Show Me the Money: Tracking Impact of Prevention and Screening Efforts

Trends in Utilization and Costs of BRCA Testing in the Context of Clinical Guidelines and National Policies, United States 2003–2014

Authors:

Zhuo Chen, Centers for Disease Control and Prevention
Katherine Kolor (Presenter)
Centers for Disease Control and Prevention

Scott Grosse, Centers for Disease Control and Prevention
Juan Rodriguez, Centers for Disease Control and Prevention
Julie Lynch, U.S. Department of Veterans Affairs Salt Lake City Healthcare System
Ridgely Green, Centers for Disease Control and Prevention
W Dotson, Centers for Disease Control and Prevention
Scott Bowen, Centers for Disease Control and Prevention
Muin Khoury, Centers for Disease Control and Prevention

Public Health Statement: Trends in BRCA genetic testing rates and costs may indicate whether clinical guidelines, national policies, and other factors that promote BRCA testing have resulted in practice changes in the United States.

Purpose: We examined twelve-year trends in BRCA testing rates and costs in the context of clinical guidelines, national policies and other factors.

Methods/Approach: Trends in BRCA testing rates and costs from 2003 to 2014 were estimated for 18–64 year olds using nationwide medical claims data (MarketScan Commercial Claims and Encounters databases), and publicly reported revenues from the primary provider of BRCA testing.

Results: In 2013, BRCA testing rates in women based on claims increased by 57%, relative to 2012, compared to annual increases of 9%, 10% and 13% over the preceding three years, and 7% in 2014. Most (70%) of the observed increase in BRCA testing rates in 2013 occurred April through June, coinciding with celebrity publicity of BRCA testing. The proportion of women with zero out-of-pocket payments decreased 2005–2012 from 78% to 63%, then increased to 71% and 80% in 2013 and 2014, respectively, coinciding with a clarification of Affordable Care Act coverage of BRCA genetic testing. Beginning in 2007, family history of breast or ovarian cancers accounted for an increasing proportion of women with BRCA tests compared with personal history, reaching 48% in 2013, consistent with the introduction of BRCA testing guidelines for primary care settings.

Conclusions/Implications: The observed trends in BRCA testing rates and costs are consistent with possible effects of clinical guidelines, national policy, celebrity publicity and other factors.

Impact of 9-Valent Human Papillomavirus Vaccine on HPV Vaccination Coverage of Youths, Ages 9–17, in North Carolina

Authors:

Justin Trogdon (Presenter)
University of North Carolina at Chapel Hill

Brianna Lindsay, Merck & Co. Inc.
Paul Shafer, University of North Carolina at Chapel Hill
Tamera Coyne-Beasley, University of North Carolina at Chapel Hill

Public Health Statement: This study will help to understand how the availability of 9vHPV may impact vaccine uptake.

Purpose: The primary objective was to evaluate the impact of introduction of 9vHPV vaccine on HPV vaccination uptake, initiation, completion and compliance. The secondary objective was to describe timing of administration and characteristics of children who received 9vHPV compared to those who received 4vHPV beginning in July 2015.

Methods/Approach: The study used a retrospective cohort analysis using North Carolina Immunization Registry (NCIR) data for youth between the ages of 9 and 17 years in 2016. We used an interrupted time series for the following dependent variables: area-level HPV vaccination uptake (doses), initiation, completion and compliance among age-eligible children. The key explanatory variable was an indicator for the introduction of 9vHPVin North Carolina in July 2015. We also used logistic regression for an indicator variable for receiving 9vHPV (relative to 4vHPV). The key explanatory variables were child and area-level demographic characteristics and other area-level market characteristics.

Results: Introduction of 9vHPV was not associated with a change in HPV vaccination rates (doses per capita, initiation, three-dose completion, or compliance) in North Carolina Zip Code Tabulation Areas (ZCTAs). Among children receiving the HPV vaccine, they were more likely to receive 9vHPV instead of 4vHPV if they lived in a ZCTA with a larger age-eligible (i.e., 9 to 17) population, a higher number of annual outpatient visits per capita, or a higher number of religious organizations. They were less likely to receive 9vHPV if they were older or lived in a ZCTA with a higher percentage of the population with less than a high school education.

Conclusions/Implications: While the quick transition from 4vHPVto 9vHPV was not associated with higher overall vaccination rates, there were disparities in the diffusion of 9vHPV across areas of North Carolina.

