1. 1 Cost Effectiveness of Outreach Interventions for Low-Income Multiethnic Women Todd Wagner, VA & Stanford Rena Pasick, UCSF Stephen McPhee, UCSF Jeanne Mandelblatt, Georgetown Clyde Schechter, Albert Einstein SOM July 27, 2005 Funded by NCI

2. 2 Trends in Breast and Cervical Cancer Breast cancer between 1990 and 2000 –age-adjusted mortality declined 2.3% per year –incidence increased ~0.4% per annum Cervical cancer 1992-1999 –age-adjusted annual incidence declined by 9.3% – mortality rates declined by 2.3% SEER data: Ries L, Eisner M, Kosary C, et al. Cancer Statistics Review, 1975-2000. Bethesda, MD: National Cancer Institute; 2003.

3. 3 What is Driving these Changes? May be caused by diagnostic technologies –Mammogram –Papanicolaou (Pap) smear Collinear with changes in –Record keeping –Natural changes in disease / other risk factors

4. 4 Belief in Diagnostics USPSTF and many health plans endorse the use of mammography and Pap smear Debates about benefits of mammography See: Gotzsche and Olsen Lancet. Jan 8 2000;355(9198):129-134. Lancet. Oct 20 2001;358(9290):1340-1342. Lancet. Jul 27 2002;360(9329):338-339

5. 5 Breast Cancer Incidence Ries L, Eisner M, Kosary C, et al. Cancer Statistics Review, 1975-2000. Bethesda, MD: National Cancer Institute; 2003.

6. 6 Cancer Screening Promotion Health providers frequently use: –Outreach (e.g., patient reminders): encourages women to see their provider for a mammogram (or Pap) –Inreach (e.g., physician reminders): reminds the physician to schedule a mammogram (or Pap)

7. 7 Role of race/ethnicity There are notable disparities by race/ethnicity Disentangling the influence of biologic and socio- economic factors is the subject of considerable debate Physician reminders assumes access, but disparities in access exist Unknown whether patient reminders are equally effective across racial/ethnic subgroups

8. 8 Project 1 Project 1: we assessed the cost effectiveness of providing individually and culturally tailored printed health guides and telephone counseling to improve periodic breast and cervical cancer screening among low-income multi-ethnic women

9. 9 Methods Randomized, controlled cohort study Modified random digit dialing (Mitofsky-Waksberg) Targeted 86 low-income and ethnically diverse census tracts in Alameda county

10. 10 Eligibility 1.Age 40-74 2.African American, Chinese, Filipina, Latina, or non-Hispanic white 3.Speak English, Cantonese, Tagalog, or Spanish 4.Residence in a targeted census tracts 5.No history of cancer 6.Willingness to be randomly assigned to an intervention or control group, tracked for 3 years, and medical record review

11. 11 Enrollment 46,206 telephone calls –32,521 (70%) were households 15,264 (47%) households screened for eligibility 2964 (19% of households) contained an eligible subject. –1841 (62% of those eligible) consented to participate. –1463 completed the baseline interview and were randomized –1175 (80.3% of those randomized) completed the study

12. 12 Intervention and Usual Care Intervention components –an individually and culturally tailored printed health guide –telephone counseling Usual Care –Women in the control group received usual care from their provider, if any

13. 13 Cost Estimation Micro-costed the intervention –Variable cost: outreach worker forms (507 hours) –Fixed cost: Space, QA, Supplies Costs were standardized to 2002 Research costs were excluded

14. 14 Effectiveness Receipt of recent mammography and recent Pap smear (last 15 month). Self report data –Accuracy of self report varied by race-ethnicity –McPhee SJ, Nguyen TT, Shema SJ, et al. Validation of recall of breast and cervical cancer screening by women in an ethnically diverse population. Prev Med. Nov 2002;35(5):463-473.

