8.6 Cost-effectiveness of screening

TABLE 8.6 Cost-effectiveness of screening

CONDITION TYPE OF SCREENING ICER RELATIVE TO NO SCREENING COMMENTS

Lung cancer Annual low-dose CT in high-risk smokers and former smokers

Colorectal cancer Commonly used screening methods

Breast cancer Biennial mammography for women ages 50–70 US$27,756 to US$243,077 (SRl 104,085 to SRl 911,539) per QALYa

US$10,000 to US$25,000 (SRl 37,500 to SRl 93,750) per life yearb

US$2,685 (SRl 10,069) per life yearb Generalizability to Saudi Arabia is unclear.

Evidence of underlying effectiveness is weak.

REFERENCES

Raymakers et al. 2016

Pignone et al. 2002

Rashidian et al. 2013

Annual mammography and MRI co-testing in high-risk women Childhood obesity Age- and genderadjusted BMI Unknown

Zl 23,601 (SRl 23,383) per individual who is no longer obese

€168 (SRl 690) per 0.1 decrease in standardized BMI; €65 (SRl 267) per family £108 (SRl 496) to £1,317 (SRl 3,234) per individual Only short-term, modest effects have been documented. Bandurska et al. 2020; Bryant et al. 2011; Coppins et al. 2011; Hughes et al. 2008; Kalavainen, Korppi, and Nuutinen 2007; McCallum et al. 2007; Reinehr et al. 2010; Wake et al. 2009

Gestational diabetes mellitus Initial glucose challenge test, oral glucose tolerance test

High blood sugar Hemoglobin A1C test, oral glucose tolerance test (high-risk population only) US$20,414 (SRl 76,553) per QALY (both cost-additive and less effective than no screening)a

US$516 to US$126,236 (SRl 1,935 to SRl 473,385) per QALYb Fitria, van Asslet, and Postma 2019

Wide variation reflects differences in population, age of initiating screening, cutoff point for diagnosis, and screening interval. Targeting high-risk individuals seems to be much more cost-effective than universal screening. Najafi et al. 2016

High blood pressure Blood pressure test (community-based hypertension screening programs) US$21,734 to US$56,750 (SRl 81,503 to SRl 212,813) per QALY in the United States US$613 to US$5,637 (SRl 2,299 to SRl 21,139) per QALY in Australia US$7,000 to US$18,000 (SRl 26,250 to SRl 67,500) per QALY in Chinab Zhang, Wang, and Joo (2017)

Lipid disorders Lipid panel US$33,800 (SRl 126,750) per QALYb Recent literature is very limited; medication costs have dropped since the study was done. Dehmer et al. 2017

Source: Original compilation for this publication. Note: BMI = body mass index. CT = computed tomography. ICER = incremental cost-effectiveness ratio. MRI = magnetic resonance imaging. QALY = quality-adjusted life year. a. Neither clearly cost-effective nor clearly cost-ineffective at conventional thresholds. b. Likely cost-effective at conventional thresholds.

provision of screening tests (Dougherty et al. 2018; O’brien et al. 2007). Auditing and giving feedback to health professionals may have a beneficial effect (when the person responsible for the audit and feedback is a supervisor or colleague), and the feedback is provided multiple times, both verbally and in writing, and includes clear goals, particularly if the health professionals are not performing well to start with (Ivers et al. 2012). A systematic review of interventions to improve antibiotic prescribing practices, however, concludes that audit and feedback have minimal effects on prescribing (Arnold and Straus 2005). Handing reminders to physicians about to examine a patient likely improves quality of care slightly, although studies find that reminders have no measurable effect on blood pressure, glycated hemoglobin, or cholesterol levels (Arditi et al. 2017).

The evidence on provider-targeted financial incentives is inconclusive. A systematic review of the literature concludes, “There is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution” (Scott et al. 2011, 2). However, in the united States, recent legislation introduced accountable care organizations (AcOs)—a new payment model that is intended to incentivize managed care organizations to control costs and improve quality of care. If health care costs fall below a specific target, AcOs receive a share of the savings. The amount the AcO receives depends in part on the provision of preventive services, including screening for colorectal cancer, breast cancer, and blood pressure. To incentivize providers to comply with screening guidelines, most AcOs tie a portion of physicians’ compensation to their adherence to those guidelines (mansour et al. 2017). The incentives seem to be working. The prevalence of breast cancer screening is significantly higher among persons enrolled in an AcO than among persons not enrolled (meyer et al. 2017).

The method of screening may affect uptake. A study in the Netherlands suggests that a glycated hemoglobin test—which uses a single blood sample—induces greater participation in type 2 diabetes screening than the more time-consuming oral glucose tolerance test (van Valkengoed et al. 2015). A systematic review and meta-analysis of interventions intended to increase colorectal cancer screening in the united States concludes that fecal blood test outreach—including sending kits to eligible patients’ homes—should be incorporated into population-based screening programs (Dougherty et al. 2018).

The location of screening may affect uptake. Screening can be provided without physician referral at dental clinics (Hadlaq et al. 2017), malls (rasooldeen 2016), laboratories (Gronowski and budelier 2020), pharmacies (lancaster et al. 2018; Willis et al. 2014), workplaces (bali et al. 2018; Neumann et al. 2015; Padwal et al. 2017; Tarride et al. 2018; Wang et al. 2019), and mosques (Davachi, Flynn, and edwards 2005). A mosque in Qatar hosted a diabetes event in which 3,150 worshippers underwent screening. The event, sponsored by the Hamad medical corporation, included 15 screening stands staffed by trained diabetes nurses and educators (Hamad medical corporation 2017). However, a literature review of screening at special events such as health fairs, parties, cultural events, and plays finds insufficient evidence of an increase in uptake of cancer screening (escoffery et al. 2014).

Demand-side interventions

Interventions aimed at individuals seem to be effective at increasing uptake. Such interventions include appointment invitations, letters, text messages, and