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Objectives. This study assessed the cost-effectiveness of cervix and breast cancer screening in a public hospital emergency room. Methods. Age-eligible women with nonurgent conditions and without recent screening were offered screening by a nurse. A decision analysis compared the costs and outcomes of emergency room screening and standard hospital screening efforts. Results. The undiscounted cost-effectiveness results for establishing new programs were $4050 (cervical cancer), $403 203 (breast cancer), and $4375 (joint cervix and breast cancer) per year of life saved. If screening is added to an existing program, results are more favorable ($429, $21 324, and $479 per year of life saved for cervix, breast, and joint screening, respectively). Results were most sensitive to volume and probability of receiving treatment after an abnormal screen. Conclusions. Emergency room screening was cost-effective for cervical cancer; breast cancer screening was relatively expensive given the low number of women reached. More intensive recruitment and follow-up strategies are needed to maximize the cost-effectiveness of such programs. (Am J Public Health. 1997;87:1182-1189)

Objectives. A randomized controlled trial was conducted to test the effectiveness and cost-effectiveness of three outreach interventions to promote well-child screening for children on Medicaid. Methods. In rural North Carolina, a random sample of 2053 families with children due or overdue for screening was stratified according to the presence of a home phone. Families were randomly assigned to receive a mailed pamphlet and letter, a phone call, or a home visit outreach intervention, or the usual (control) method of informing at Medicaid intake. Results. All interventions produced more screenings than the control method, but increases were significant only for families with phones. Among families with phones, a home visit was the most effective intervention but a phone call was the most cost-effective. However, absolute rates of effectiveness were low, and incremental costs per effect were high. Conclusions. Pamphlets, phone calls, and home visits by nurses were minimally effective for increasing well-child screenings. Alternate outreach methods are needed, especially for families without phones. (Am J Public Health. 1995;85:1412-1417), Efforts to increase the number of families on Medicaid obtaining free routine health screening for their children may succeed, but the increase may be small and the costs per additional child screened great. Families on Medicaid in six North Carolina counties with children overdue for well-child screening were randomly assigned to be receive one of a variety of information notices, or no notice beyond that provided to all families at the intake Medicaid interview. The novel types of notification included mailed pamphlets, letters describing the benefits of screening, assistance in scheduling appointments and with transportation, telephone calls, and home visits delivering the same message in person. Overall, 2053 families took part. The novel strategies resulted in two to four-fold increases in the percentage of children receiving screening,depending on the method, but even the largest increase resulted in 16% of the children being screened compared with 5% in the control group. Because of the low response, the cost per each additional family obtaining screening ranged from $306 to $1022.

Objectives. This study describes the costs and outcomes of community-based tuberculin screening programs conducted between 1987 and 1991 in Montreal, Quebec, Canada. Methods. Follow-up information was abstracted from hospital records of all reactors detected in tuberculin screening of students in grades 6 and 10, of first-year health professional students, and of workers aged 18 to 25 in a number of workforces. Screening costs were estimated directly from survey records, and follow-up costs were estimated from the annual financial report of the Montreal Chest Hospital for 1989/90. Results. Of 7669 persons tested, 782 (10.2%) had positive results and 757 (9.9%) were referred to a clinic. Of those, 525 (6.8% of the original 7669) reported, 293 (3.8%) were prescribed therapy, and 154 (2.0%) were compliant. In Canadian dollars, screening cost $5.70 per person tested and $56 per tuberculin reactor detected, but follow-up of reactors accounted for 73% of the total program cost of $13 455 to $18 753 per case of tuberculosis prevented. Conclusions. Because of high rates of patient and provider noncompliance, a tuberculin screening program was much less cost-effective than anticipated. Screening costs must be targeted to the highest risk populations, and compliance with recommendations for preventive therapy must be maximized. (Am J Public Health. 1995; 85:786-790), A tuberculosis screening program in Montreal was not cost effective because of failure of patients and doctors to follow recommended therapy for tuberculosis prevention. Tuberculin tests were given to grade school students, health care professional students, and adults in various occupations. Of the 7669 people screened, 10.2% tested positive, 9.9% received referrals for treatment, 6.8% followed this referral, 3.8% were prescribed treatment, and 2.0% followed the prescribed treatment. The cost per person screened was $5.70, in Canadian dollars. The total cost of the program was $13,455 to $18,753 per case of tuberculosis prevented and most of this cost came from clinic visits. To be more cost effective, such screening programs should focus on high risk groups and work to ensure patient and doctor compliance.