15. 15 Cost Effectiveness Analysis We calculated the incremental cost per woman screened C 1 -C 0 E 1 -E 0 Incremental Cost- Effectiveness Ratio =

16. 16 Behavioral Interventions General CEA framework holds, but caveats … –Behavior change is a “ slow ” process –Treat many to prevent a few –Use of intermediate outcomes (proxies)

17. 17 Intermediate Outcomes Outcome is clinically relevant and predicts mortality or morbidity –Receipt of a mammogram –Substance use abstinence –Change in dietary fiber QALYs would require huge and/or very long studies

18. 18 CEA with an Intermediate Outcome Sufficient for publication Hard to interpret ICER –Can’t easily compare two CEAs with different intermediate outcomes –Can’t compare CEA to other CEA from another clinical area Sometimes only feasible approach

19. 19 CEA with QALYs Measure QALYs or Translate intermediate outcome to QALYs –Either build a model de novo or use an existing model –Requires a lot of resources Most useful, but most challenging

20. 20 CEA and Behavior Change “ Getting the person to recognize that they have a problem is half the battle. ” Behavior change is a process, not a dichotomous outcome Need to measure: –Starting point in the process –Movement in the process Wagner TH, Goldstein MK. Behavioral interventions and cost- effectiveness analysis. Prev Med 2004;39(6):1208-14.

21. 21 Subgroup Analysis Calculated cost-effectiveness ratios by baseline stage of change. never inconsistent (prior test, but not in last 15 months) recent (prior test in last 15 months) regular (prior test in last 15 months and another within two years of the last test).

22. 22 Cost per Life Year Saved Modified existing model to assess cost per life year saved. –Only effects of mammography are included Mandelblatt JS, Schechter CB, Yabroff KR, et al. (2004) Benefits and costs of interventions to improve breast cancer outcomes in African American women. J Clin Oncol. 22(13):2554- 2566.

23. 23 Results: Sample Characteristics

24. 24 Mammography Effect

25. 25 Pap Smear Effect

26. 26 Unit Costs

27. 27 Cost per Woman Screened

28. 28 Subgroup Analysis

29. 29 Cost per Life Year Saved

30. 30 Summary Incremental cost per woman screened –$436 per mammography –$380 per Pap smear Cost per life year saved of $109,812- >$500,000 –Low estimate= 1 “dose” –High estimate= repeats every two years –Annually > $1 million

31. 31 Prior Research Andersen et al (2002) much lower cost- effectiveness ratio, but effectiveness of intervention was not statistically significant. Our intervention was highly effective (+7% more than Andersen)

32. 32 Limitations Cannot separate effect of health guide versus telephone counseling No utility weights in model Model only looks at mammography

33. 33 Project 2: Abnormal Pap Smears Highland Hospital (Oakland CA) routinely performs Pap smears in the ED Low rates of follow-up among abnormal Pap smears (~30%)

34. 34 Project 2 Usual care: send the woman a letter if there is an abnormal Pap smear This study evaluates the cost-effectiveness of usual care (a mailed postal reminder) with a tailored outreach intervention compared to usual care alone

35. 35 Pap Abnormality Atypical squamous cells of undetermined significance (ASCUS) Atypical glandular cells of undetermined significance (AGUS) Low-grade squamous intraepithelial lesion (LGSIL) High-grade squamous intraepithelial lesion (HGSIL) Solomon D, Davey D, Kurman R, et al. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA 2002; 287:2114-9.

36. 36 Methods Eligibility –Abnormal Pap at Highland Hospital –Age 18-74 –English or Spanish speaking Excluded –In process of follow-up –Pregnant and due after intervention period

37. 37 Intervention Randomized, controlled cohort trial Two groups –Usual care: notified by telephone or mail, depending on the degree of abnormality –Usual care plus outreach and tailored individual counseling Randomization without consent; 6-month rescue

38. 38 Main Outcomes Follow-up at 6 months Costs Incremental cost per follow-up

39. 39 Costing Micro-costed the intervention –Variable cost: outreach worker forms –Fixed cost: Space, QA, Supplies We used payroll systems to identify outreach worker overhead costs

40. 40 Results

41. 41 Effectiveness (non-OB)

42. 42 Effectiveness (OB)

43. 43 Unit Costs

44. 44 Cost per follow-up

45. 45 Break Even Analysis 8% (n=29) had HGSIL (highest risk) –Intervention: 93% had follow-up –Control: 43% had follow-up

46. 46 Conclusion In this population, augmenting usual care with outreach and tailored individual counseling was relatively inexpensive and highly effective.