1. Cost Effectiveness Analysis To Enhance Mammography Use Dave Alvey Paul Moley

2. Plan of Presentation IntroductionDave Design of TrialPaul TablesDave Results and ConclusionPaul

3. Introduction A study to estimate the cost-effectiveness of three strategies to increase breast cancer screening – Reminder postcard – Reminder telephone call – Motivational telephone call Published in Effective Clinical Practice (2000) – Authors: Fishman, Taplin, Meyer, Barlow Based on trial conducted by Taplin et al (2000)

4. Why Cost Effectiveness Analysis? Cost effectiveness analysis (CEA) more appropriate than cost benefit analysis in many health care applications Screening women aged 50-69 for breast cancer is known to reduce cancer mortality by 25%-30% within 5 or 6 years Benefits so great: no choice but to use screening Cost effectiveness of screening, including promotion method, is the appropriate economic analysis

5. Market Context Health care market prompts plans to improve delivery of preventive services like mammographic screening Health insurance purchasers prefer insurance plans conforming to standards like HEDIS ( Health Plan Employer Data Information Set ) HEDIS includes mammography participation Health Plans, increasingly, will need to provide screening

6. Research Context Most cost analyses have focused on value of mammographic screening Research consensus: – screening of women aged 50-69 reduces mortality rate Hurley et al, 1992, analyzed the costs of screening and concluded that: – personal promotion strategies (personalized letters) are more cost effective than public promotion strategies (newspaper ads or community campaigns)

7. The Data Source Data based on a trial at Group Health Cooperative (GHC) of Puget Sound, western Washington State GHC is a health maintenance organization – an organization that provides managed care for health insurance contracts as a liaison with health care providers (hospitals, doctors, etc) GHC wished to improve participation in their breast cancer screening programme GHC has 500,000 enrollees Socioeconomic status of enrollees similar to that of the communities in which it provides care

8. Design of Trial (part 1) 11,570 women due for a mammogram 6,147 women approached for recruitment 5,062 eligible women 50-79 of age due for a mammogram 703 already scheduled; 382 otherwise ineligible 3,743 women 50-79 years of aged completed survey Mailed recommendation to schedule mammography Mammography scheduled within 2 months?

9. Trial Design (pt 2) Mammography scheduled within 2 months? Withdrew before random assignment (n = 13) No Randomly assigned to intervention group (n = 1,765) Yes (N = 1,965) Postcard reminder (n = 590 Reminder call (n -= 585) Motivational call (n = 590)

10. The Three Intervention Groups Postcard Reminder (590) – screening important, please make an appointment Reminder Call (585) – same message by phone Motivational Call (590) – engaged woman in discussion on merits of screening

11. Characteristics of Participants in the Randomized Trial VariablePromotional Strategy Reminder Postcard (n = 590) Reminder Call (n = 585) Motivational Call (n = 590) Mean age ± SD, yr61.7 ± 9.362.2 ± 8.861.9 ± 9.1 Ethnicity White90%89%88% Hispanic<1%1% Black4% Asian or Pacific Islander3%4% Other3%2%3% Participants who had previous mammogram72%73%72%

12. Chart of Effectiveness of Interventions

13. Costs Table

14. Calculation of Cost Effectiveness VariableCost Marginal CostEffectiveness Marginal Effectiveness Marginal Cost Effectiveness All women Initial recommendation letter$2.07 0.1805 Reminder postcard$6.02$3.950.3610.1805$21.88 Reminder call$21.22$15.200.5260.165$92.12 Motivation call$25.99$4.770.503-0.023Dominated Women with previous mammography Initial recommendation letter$2.07 0.2275 Reminder postcard$6.02$3.950.4550.2275$17.36 Reminder call$21.24$15.220.6250.17$89.53 Motivation call$25.76$4.520.604-0.021Dominated Women without previous mammography Initial recommendation letter$2.07 0.0565 Reminder postcard$6.02$3.950.1130.0565$69.91 Reminder call$21.19$15.170.2650.152$99.80 Motivation call$26.51$5.320.24-0.025Dominated

15. ICER compared to Marginal Cost Effectiveness For comparing two alternative treatments, the incremental cost effectiveness ratio (ICER) is used ICER = (Cost A – Cost B) / (Effect A – Effect B) Generally, B is the status quo ICER below a certain threshold is considered cost-effective ICER below zero indicates an intervention that is cost-effective and cost saving Marginal Cost Effectiveness - a Similar Ratio Marginal Cost (MC) of Postcard = Cost of initial letter and postcard – Cost of Initial Letter Marginal Effectiveness of Postcard = Effectiveness of Postcard – Effectiveness of Letter Marginal Cost Effectiveness of Postcard = MC of Postcard / Marginal Effectiveness of Postcard

16. Cost Accounting Issue The unit cost of each strategy per participant is: Initial LetterReminder Postcard Reminder CallMotivational Call $2.07$6.02$21.22$25.99 The cost per woman screened is a better measure of cost because the strategies had varying degrees of success. This is calculated by dividing the unit cost by the effectiveness rate of each strategy. Initial LetterReminder Postcard Reminder CallMotivational Call $2.07 /.1805$6.02 /.361$21.22 /.526$25.99 /.503 = $11= $17= $40= $52

17. Sensitivity Analysis Graphic

18. Discussion of Results Randomized trial of women aged 50-79 yrs who had failed to schedule a mammogram following a recommendation letter Cost per women screened was: – $17 for reminder card – $40 for reminder call – $52 for motivational call Marginal cost effectiveness was: – $22 for reminder card – $92 for reminder call – motivational call was dominated

19. Discussion of Results Cont’d Motivational call not cost effective – higher cost than reminder call – less effective than reminder call Reminder call more effective than postcard But analysis showed reminder call’s greater unit cost outweighed its greater effectiveness Therefore reminder postcard is most cost effective option

20. Discussion of Results Cont’d Cost effectiveness ratios were influenced by whether women previously had mammography the advantage of the postcard over the call decreased among women who had never had mammography Health plans may place a high enough value on the increased participation to warrant the additional expense

21. Concluding Qualifications Results limited by relying on a trial at a single health plan Promotional strategies may have different effects in settings with different experiences with breast cancer screening Analysis did not address whether the value of postcard strategy deteriorates over time – Subject for future research?