Objectives. Recent legislation will improve insurance coverage for screening mammography and effectively lower its cost to many women. Although cost has been cited as a barrier to use, evidence of the magnitude of its effect on use is limited. Methods. Mammography use in the past 2 years among women aged 50 to 75 residing in four suburban or rural counties in Washington State was estimated from 1989 survey data. Logistic regression analysis was used to estimate the odds ratio of mammography use as a function of economic and other variables. Within a residential area, averages were used to measure the market price of mammography and the time cost to obtain a mammogram. Results. Use was lower among women who faced a higher net price or who preferred to obtain a mammogram during weekend or evening hours and higher among women with higher incomes. Visiting no doctor regularly and smoking were predictors of failure to use mammography. Conclusion. The effects of economic variables on mammography use are important and stable across subsets of the population, but they are modest in size. (Am J Public Health. 1994;84:50-55), The cost of mammography is an important consideration, but it may have limited effects on frequency of use by women. Researchers conducted telephone surveys in 1989 with women aged 50 to 75 years to determine factors prohibiting their use of screening mammography. About 41% of women responding had been screened within the previous year, 19% had been screened in the prior one to two years and 26% had never been screened. More than half of the women reported that their insurance paid for all or part of screening mammography. Half of those women who did not know whether their insurance covered mammography had never been screened. The average price of screening was $31 among users of mammography and $35 among nonusers. Use was higher among women who visited gynecologists and doctors regularly, had a family history of breast cancer and were not smokers. Nonusers had lower incomes and felt screening on weekdays was inconvenient.

Abstract: To evaluate premarital human immunodeficiency virus (HIV) screening as an approach to AIDS prevention in the United States, we determined the HIV antibody seroprevalence in marriage license applicants in eight areas by blinded testing of blood specimens routinely collected for syphilis serology. The seroprevalences were 0.0-0.4 percent in women and 0.0-1.1 percent in men. We also examined the impact of mandatory premarital HIV screening on marriage rates in Louisiana and Illinois. In 1988, after screening began, 9 percent and 16 percent fewer marriage licenses than in the previous two years were issued in Louisiana and Illinois, respectively. We estimated that mandatory premarital screening, if adopted nationally, would cost $167,230,000. We conclude that compared with other HIV prevention programs mandatory premarital screening would be expensive and would probably have a minor impact on the HIV epidemic. (Am J Public Health 1990; 80:1087-1090.), Infection with a virus, including the human immunodeficiency virus (HIV), results in the production of antibodies, or immune proteins, that specifically bind to that virus. The detection of HIV antibodies can be used to test for HIV infection. Premarital screening for HIV antibodies may help to reduce the transmission of HIV infection by heterosexual contact or from an HIV-infected mother to an infant during birth. However, mandatory or legally enforced premarital screening in every state would involve testing of 2.4 million couples each year. One study showed that premarital screening would not be cost-effective, as indicated by HIV seroprevalence rates, the incidence of HIV antibody, among samples of blood from donors. However, blood samples from donors may be different than those from persons applying for a marriage license. HIV seroprevalence may be lower among blood donors because those with a high risk of HIV infection are discouraged from donating blood. The effectiveness of premarital screening in preventing HIV transmission was assessed. The HIV seroprevalence was determined for marriage license applicants in eight areas. The effect of mandatory premarital screening of number of marriages in Illinois and Louisiana was also examined. Blood samples from marriage license applicants are routinely obtained to test for syphilis, a sexually transmitted disease, and these were also screened (anonymously) for HIV antibody. HIV antibody was detected in 0.0 to 0.4 percent of women and 0.0 to 1.1 percent of men. Mandatory premarital screening, which began in 1988, was associated with nine percent fewer marriages in Louisiana and 16 percent fewer marriages in Illinois. The estimated cost of mandatory national premarital screening for HIV antibody was $167,230,000. This figure is not too much less than the $211,889,000 budgeted for all HIV control measures combined in 1988. These findings suggest that mandatory premarital screening for HIV antibody would be expensive in comparison with other HIV prevention programs and would have limited effects on the HIV epidemic. (Consumer Summary produced by Reliance Medical Information, Inc.)

