Pain during mammography: implications for breast screening programmes

Pain experienced during mammography can deter women from attending for breast cancer screening. Review of the current literature on pain experienced during mammography reveals three main areas of interest: reports of the frequency of pain, identification of predictors of pain and strategies for responding to pain. Implications of this literature for breast screening programmes include the need for appropriate measurements of pain during mammography that are valid for screening populations, a further understanding of organizational factors involved in screening programmes that may be predictors of pain and for the development of valid strategies for responding to pain within breast screening programmes.

Cost-effectiveness analysis of screening for lung cancer with low dose spiral CT (computed tomography) in the Australian setting

Introduction:
Low dose spiral computed tomography (CT) is a sensitive screening tool for lung cancer that is currently being evaluated in both non-randomised studies and randomised controlled trials.
Methods:
We conducted a quantitative decision analysis using a Markov model to determine whether, in the Australian setting, offering spiral CT screening for lung cancer to high risk individuals would be cost-effective compared with current practice. This exploratory analysis was undertaken predominantly from the perspective of the government as third-party funder. In the base-case analysis, the costs and health outcomes (life-years saved and quality-adjusted life years) were calculated in a hypothetical cohort of 10,000 male current smokers for two alternatives: (1) screen for lung cancer with annual CT for 5 years starting at age 60 year and treat those diagnosed with cancer or (2) no screening and treat only those who present with symptomatic cancer.
Results:
For male smokers aged 60–64 years, with an annual incidence of lung cancer of 552 per 100,000, the incremental cost-effectiveness ratio was $57,325 per life-year saved and $105,090 per QALY saved. For females aged 60–64 years with the same annual incidence of lung cancer, the cost-effectiveness ratio was $51,001 per life-year saved and $88,583 per QALY saved. The model was used to examine the relationship between efficacy in terms of the expected reduction in lung cancer mortality at 7 years and cost-effectiveness. In the base-case analysis lung cancer mortality was reduced by 27% and all cause mortality by 2.1%. Changes in the estimated proportion of stage I cancers detected by screening had the greatest impact on the efficacy of the intervention and the cost-effectiveness. The results were also sensitive to assumptions about the test performance characteristics of CT scanning, the proportion of lung cancer cases overdiagnosed by screening, intervention rates for benign disease, the discount rate, the cost of CT, the quality of life in individuals with early stage screen-detected cancer and disutility associated with false positive diagnoses. Given current knowledge and practice, even under favourable assumptions, reductions in lung cancer mortality of less than 20% are unlikely to be cost-effective, using a value of $50,000 per life-year saved as the threshold to define a “cost-effective” intervention.
Conclusion:
The most feasible scenario under which CT screening for lung cancer could be cost-effective would be if very high-risk individuals are targeted and screening is either highly effective or CT screening costs fall substantially.

Cost-effectiveness analysis of a two-stage screening intervention for hepatocellular carcinoma in Taiwan

Background/Purpose

Hepatocellular carcinoma (HCC) has been the leading cause of cancer death in Taiwan since the 1980s. A two-stage screening intervention was introduced in 1996 and has been implemented in a limited number of hospitals. The present study assessed the costs and health outcomes associated with the introduction of screening intervention, from the perspective of the Taiwanese government. The cost-effectiveness analysis aimed to assist informed decision making by the health authority in Taiwan.
Methods

A two-phase economic model, 1-year decision analysis and a 60-year Markov simulation, was developed to conceptualize the screening intervention within current practice, and was compared with opportunistic screening alone. Incremental analyses were conducted to compare the incremental costs and outcomes associated with the introduction of the intervention. Sensitivity analyses were performed to investigate the uncertainties that surrounded the model.
Results

The Markov model simulation demonstrated an incremental cost-effectiveness ratio (ICER) of NT$498,000 (US$15,600) per life-year saved, with a 5% discount rate. An ICER of NT$402,000 (US$12,600) per quality-adjusted life-year was achieved by applying utility weights. Sensitivity analysis showed that excess mortality reduction of HCC by screening and HCC incidence rates were the most influential factors on the ICERs. Scenario analysis also indicated that expansion of the HCC screening intervention by focusing on regular monitoring of the high-risk individuals could achieve a more favorable result.
Conclusion

Screening the population of high-risk individuals for HCC with the two-stage screening intervention in Taiwan is considered potentially cost-effective compared with opportunistic screening in the target population of an HCC endemic area.

