(6): 859-869, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30143994

RESUMO

BACKGROUND: The Affordable Care Act (ACA) requires non-grandfathered private insurance plans, starting with plan years on or after September 23rd, 2010, to provide certain preventive care services without any cost sharing in the form of deductibles, copayments or co-insurance. This requirement may affect racial and ethnic disparities in preventive care as it provides the largest copay reduction in preventive care. OBJECTIVES: We ask whether the ACA's free preventive care benefits are associated with a reduction in racial and ethnic disparities in the utilization of four preventive services: cholesterol screenings, colonoscopies, mammograms, and Pap smears. METHODS: We use a data set of over 6000 individuals from the 2009, 2010, and 2013 Medical Expenditure Panel Surveys (MEPS). We restrict our data set only to individuals who are old enough to be eligible for each preventive service. Our difference-in-differences logistic regression model classifies privately insured Hispanics, African Americans, and Asians as the treatment groups and 2013 as the after-policy year. Our control group consists of non-Hispanic whites on Medicaid as this program already covered preventive care services for free or at a low cost before the ACA. RESULTS: After controlling for income, education, marital status, preferred interview language, self-reported health status, employment, having a usual source of care, age and gender, we find that the ACA is associated with increases in the probability of the median, privately insured Hispanic person to get a colonoscopy by 3.6% and a mammogram by 3.1%, compared to a non-Hispanic white person on Medicaid. Similarly, we find that the median, privately insured African American person's probability of receiving these two preventive services improved by 2.3 and 2.4% compared to a non-Hispanic white person on Medicaid. We do not find any significant improvements for any racial or ethnic group for cholesterol screenings or Pap smears. Furthermore, our results do not indicate any significant changes for Asians compared to non-Hispanic whites in utilizing the four preventive services. These reductions in racial/ethnic disparities are robust to reconfigurations of time periods, previous diagnosis, and residential status. CONCLUSIONS: Early effects of the ACA's provision of free preventive care are significant for Hispanics and African Americans. Further research is needed for the later years as more individuals became aware of these benefits.


Assuntos
Disparidades em Assistência à Saúde/legislação & jurisprudência , Patient Protection and Affordable Care Act , Medicina Preventiva/legislação & jurisprudência , Adulto , Afro-Americanos/estatística & dados numéricos , Colesterol/sangue , Colonoscopia/economia , Colonoscopia/estatística & dados numéricos , Feminino , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hispano-Americanos/estatística & dados numéricos , Humanos , Masculino , Mamografia/economia , Mamografia/estatística & dados numéricos , Pessoa de Meia-Idade , Teste de Papanicolaou/economia , Teste de Papanicolaou/estatística & dados numéricos , Patient Protection and Affordable Care Act/organização & administração , Patient Protection and Affordable Care Act/estatística & dados numéricos , Medicina Preventiva/estatística & dados numéricos , Estados Unidos
16.
Womens Health Issues ; 28(5): 462-469, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30098875

RESUMO

BACKGROUND: Breast cancer is the second leading cause of cancer mortality, yet mammography screening rates remain less than optimal and differ by income levels. The purpose of this study was to compare factors predicting mammography adherence across income groups. METHODS: Women 41 to 75 years of age (N = 1,681) with health insurance and with no mammogram in the last 15 months were enrolled to participate in an interventional study. Binary logistic regression was used to estimate multivariable-adjusted odds ratios (ORs) for demographic and health belief factors predicting mammography adherence for each income group: 1) low, less than $30,000, 2) middle, $30,000 to 75,000, and 3) high, greater than $75,000 per year. RESULTS: Being in the contemplation stage (vs. precontemplation) of obtaining a mammogram predicted mammography adherence across all income groups and was the only predictor in the middle-income group (OR, 3.9; 95% CI, 2.61-5.89). Increase in age was associated with 5% increase (per year increase in age) in mammography adherence for low-income (OR, 1.05; 95% CI, 1.01-1.09) and high-income (OR, 1.05; 95% CI, 1.02-1.08) women. Having a doctor recommendation predicted mammography adherence only in low-income women (OR, 10.6; 95% CI, 2.33-48.26), whereas an increase in perceived barriers predicted mammography adherence only among high-income women (OR, 0.96; 95% CI, 0.94-0.99). In a post hoc analysis, high-income women reported difficulty in remembering appointments (53%) and lack of time to get a mammogram (24%) as key barriers. CONCLUSIONS: For all income groups, being in contemplation of obtaining a mammogram predicted mammography adherence; however, age predicted mammography adherence for low- and high-income groups, whereas doctor recommendation and perceived barriers were unique predictors for low- and high-income women, respectively. Health care providers should be aware of differences in factors and emphasize strategies that increase mammography adherence for each income group.