To evaluate the cost and benefits of screening tests for Chlamydia trachomatis in adolescent males, we developed a decision analysis model and compared the leukocyte esterase urine dipstick test with culture, with direct-smear fluorescent antibody (DFA), and with the option of no screening (no treatment). The leucokyte esterase test has the lowest average cost-per-cure ($51) compared with direct-smear fluorescent antibody ($192) and culture ($414). Compared with the DFA, we estimate that the leukocyte esterate test saves over $9,727 per cohort of 1,000 sexually active adolescent males screened. Sensitivity analyses show the leukocyte esterase test results in a lower cost-per-cure and lower overall costs (per cohort) than culture and direct-smear fluorescent antibody at any prevalence of C. trachomatis infection, and lower overall costs (per cohort) than no screening at prevalence above 21 percent. (Am J Public Health 1990; 80:545-550.), Infections caused by Chlamydia trachomatis are among the most common and costly to treat in the United States. Teenagers have the highest rates of chlamydial infection and related complications. Routine screening efforts currently in use are primarily directed at the female population. With the newer, more reliable, and less expensive tests now available, routine screening of at-risk males should be considered. The decision-tree model was used to evaluate three screening procedures for C. trachomatis in males. The tests were: leukocyte esterase (LE) urine dipstick test with a 1+ or 2+ reading on first catch urine; bacterial cultures of urethral exudates; and antigen detection by direct smear fluorescent antibody (DFA) examination. The LE test resulted in the lowest average cost-per-cure compared with bacterial cultures or the DFA method. The cost-benefit analysis took into consideration the costs of the tests, treatment costs, patient non-compliance, and the potential cost of infection of a female partner. An added benefit of the test was the simultaneous identification and concurrent treatment of Neisseria gonorrhea infections. This screening modality would be an appropriate addition to ongoing programs for Chlamydia detection in women. (Consumer Summary produced by Reliance Medical Information, Inc.)

Decision analysis was used to compare the costs of three screening strategies for childhood lead poisoning: (1) venipuncture; (2) capillary sample with venipuncture confirmation if the blood lead level is elevated; (3) stratification by risk, with venipuncture for high-risk children and capillary sample for low-risk children. Under baseline conditions, the cost of screening by the venipuncture, stratification, and capillary strategies is $22, $25, and $27, respectively. Venipuncture remains the least expensive strategy unless the cost of venipuncture is more than three times that of capillary sampling. The annual cost of a national lead screening program that uses a single venipuncture sample would be $352 million. Initial screening with a capillary sample would cost $432 million, 23% more than venipuncture. (Am J Public Health. 1994;84:110-112), A single venipuncture sample appears to be the least expensive method of childhood lead poisoning screening. Investigators conducted a cost analysis of three lead screening strategies. The strategies included venous blood sampling or venipuncture; capillary blood sampling with venipuncture validation; and a stratified method in which venipuncture was used for high-risk children and capillary sampling was use for low-risk children. Screening all children with venipuncture alone cost $22 per child, compared to $25 for stratification and $27 for capillary screening. As the incidence of elevated lead blood levels decreased among the children, the cost of venipuncture remained stable, while stratification dropped to $24 and capillary sampling dropped to $25. When prevalence of lead poisoning was low (5%) and venipuncture costs remained high ($10), the stratification strategy became the least costly screening method.

A screening programme for latent tuberculosis (TB) infection could be implemented cost-effectively in such a way that most immigrants with the disease would be identified. Such screening would prevent substantial [...]

The decision-tree analytic model frequently provokes controversy and is subject to varying degrees of acceptance. In the May 1990 issue of the American Journal of Public Health, Randolph and Washington present a careful and thorough report using this model in determining the cost-benefit ratio of screening adolescent boys for Chlamydia trachomatis. Their analysis determined that the overall cost-benefit of the leucocyte esterase (LE) urine dipstick method, one of three tests considered, was the best. Assumptions using these models are frequently based on weak data, small numbers of cases, and in this instance, inadequate evaluation of the sensitivity and specificity of the test procedure. Three questions remain unanswered or inadequately answered. They are: would the technique be acceptable when applied to adolescent populations; would clinicians be willing to treat patients on the basis of a screening test; and would the detection and treatment of Chlamydia in young males add significantly to ongoing disease control efforts? No effective national screening program for Chlamydia, particularly to identify asymptomatic infection, is in place. This study suggests that any new screening program might include the relatively inexpensive LE tests for males; the LE test is not useful for screening women. At this time it may be worthwhile to study the impact that screening of males with the LE test would have on control of chlamydia infection. (Consumer Summary produced by Reliance Medical Information, Inc.)

A cost-benefit methodology was used for the economic evaluation of a health care program using mobile mammographic screening units in the rural areas of Australia. The travel cost approach was used to estimate the benefits of the project as an alternative to the contingent valuation method. Results indicate that the distance of a town from the nearest fixed screening unit is a major factor in estimating the level of welfare benefits.

Objectives. A randomized controlled trial evaluated the impact of feedback and financial incentives on physician compliance with cancer screening guidelines for women 50 years of age and older in a Medicaid health maintenance organization (HMO). Methods. Half of 52 primary care sites received the intervention, which included written feedback and a financial bonus. Mammography, breast exam, colorectal screening, and Pap testing compliance rates were evaluated. Results. From 1993 to 1995, screening rates doubled overall (from 24% to 50%), with no significant differences between intervention and control group sites. Conclusions. Financial incentives and feedback did not improve physician compliance with cancer screening guidelines in a Medicaid HMO. (Am J Public Health. 1998;88:1699-1701)