RTI International
RTI International is a trade name of Research Triangle Institute. www.rti.org
Projected Cost and Effectiveness of Integrated Screening Approaches– India and Kenya Models Sujha Subramanian, Ph.D.
Fellow, Health Economics & Policy, RTI Senior Visiting Scientist, WHO-IARC November 1, 2016
RTI International
Efficiency in Integrated Screening Cost Effectiveness Ratio = Cost of Screening Delivery Effectiveness of Screening
Cost of screening can be decreased through synergies related to providing
integrated screening for several cancer sites or other health care services Screening effectiveness can be increased by higher levels of patient
compliance or improvement in quality of the screen provided In the real world, this is not static but instead should result in continuous
efficiency improvement processes
Decrease in Cost per Screen or Cost per QALYs
RTI International
Scaling-up Screening: Multi-level Perspective
Access to care Quality of care Adherence to 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
Successful Scale Up of Screening Program (early detection and prevention to reduce mortality from cervical cancer)
RTI International
Complex Interactions between Cost and Effectiveness Key activities Cost of scale-up
versus clinical trial (cost per screen)*
Effectiveness impact
Potential impact of inadequate resources for activity or
component
Provider Training or = Quality Cost (over diagnosis) Harms (over treatment) Outcomes (under diagnosis)
Patient education Adherence Compliance with screening Outcomes Cost (treatment & patient time)
Quality Monitoring & Program Evaluation
Program Effectiveness Program Cost-Effectiveness
Access Quality Adherence
* Projected impact at scale up
RTI International
Clinical Trial to Implementation: Cervical Cancer Screening Adherence Measures
Pilot StudyDindigul Osmanabad Mumbai TNHSP
VIA VIA VIA VIA/VILI49,311 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
Randomized Screening Trials
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
based on several screening trials; • 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 of tobacco and/or alcohol users; 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.
CFCHC Ambilikkai
RTI International
Intervention % (95% CI)
Control % (95% CI)
P value
Advanced stage (IIB-IV) cancer
45.0 (34.1 to 55.9)
68.3 (56.8 to 79.7) .005
Breast Cancer Incidence for Women 30-69 years, 2006-2009
Trivandrum Breast Cancer Screening Study (TBCS)
Sankaranarayanan et al., 2011, JNCI
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
RTI International
Cost per Women Screened – Cervical Cancer Screening Trial
Integrated delivery of services possible
Site or disease specific triage
INR US $* % Total Cost
Programmatic Cost Provider Training 44.62 0.74 5.7% Patient Education/Recruitment 7.24 0.12 0.9% Research & Data Collection 96.50 1.61 12.3% Management & Administration 81.52 1.79 13.7% Screening Delivery VIA Screening Labor 46.50 0.77 5.9% Consumables/Equipment 50.66 0.84 6.5% Screening Clinics 48.53 0.81 6.2%
Diagnosis and Treatment 383.43 6.40 48.9%
VIA = Visual Inspection with Acetic Acid; INR = Indian Rupees; *2014 exchange rate
RTI International
Cost per Person Screened – Oral Cancer Screening Trial
Integrated delivery of services possible
Site or disease specific triage
US $* % Total Cost
Programmatic Cost $2.10 42.0% Screening delivery $0.61 12.3%
Diagnsosis and Treatment $1.69 33.7%
Patient time** $0.60 12.1%
* 2004 conversion rate** Based on dialy wage rate of 200 rupees or about $5
One-stop services decreases time cost to patient for screening
RTI International
Integration Cost Savings
Patient recruitment and education Program management and administration Shared infrastructure Provider Training Data Collection and Monitoring
Potential savings with integrated delivery
Savings will depend on type of approach used for these program activities
RTI International
Patient Awareness of Oral Cancer Risk Factors
Study at two Regional Cancer Centers in India; RCC site of oral cancer clinical trial
Kidwai, Bangalore, Karnataka RCC, Trivandrum, Kerala
The centers offer free care to low income populations and at reasonable
charge to those at higher income levels. Both centers provide oral cancer care in specialty clinics to more than 1,000
oral cancer patients annually. Survey of 200 oral cancer patients in each center
RTI International
RTI International is a trade name of Research Triangle Institute. www.rti.org
RTI International
RTI International is a trade name of Research Triangle Institute. www.rti.org
RTI International
Training of Providers for Screening Delivery
Site Type of test Personnel trained Duration of training
Cervical VIA & HPV Nurses or Midwives 3 weeks
Breast CBEFemale health workers with
bachelor's degree3 weeks
Oral Visual Inspection Non-medical university graduate 6 weeks
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 remain a challenge that will need
to be addressed At the clinic level, there will be more complicated triage processes and
wait time may increase Significant funding or resources will still be required as a large proportion
of the cost are related to diagnosis and treatment
RTI International
Research for Actionable Policies: Implementation Science Priorities to Scale Up Non-Communicable Disease Interventions in Kenya
#NCDsKE16
Safari Park Hotel Nairobi, Kenya
7–8 September 2016
RTI International
MSF Approach in Kenya, Kibera Health Center
Integrated model for NCD care using simplified treatment and referral guidelines
One-stop clinic location for all services; referred for follow up care
Patient focused approach - task shifting to allow NCD patients to be seen on all clinic days
Limited cancer screening; higher proportion of hypertension and diabetes management
Adherence Management Clubs – for HIV and NCD patients for compliance with medications
Patient retention, follow-up and proactive screening remain challenges
RTI International
AMPATH Model
Academic collaboration since 2001 Integrated screening across NCDs; providing
cervical cancer screening and assessing clinical breast exams
Recent study found that those with prior knowledge of breast cancer risk factors are more likely to participate in screening
Approach focused on increasing linkage with patient and retaining individuals so they stay engaged and receive continual services
Plans to track patients using common EMR and universal ID across health centers
RTI International
Integration with HIV programs – Part 1 B
arrie
rs
Education & Awareness
Provider training & Guidelines
Access & Affordability
Solu
tions
Increased awareness of hypertension
and mobilised patients to seek screening and treatment within the
project period
Increased provider understanding of HTNIncreased # of HTN
patientsIncreased outreach to
screen patients
Increased availability of HTN medications
Out
com
es 1. Increased awareness of risks of hypertension2. Increased motivation to be diagnosed and seek the right treatment3. Increased access to appropriate and affordable medicine
RTI International
Integration with HIV Programs
PEPFAR is the world’s largest global health funder focused entirely on HIV/AIDS
HYPERTENSION SCREENING AND MANAGEMENT Opportunity to use hypertension as entry point to access key HIV
population of younger working age males (25-50 years) Hypertension services can be provided to a large cohort of individuals
through the HIV/AIDS infrastructure developed by PEPFAR CERVICAL CANCER SCREENING PEPFAR is also a key supporter of efforts to integrate cervical cancer
screening within HIV treatment delivery systems
RTI International
Integration: Multiple Models of Delivery The outcome and key measures can vary – Increasing screening compliance or increasing compliance with treatment
recommendations; Linking and retaining individuals in the health system; Enhancing service delivery for specific populations, example HIV positive individuals
Depending on the model, the focus can be on improving outcomes, reducing cost or both
The cost and effectiveness of any program can vary over time and it is not static Operational research can be employed to improve efficiency and address
unique program, health system and patient or community level factors