Assuntos
Neoplasias da Mama/prevenção & controle , Acesso aos Serviços de Saúde , Mamografia/estatística & dados numéricos , Programas de Rastreamento , Cooperação do Paciente , Pobreza , Adulto , Idoso , Neoplasias da Mama/economia , Detecção Precoce de Câncer , Feminino , Comportamentos Relacionados com a Saúde , Pesquisas sobre Serviços de Saúde , Humanos , Renda , Seguro Saúde , Mamografia/economia , Pessoa de Meia-Idade , Classe Social
17.
Value Health ; 21(7): 799-808, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-30005752

RESUMO

OBJECTIVE: Personalized breast cancer screening has so far been economically evaluated under the assumption of full screening adherence. This is the first study to evaluate the effects of nonadherence on the evaluation and selection of personalized screening strategies. METHODS: Different adherence scenarios were established on the basis of findings from the literature. A Markov microsimulation model was adapted to evaluate the effects of these adherence scenarios on three different personalized strategies. RESULTS: First, three adherence scenarios describing the relationship between risk and adherence were identified: 1) a positive association between risk and screening adherence, 2) a negative association, or 3) a curvilinear relationship. Second, these three adherence scenarios were evaluated in three personalized strategies. Our results show that it is more the absolute adherence rate than the nature of the risk-adherence relationship that is important to determine which strategy is the most cost-effective. Furthermore, probabilistic sensitivity analyses showed that there are risk-stratified screening strategies that are more cost-effective than routine screening if the willingness-to-pay threshold for screening is below US $60,000. CONCLUSIONS: Our results show that "nonadherence" affects the relative performance of screening strategies. Thus, it is necessary to include the true adherence level to evaluate personalized screening strategies and to select the best strategy.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/economia , Detecção Precoce de Câncer/economia , Custos de Cuidados de Saúde , Mamografia/economia , Cooperação do Paciente , Medicina de Precisão/economia , Idoso , Neoplasias da Mama/mortalidade , Tomada de Decisão Clínica , Simulação por Computador , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Detecção Precoce de Câncer/efeitos adversos , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Mamografia/efeitos adversos , Mamografia/métodos , Cadeias de Markov , Pessoa de Meia-Idade , Modelos Econômicos , Medicina de Precisão/métodos , Valor Preditivo dos Testes , Prognóstico , Fatores de Risco , Fatores de Tempo
19.
AJR Am J Roentgenol ; 211(1): 217-223, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29792736

