RTI International Scaling up breast, cervical and oral cancer screening in the limited resource setting: Lessons from economic evaluations in India Sujha Subramanian, Ph.D. Fellow, Health Economics & Policy, RTI International Senior Visiting Scientist, WHO-IARC December 5, 2017 www.rti.org RTI International is a trade name of Research Triangle Institute.
RTI International Efficiency in Integrated Screening Decrease in Cost per Cost Effectiveness Ratio = Cost of Screening Delivery Screen or Effectiveness of Screening Cost per QALYs Cost of screening can be decreased through synergies related to providing integrated screening Screening effectiveness can be increased by higher levels of patient compliance or improvement in quality In the real world, this is not static but instead should result in continuous efficiency improvement processes
RTI International Scaling-up Screening: Multi-level Perspective Successful Scale Up of Screening Program (early detection and prevention to reduce mortality from cervical cancer) Adherence to care Access to care Quality of care Health System / Provider Screening Program Patient / Community Geographic distribution; Patient education; provider Lack of trust; convenience; capacity; referral process; training; guidelines; data knowledge of screening supply of disposables etc. collection; quality metrics options; community support
RTI International Complex Interactions between Cost and Effectiveness Key activities Scale-up Effectiveness Potential impact of versus clinical impact inadequate resources for trial (cost) activity or component or Cost (over diagnosis) Provider Training Quality Harms (over treatment) Outcomes (under diagnosis) Compliance with screening Patient education Adherence Outcomes Cost (treatment & patient time) Program Effectiveness Quality Monitoring Access Program Cost-Effectiveness & Program Quality Evaluation Adherence
RTI International Clinical Trial to Implementation: Cervical Cancer Screening Adherence Measures Randomized Screening Trials Pilot Study Dindigul Osmanabad Mumbai TNHSP VIA VIA VIA VIA/VILI 49,311 34,074 75 360 660,917 Screening 63.6% 78.5% 71.5% 73.9% Diagnosis (colposcopy) 98.8% 98.7% 79.4% 56.5% Treatment 72.0% 85.0%* 85.0%* 13.0% * Approximate estimates based on treatment for precancer and cancers
RTI International Evidence Base for Screening: Clinical Trials in India Cervical cancer prevention/screening: Visual inspection and HPV DNA testing shown to be cost-effective; • Cost per cancer/pre-cancer detected: $235-$314; • Programmatic:$4-$6; Screening delivery:$8-$10. • Oral cancer screening: Visual screening randomized trial; Incremental cost per life-year saved of $156 for the high-risk population; Screening for under $6 per person. Breast cancer early detection: Randomized clinical trial of clinical breast exams (CBEs) is ongoing; Modeling studies report CBEs to be cost-effective: $450-$794 per life year saved.
RTI International Trivandrum Breast Cancer Screening Study (TBCS) A cluster randomized controlled trial was initiated in the Trivandrum district (India) on January 1, 2006, to evaluate whether three rounds of triennial CBE Statistically significant difference in stage at diagnosis between intervention and control groups; earlier diagnosis among the screened group Cost-effectiveness assessment ongoing Breast Cancer Incidence for Women 30-69 years, 2006-2009 Intervention Control P % (95% CI) % (95% CI) value Advanced stage (IIB-IV) cancer 45.0 (34.1 to 55.9) 68.3 (56.8 to 79.7) .005 Sankaranarayanan et al., 2011, JNCI
RTI International Cost per Women Screened – Cervical Cancer Screening Trial % Total INR US $* Cost Programmatic Cost Provider Training 44.62 0.74 5.7% Integrated Patient Education/Recruitmen 7.24 0.12 0.9% delivery of Research & Data Collection 96.50 1.61 12.3% services Management & Administration81.52 1.79 13.7% possible for Screening Delivery most VIA Screening activities Labor 46.50 0.77 5.9% Consumables/Equipment 50.66 0.84 6.5% Screening Clinics 48.53 0.81 6.2% Site or disease Diagnosis and Treatment 383.43 6.40 48.9% specific triage VIA = Visual Inspection with Acetic Acid; INR = Indian Rupees; *2014 exchange rate
RTI International Cost per Person Screened – Oral Cancer Screening Trial US $* % Total Cost $2.10 42.0% Programmatic Cost Integrated delivery of services possible $0.61 12.3% Screening delivery Site or disease $1.69 33.7% Diagnsosis and Treatment specific triage One-stop services $0.60 12.1% Patient time** decreases time cost to patient for * 2004 conversion rate screening ** Based on dialy wage rate of 200 rupees or about $5
RTI International Integration Cost Savings Patient recruitment and education Potential savings with Program management and administration integrated delivery Shared infrastructure Savings will depend Provider Training on type of approach Data Collection and Monitoring used for these program activities
RTI International Opportunities and Challenges – India Experience Opportunities……… One-stop delivery of screening services can increase patient compliance; Shared infrastructure and management processes can lead to lower cost Potential innovations and efficiencies in patient follow-up, repeat screening, tracking and data management Ability to introduce new approaches to training that can increase synergies Challenges………. Compliance with diagnostic follow-up will need to be addressed At the clinic level, there will be more complicated triage processes and wait times may increase Significant funding or resources will still be required as a large proportion of the cost are related to diagnosis and treatment
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