Statistical models for cancer screening

This paper reviews the application of statistical models to planning and evaluating cancer screening programmes. Models used to analyse screening strategies can be classified as either surface models, which consider only those events which can be directly observed such as disease incidence, prevalence or mortality, or deep models, which incorporate hypotheses about the disease process that generates the observed events. This paper focuses on the latter type. These can be further classified as analytic models, which use a model of the disease to derive direct estimates of characteristics of the screening procedure and its consequent benefits, and simulation models, which use the disease model to simulate the course of the disease in a hypothetical population with and without screening and derive measures of the benefit of screening from the simulation outcomes. The main approaches to each type of model are described and an overview given of their historical development and strengths and weaknesses. A brief review of fitting and validating such models is given and finally a discussion of the current state of, and likely future trends in, cancer screening models is presented.

Computer reminders for chlamydia screening in general practice : a randomized controlled trial

Background: Chlamydia notifications are increasing in Australia, and the use of a computer alert prompting general practitioners to test young women is a potential way to increase opportunistic chlamydia testing. The aim of this trial was to determine the effectiveness of a computer alert in general practice on chlamydia testing in young women.

Methods: In 2006, clinics (n = 68) in Melbourne, Australia were cluster randomized into 2 groups: the intervention group received a computerized alert advising the general practitioner to discuss chlamydia testing with their patient which popped up when the medical record of a 16- to 24-year-old woman was opened; the control group received no alert. The outcome was whether or not that patient received a chlamydia test at the level of a single consultation with an eligible patient. A mixed effects logistic regression model adjusting for clustering was used to assess the impact of the alert on the proportion of women tested for chlamydia during the trial period.

Results: Testing increased from 8.3% (95% confidence interval (CI): 6.8, 9.8) to 12.2% (95% CI: 9.1, 15.3) (P < 0.01) in the intervention group, and from 8.8% (95% CI: 6.8, 10.7) to 10.6% (95% CI: 8.5, 12.7) (P < 0.01) in the control group. Overall, the intervention group had a 27% (OR = 1.3; 95% CI: 1.1, 1.4) greater increase in testing.

Conclusion: The results of this study suggest that alerts alone may not be sufficient to get chlamydia testing levels up sufficiently high enough to have an impact on the burden of chlamydia in the population but that they could be included as part of a more complex intervention.

Decision support and the effectiveness of web-based delivery and information tailoring for bowel cancer screening : an exploratory study

Background: Colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and the second in females throughout the developed world. Population screening using fecal occult blood tests (FOBTs) facilitates early detection and greater chance of survival, but participation rates are low. We developed a Web-based decision tool to provide information tailored to an individual’s decision stage for CRC screening and attitude toward screening utilizing the Preventive Health Model (PHM) and Precaution Adoption Process Model (PAPM) as theoretical frameworks for screening behavior. We describe the practical steps employed in the tool’s design and the subsequent conduct of an exploratory study.
Objective: To design a decision tool for CRC screening and conduct an exploratory study among average-risk men and women to (1) test the impact of message type (tailored vs non-tailored) and message delivery modality (Web-based vs paper-based) on attitudes toward screening and screening uptake, and (2) investigate the acceptability of the decision tool and relevance of materials.
Methods: Participants (n = 100), recruited from a population sample of men and women aged 50-76 residing in urban Adelaide, Australia, were randomly assigned to a control group or one of 4 interventions: (1) Web-based and tailored information, (2) paper-based and tailored information, (3) Web-based and non-tailored (generic) information, or (4) paper-based and non-tailored information. Participation was augmented by snowball recruitment (n = 19). Questionnaires based on PHM variables were administered pre- and post-intervention. Participants were given the opportunity to request an FOBT. Following the intervention, participants discussed the acceptability of the tool.
Results: Full data were available for 87.4% (104/119) of participants. Post-intervention, perceived susceptibility scores for individuals receiving tailored information increased from mean 10.6 (SD 2.1) to mean 11.8 (SD 2.2). Scores on self-efficacy increased in the tailored group from mean 11.7 (SD 2.0) to mean 12.6 (SD 1.8). There were significant time x modality x message effects for social influence and salience and coherence, reflecting an increase in these scores for tailored Web-based participants only; social influence scores increased from mean 11.7 (SD 2.6) to mean 14.9 (SD 2.3), and salience and coherence scores increased from mean 16.0 (SD 2.2) to mean 17.7 (SD 2.1). There was no greater influence of modality or message type on movement toward a decision to screen or screening uptake, indicating that neither tailored messages nor a Web modality had superior effect. Overall, participants regarded tailored messages positively, but thought that the Web tool lacked “media richness.”
Conclusions: This exploratory study confirms that tailoring on PHM predictors of CRC screening has the potential to positively address attitudes toward screening. However, tailoring on these variables did not result in significantly increased screening uptake. Future research should consider other possible psychosocial influences. Mode of delivery did not affect outcomes, but as a delivery medium, the Web has economic and logistical advantages over paper.