RESUMO

OBJECTIVE: The objective of this study is to analyze the incidence of women with breast pain who present to an imaging center and assess the imaging findings, outcomes, and workup costs at breast imaging centers affiliated with one institution. MATERIALS AND METHODS: Demographic characteristics of and imaging findings for female patients presenting with breast pain at three community breast imaging centers between January 1, 2014, and December 31, 2014, were reviewed. Patients who were pregnant, were lactating, had a history of breast cancer, or presented with palpable nipple or skin findings were excluded. RESULTS: A total of 799 patients met the study criteria. Pain was diffuse in 30%, was focal in 30%, and was not localized in 40%. Of the 799 patients with breast pain, 790 (99%) presented for a diagnostic evaluation; 759 (95%) of these evaluated patients had negative findings. A benign sonographic correlate was detected in the area of pain in 5% of patients (39/799). One patient had a single cancer detected in the contralateral asymptomatic breast. When correlations between breast pain and the presence of cancer in the study patients were compared with the concurrent cancer detection rate in the screening population (5.5 cases per 1000 examinations performed), breast pain was not found to be a sign of breast cancer (p = 0.027). Patients younger than 40 years (316/799) underwent a total of 454 workup studies for breast pain; all findings were benign, and the cost of these studies was $87,322. Patients 40 years or older (483/799) underwent 745 workup studies, for a cost of $152,732. CONCLUSION: Breast pain represents an area of overutilization of health care resources. For female patients who present with pure breast pain, breast imaging centers should consider the following imaging protocols and education for referring physicians: an annual screening mammogram should be recommended for women 40 years or older, and reassurance without imaging should be offered to patients younger than 40 years.


Assuntos
Mastodinia/diagnóstico por imagem , Procedimentos Desnecessários/economia , Revisão da Utilização de Recursos de Saúde , Adulto , Idoso , Meios de Contraste , Feminino , Humanos , Imagem por Ressonância Magnética/economia , Mamografia/economia , Pessoa de Meia-Idade , Estudos Retrospectivos , Ultrassonografia Mamária/economia , Estados Unidos
20.
J Clin Oncol ; 36(11): 1121-1127, 2018 04 10.
Artigo em Inglês | MEDLINE | ID: mdl-29489428

RESUMO

Purpose High-deductible health plans (HDHPs) require substantial out-of-pocket spending and might delay crucial health services. Breast cancer treatment delays of as little as 2 months are associated with adverse outcomes. Methods We used a controlled prepost design with survival analysis to assess timing of breast cancer care events among 273,499 women age 25 to 64 years without evidence of breast cancer before inclusion. Women were included if continuously enrolled for 1 year in a low-deductible ($0 to $500) plan followed by up to 4 years in a HDHP (at least $1,000 deductible) after an employer-mandated switch. Study inclusion was on a rolling basis, and members were followed between 2003 and 2012. The comparison group comprised 2.4 million contemporaneously matched women whose employers offered only low-deductible plans. Measures were times to first diagnostic breast imaging (diagnostic mammogram, breast ultrasound, or breast magnetic resonance imaging), breast biopsy, incident early-stage breast cancer diagnosis, and breast cancer chemotherapy. Outcomes were analyzed by using Cox models and adjusted for age-group, morbidity score, poverty level, US region, index date, and employer size. Results After the index date, HDHP members experienced delays in receipt of diagnostic imaging (adjusted hazard ratio [aHR], 0.95; 95% CI, 0.94 to 0.96), biopsy (aHR, 0.92; 95% CI, 0.89 to 0.95), early-stage breast cancer diagnosis (aHR, 0.83; 0.78 to 0.90), and chemotherapy initiation (aHR, 0.79; 95% CI, 0.72 to 0.86) compared with the control group. Conclusion Women switched to HDHPs experienced delays in diagnostic breast imaging, breast biopsy, early-stage breast cancer diagnosis, and chemotherapy initiation. Additional research should determine whether such delays cause adverse health outcomes, and policymakers should consider selectively reducing out-of-pocket costs for key breast cancer services.


Assuntos
Neoplasias da Mama/economia , Neoplasias da Mama/terapia , Dedutíveis e Cosseguros/economia , Custos de Cuidados de Saúde , Gastos em Saúde , Cobertura do Seguro/economia , Seguro Saúde/economia , Tempo para o Tratamento/economia , Adulto , Biópsia/economia , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/mortalidade , Diagnóstico Tardio/economia , Detecção Precoce de Câncer/economia , Feminino , Humanos , Mamografia/economia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Valor Preditivo dos Testes , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
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