Economic Analysis of the National Breast and Cervical Cancer Early Detection Program

Authors:

Donatus (Don) Ekwueme (Presenter)
Centers for Disease Control and Prevention

Justin Trogdon, University of North Carolina at Chapel Hill
Jacqueline Miller, Centers for Disease Control and Prevention

Public Health Statement: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) is the largest organized cancer screening program for medically underserved, low-income women in the United States. The program provides access to timely breast and cervical cancer screening and diagnostic services in all 50 states, the District of Columbia, five U.S. territories, and 12 American Indian/Alaska Native tribes or tribal organizations. As the largest organized cancer screening program in the US, substantial resources are required to deliver comprehensive cancer screening and diagnostic services through the program. During the last decade, economic analysis has become increasingly important in identifying the most cost-effective means of delivering preventive cancer screening programs. Such economic assessments require detailed program cost data, but there is no standardized instrument for obtaining these data.

Purpose: The purpose of the project is to develop, design, and conduct comprehensive economic analyses to evaluate the efficiency of the NBCCEDP in delivering preventive cancer screening and diagnostic services.

Methods/Approach: We developed a cost assessment tool (CAT)—a standardized web-based instrument designed to collect activity-based cost data and other resource-use information on screening for breast and cervical cancer from the 68 grantees in the NBCCEDP. We collected three years of program data (i.e., 2007, 2009, and 2010). Further, we also collected additional cost data from in-kind donations. Effectiveness of the program was measured using data from the NBCCEDP’s surveillance database and data from non-CDC-funded screens. These data were used to ascertain the costs of delivering cancer screening in the NBCCEDP.

Results: The overall cost of delivering preventive cancer screening and diagnostics services to low-income, uninsured women will be presented. The results will be stratified with and without in-kind donations and compared with the average national Medicare reimbursement rates. Further, we will present multivariate analyses exploring factors that may contribute to the observed substantial variation in the average cost per woman served in the program.

Conclusions/Implications: The NBCCEDP cost estimates and other economic issues related to the program may assist policy and decision makers in allocating program resources equitably across the individual programs. Further, the results from this program may help policy-makers in planning and implementing large scale national programs similar to NBCCEDP.

Estimated Impact of the National Breast and Cervical Cancer Early Detection Program on Breast and Cervical Cancer Mortality Among Low-Income Uninsured Women in the United States

Authors:

Donatus (Don) Ekwueme (Presenter)
Centers for Disease Control and Prevention

Jacqueline Miller, Centers for Disease Control and Prevention
Janet Royalty, Centers for Disease Control and Prevention
Vladislav Uzunangelov, University of San Diego

Public Health Statement: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) is the largest organized cancer screening program for low-income, uninsured and underinsured women. Although the program has successfully provided cancer screening services to medically underserved women since 1991, the program’s effectiveness in increasing the life expectancy of participating women has never been measured.

Purpose: To estimate the benefits of NBCCEDP-funded breast and cervical cancer screening in terms of life-years (LYs) gained compared to No Program and No Screening scenarios.

Methods/Approach: We constructed simulation models based on existing Cancer Intervention and Surveillance Modeling Network models. For breast cancer, we modified the screening model to reflect screening frequency for NBCCEDP participants from 1991–2006. For cervical cancer, we modified the age and screening schedule to reflect screening frequency for NBCCEDP participants from 1991–2007. The screening impact was estimated as the difference in LYs between women who received screening in the NBCCEDP (Program), women who potentially received screening without the NBCCEDP (No Program), and women who received no screening (No Screening).The analyses were performed from age 40–64 years for breast and age 18–64 years for cervical, based on NBCCEDP eligibility criteria. For both cancers, we estimated the total life-years that may have been saved in NBCCEDP per 100,000 women.

Results: For breast cancer, between 1991 and 2006, the Program saved 5,600 LYs/100,000 women compared with No Program and 20,500 LYs/100,000 women compared with No Screening. For cervical cancer, between 1991 and 2007, the Program saved 600 LYs/100,000 compared with No Program and 5,500 LYs/100,000 compared with No Screening. For cervical cancer among women aged 18–29 years, the Program saved 2,300 LYs/100,000 and 29,900 LYs/100,000 compared with No Program and No Screening, respectively.

Conclusions/Implications: These estimates suggest that organized cancer screening may have increased life expectancy among underserved, low-income women who received services through NBCCEDP.