Randomized controlled trial of proactive web-based alcohol screening and brief intervention for university students

BACKGROUND: University students drink more heavily than their nonstudent peers and are often unaware that their drinking is risky and exceeds normative levels. We tested the efficacy of a proactive Web-based alcohol screening and brief intervention program. METHODS: A randomized controlled trial was conducted at an Australian university in 2007. Invitations were sent to 13 000 undergraduates (age range, 17-24 years) to complete a Web-based Alcohol Use Disorders Identification Test. Of 7237 students who responded, 2435 scored in the hazardous/harmful range (> or =8) and were randomized, and 2050 (84%) completed at least 1 follow-up assessment. Intervention was 10 minutes of Web-based motivational assessment and personalized feedback. Controls received only screening. Follow-up assessments were conducted at 1 and 6 months with observers and participants blinded to allocation. Outcome measures were drinking frequency, typical occasion quantity, overall volume, number of personal problems, an academic problems score, prevalence of binge drinking, and prevalence of heavy drinking. RESULTS: Mean (SD) baseline Alcohol Use Disorders Identification Test scores for control and intervention groups were 14.3 (5.1) and 14.2 (5.1), respectively. After 1 month, participants receiving intervention drank less often (rate ratio [RR], 0.89; 95% confidence interval [CI], 0.83-0.94), smaller quantities per occasion (RR, 0.93; 95% CI, 0.88-0.98), and less alcohol overall (RR, 0.83; 95% CI, 0.78-0.90) than did controls. Differences in alcohol-related harms were nonsignificant. At 6 months, intervention effects persisted for drinking frequency (RR, 0.91; 95% CI, 0.85-0.97) and overall volume (RR, 0.89; 95% CI, 0.82-0.96) but not for other variables. CONCLUSION: Proactive Web-based screening and intervention reduces drinking in undergraduates, and such a program could be implemented widely.

Improving outcomes of preschool language delay in the community : protocol for the Language for Learning randomised controlled trial

Background

Early language delay is a high-prevalence condition of concern to parents and professionals. It may result in lifelong deficits not only in language function, but also in social, emotional/behavioural, academic and economic well-being. Such delays can lead to considerable costs to the individual, the family and to society more widely. The Language for Learning trial tests a population-based intervention in 4 year olds with measured language delay, to determine (1) if it improves language and associated outcomes at ages 5 and 6 years and (2) its cost-effectiveness for families and the health care system.

Methods/Design

A large-scale randomised trial of a year-long intervention targeting preschoolers with language delay, nested within a well-documented, prospective, population-based cohort of 1464 children in Melbourne, Australia. All children received a 1.25-1.5 hour formal language assessment at their 4th birthday. The 200 children with expressive and/or receptive language scores more than 1.25 standard deviations below the mean were randomised into intervention or ‘usual care’ control arms. The 20-session intervention program comprises 18 one-hour home-based therapeutic sessions in three 6-week blocks, an outcome assessment, and a final feed-back/forward planning session. The therapy utilises a ‘step up-step down’ therapeutic approach depending on the child’s language profile, severity and progress, with standardised, manualised activities covering the four language development domains of: vocabulary and grammar; narrative skills; comprehension monitoring; and phonological awareness/pre-literacy skills. Blinded follow-up assessments at ages 5 and 6 years measure the primary outcome of receptive and expressive language, and secondary outcomes of vocabulary, narrative, and phonological skills.

