Mind the Gaps: Reducing the Inequalities & Research - - PowerPoint PPT Presentation

Mind the Gaps: Reducing the Inequalities & Research Implementation Gaps in the English National Health Service

Dr Rosalind Raine Professor & Head of Department of Applied Health Research University College London, UK

The NHS is free for everyone regardless of ability to pay

But

• widespread socio-economic gradients in use of and outcomes from care

eg National Bowel Cancer Screening Programme:

• verall uptake 54% but varies 61-35% (affluent-> deprived)

We aimed to reduce the:

• gradient (rather than the gap) in inequality
• research-> implementation gap

Colorectal cancer

New bowel cancer cases (2012) Bowel cancer deaths (2012) Survive for 10 or more years (2010) Preventable bowel cancer cases In the UK:

• 2nd leading cause of cancer death (16 000 people die p.a.) &
• 4th most common cancer (41 000 cases p.a.)
• Accounts for 12% of all cancer cases

• If diagnosed early, more than 90% of bowel cancer cases can be

treated successfully

• NHS Screening Programme rolled out 2008
• Aged 60-74
• Biennial Faecal Occult Blood Testing
• Small sample of faeces onto test card
• 3 times over two weeks
• 16% relative risk reduction (population level)

NHS Bowel Cancer Screening Programme

54% uptake overall 61% in least deprived 35% in most deprived

von Wagner et al., IJE 2011

Identifying source of inequality

Faecal Occult Blood Test (FOBT) uptake Subsequent Colonoscopy: Overall uptake 88.4% Variation by deprivation (86.4% to 89.5%)

Morris et al. BJC 2012

GP endorsed letter development

Practice names only appeared

• n letters sent to patients

randomly allocated to the ‘GP endorsement’ group

Enhanced Reminder letter

NARRATIVE leaflet GIST leaflet GP endorsed invitation Enhanced Reminder

ASCEND Study Interventions

RCT 1 5 - 16 November 2012 RCT 2 4 - 15 March 2013 RCT 3 3 - 28 June 2013 RCT 4 1 July - 2 August 2013

Interventions

Invitation Letter (S1) Kit letter (S9) Reminder Letter (S10)

Usual Practice Week 0 Week 1 Week 5 Bowel Cancer Screening System

• Large, national, cluster RCTs of each intervention
• RCTs didn't disrupt usual delivery of NHS service
• consent from 80% of primary care practitioners (GPs) nationally
• Included everyone (60–74 years) eligible for screening in England
• Blinding of individuals not possible, but minimal possibility of bias due to no direct

contact with participants

• Effect of interventions analysed by logistic regression, taking account of cluster

randomisation

• Applied published data on screening positivity rates, uptake of further investigations,

and investigation outcomes to predict impact of GP endorsement and enhanced reminders on bowel cancer/ polyp detection in NHS BCSP

Gold Standard Methods…in routine practice

• The primary outcome was the proportion of people adequately screened

and its variation by quintile of Index of Multiple Deprivation (IMD)

• We also calculated average marginal effects of GP endorsement and the

enhanced reminder from the RCTs and used these to predict their impact on the detection of colorectal adenomas and cancer by the BCSP

Gold Standard Methods…in routine practice

N=265 434 Increased odds of overall uptake by 7% (adjusted OR: 1·07, 95% CI 1·04–1·10, p<0·0001) but no effect on the socio-economic gradient If GP endorsement were implemented nationally, 39,766 extra people would be screened per annum. detect up to 165 more people with high / intermediate risk polyps and 61 people with a colorectal cancer each year.

GP endorsement RCT

N=168 480 Significant interaction with socio-economic status gradient (p=0·005), with a stronger effect in the most deprived quintile (adj OR 1·11, 95% CI 1·04–1·20, p=0·003) than in the least deprived (adj 1·00, 0·94–1·06, p=0·98). 3.6% relative increase in overall uptake (adj OR 1·07, 1·03–1·11, p=0·001). If enhanced reminder were implemented nationally, 19,298 extra people would be screened per annum. detect up to 80 more people with high / intermediate risk polyps and 30 people with a colorectal cancer each year.

Enhanced Reminder RCT

GP endorsement and enhanced reminder incurred a one-off cost to modify the standard invitation and reminder letters = £78,000. This would not need to be incurred again on national implementation. No additional costs were incurred per person invited to screening. Hence the average marginal cost per GPE screening invitation and enhanced reminder = £0. Up to 59000 more people might take a bowel cancer test p.a ….leading to an additional 91 people who have bowel cancer being identified & 245 high or medium-risk polyps p.a.

Costs and Impact

Implementation

{no title: give entire slide over to screen shots of newspaper articles eg in the Mail}

Spring 2016 The BCSP nationally have agreed to implement the enhanced reminder and BCSP London Hub are preparing to implement GP endorsement

Research implementation:

Measur ures Invited: count of people invited to participate of FOBt screening by the BCSP Adequate: count of people reaching a definitive gFOBt outcome (normal or abnormal) Abnormal: count of people reaching a definitive gFOBt outcome of abnormal Specialist Screening Practitioner (SSP) Invites: Count of people who have been invited for a SSP appointment SSP Attendance: Count of people who attended SSP appointment Diagnostic Test Invited: Count of people who have been invited for a diagnostic test (colonoscopy OR CT colonography) Diagnostic Test Attendance: Count of people who have attended their diagnostic test All by: socioeconomic deprivation, age, sex, geographical region, screening round (first prevalent (first invite), prevalent (previous non-responders) and incident (at least one round of previous screening))

Monitoring over time

DEDICATED TO THE MEMORY OF PROFESSOR JANE WARDLE PhD, FBA, FMedSci

OCTOBER 30TH 1950 – OCTOBER 20TH 2015

ASCEND Study Team

UCL Professor Rosalind Raine Professor Jane Wardle Dr Christian von Wagner Dr Sam Smith Dr Cecily Palmer Dr Leslie McGregor Dr Nick Counsell Professor Allan Hackshaw Dr Gemma Vart Professor Steve Morris Dr Francesca Solmi Imperial College London Professor Stephen Duffy Professor Sue Moss Queen Mary, University of London Wendy Atkin Rosemary Howe Ines Kralj-Hans NHS Bowel Cancer Screening Programme Stephen Halloran Helen Seaman Steve Smith Richard Logan Julia Snowball Graham Handley Sandra Rainbow

r.raine@ucl.ac.uk