Discussion

A key strength of this robust study is the implementation of a therapeutic framework that provides a standardised yet tailored approach for each child, with a focus on specific language domains known to be associated with later language and literacy. The trial responds to identified evidence gaps, has outcomes of direct relevance to families and the community, includes a well-developed economic analysis, and has the potential to improve long-term consequences of early language delay within a public health framework.

Relationship between body mass index and the use of healthcare services in Australia

Objective: To examine the relationship between body mass index (BMI) and the use of medical and preventive health services. Research Methods and Procedures: This study involved secondary analysis of weighted data from the Australian 1995 National Health Survey. The study was a population survey designed to obtain national benchmark information about a range of health-related issues. Data were available from 17,033 men and 17,174 women, 20 years or age. BMI, based on self-reported weight and height, was analyzed in relation to the use of medical services and preventive health services. Results: A positive relationship was found between BMI and medical service use, such as medication use, visits to hospital accident and emergency departments (for women only); doctor visits, visits to a hospital outpatient clinics; and visits to other health professionals (for women only). A negative relationship was found in women between BMI and preventive health services. Underweight women were found to be significantly less likely to have Papanicolaou smear tests, breast examinations, and mammograms. Discussion: This research shows that people who fall outside the healthy weight range are more likely to use a range of medical services. Given that the BMI of industrialized populations appears to be increasing, this has important ramifications for health service planning and reinforces the need for obesity prevention strategies at a population level.

Nutrition screening in long-term care facilities : an evaluation of the methodological quality of available instruments

A variety of nutrition screening instruments have been developed and implemented for identifying the risk of undernutrition among community and hospitalized older adults. Despite the high prevalence of undernutrition amongst older adults in long-term care, few screening instruments have been developed or evaluated in this setting. This review aims to evaluate the validity, reproducibility and feasibility of nutrition screening instruments developed for use, or described as being used, with older adults in long-term care. Ten publications encompassing nine independent nutrition screening tools were identified using electronic databases and manual searches of reference lists. The Mini Nutritional Assessment-Short Form (MNA-SF) was the most widely evaluated nutrition screening instrument and met the requirements for a valid instrument (sensitivity and specificity >0.9) for use in the long-term care setting. Modified versions of the MNA for use in China and South Africa also demonstrated acceptable levels of sensitivity and specificity. Other nutrition screening instruments were found to have variable levels of sensitivity and specificity and while some demonstrated levels consistent with the MNA-SF, only two were evaluated across more than one study population, Body Mass Index (BMI)+weight loss and BMI+albumin. These same instruments reported the highest levels of inter-rater and test-retest reproducibility, although this was only tested in one other instrument (Chinese Nutrition Screen -modified MNA). In conclusion, it is evident from this review that further work in this area is needed. Based on validity, reproducibility and feasibility it appears that BMI+weight loss is the most suitable nutrition screening instrument for use in the long-term care setting at this time. MNA-SF is promising; however, there is currently no data for inter-rater or test-retest reproducibility in the long-term care setting.

Fractal analysis of bone texture : a screening tool for stress fracture risk?

Background The aim of this study was to identify specific bone characteristics of stress fracture (SF) cases in sportswomen. To date, no tool is able to distinguish individuals who are at risk, limiting preventive measures.

Material and methods We investigated the skeletal system of sportswomen who did sustain SF in the past (n = 19) and compared it with that of female controls (C) with a similar sporting history but without any fracture history (n = 20).

Bone mass and body composition were measured using dual-energy X-ray absorptiometry. Bone micro-architecture was investigated by calcaneal ultrasound and fractal analysis of calcaneus radiographic images. Oestradiol levels were measured by E.I.A, and IGF-1 by R.I.A. Menstrual characteristics, nutrient intake, and training were assessed using questionnaires.

Results The result of the fractal analysis, expressed by the Hmean parameter, was significantly lower in the SF group, reflecting a more complex structure of the trabecular micro-architectural organization (P < 0·005). Body mass index (BMI) at birth was also found to be lower in the SF cases as compared with their C (P < 0·03).

Multivariate analysis revealed that the fractal parameter Hmean, bone mineral content (BMC) at Ward's triangle and the BMI at birth correctly assigned 84·85% of the female athletes into their respective SF or C groups (P = 0·001).

Conclusion These results suggest that the fractal parameter and the BMI at birth may be able to identify female athletes most at risk for this overuse bone injury, as their low indexes might reflect a greater skeletal sensitivity.

Role of emergency departments in screening for obese and overweight children

Introduction
Childhood obesity is a major and increasing public health issue. The role of Emergency Departments (EDs) in screening for overweight and obese children has not been studied extensively. The main aim of this study was to estimate the prevalence of overweight children in Emergency Department (ED) populations. A secondary objective was to compare the characteristics of overweight and obese children with healthy weight children.

Methods
This prospective exploratory study was conducted in the two district urban EDs in Melbourne, Australia. A total of 87 ED patients aged 2 to 15 years were included in the study. The main outcome measures were body mass index, weight and height percentiles.

Results
The median absolute BMI was 16.8 (IQR = 15.4 to 18.8). The total number of children found to be overweight (BMI > 85th percentile) or obese (BMI > 95th percentile) was 21.8% (n = 19). Of these, 5.7% (n = 5) of children in this study were classified as obese. Comparison of overweight/obese children and healthy weight children showed no differences in triage but a higher incidence of respiratory illness (15.8% compared to 2.9%).

Conclusions
This pilot study showed that 1 in 5 children who presented to EDs were either overweight or obese suggesting a possible role for EDs in the detection and referral of overweight and obese children to intervention programs. Our findings suggest that a sufficiently powered randomised controlled trial is warranted to examine the effectiveness and efficacy of EDs screening for obese and overweight children.

Breakfast size is related to body mass index for men, but not women

The objective of this study was to examine the effect of self-reported breakfast size, daily eating, and other health habits on body mass index (BMI). We hypothesized that a consumption of a substantial breakfast compared with skipping or small breakfasts would be associated with lower BMI. Three independent, cross-sectional, screening surveys were conducted by Sydney Adventist Hospital in 1976, 1986, and 2005 in the surrounding community. The archived survey forms of 384 men and 338 women in 1976, 244 men and 229 women in 1986, and 270 men and 62 women in 2005 were randomly selected. Body mass index was determined from height and weight measured by hospital staff. The reported amount consumed at breakfast was one of several eating habits that predicted BMI for men but not women. It explained 5% to 6% of the variance in male BMI in all 3 years examined. As the reported breakfast amount increased, men's BMI decreased. Lifestyle confounders including vegetarianism and physical activity did not affect this relationship. However, the consumption of breakfast was significantly positively associated with consumption of cereals, bread, fruit, and spreads, while coffee consumption was significantly associated with smaller breakfasts or breakfast skipping. The consumption of relatively large breakfasts may influence BMI in men, and its promotion may help reduce the prevalence of obesity in Australia and elsewhere.

Association between sexual behavior and cervical cancer screening

Background: Not much is known about whether women who follow Pap testing recommendations report the same pattern of sexual behavior as women who do not.
Methods: Data come from part of a larger population-based computer-assisted telephone survey of 8656 Australians aged 16–64 years resident in Australian households with a fixed telephone line (Australian Longitudinal Study of Health and Relationships [ALSHR]). The main outcome measure in the current study was having had a Pap test in the past 2 years.
Results: Data on a weighted sample of 4052 women who reported sexual experience (ever had vaginal intercourse) were analyzed. Overall, 73% of women in the sample reported having a Pap test in the past 2 years. Variables individually associated with Pap testing behavior included age, education, occupation, cohabitation status, residential location, tobacco and alcohol use, body mass index (BMI), lifetime and recent number of opposite sex partners, sexually transmitted infection (STI) history, and condom reliance for contraception. In adjusted analyses, women in their 30s, those who lived with their partner, and nonsmokers were more likely to have had a recent Pap test. Those who drank alcohol at least weekly were more likely to have had a recent test than irregular drinkers or nondrinkers. Women with no sexual partners in the last year were less likely to have had a Pap test, and women who reported a previous STI diagnosis were more likely to have had a Pap test in the past 2 years.
Conclusions: There are differences in Pap testing behavior among Australian women related to factors that may affect their risk of developing cervical abnormalities. Younger women and regular smokers were less likely to report a recent test. Screening programs should consider the need to focus recruitment strategies for these women.