Health Services Research & Development

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2006 HSR&D National Meeting Abstract

1058 — The Cost Effectiveness of An Outreach Intervention for High-Risk Women with Abnormal Pap Smears

Author List:
Wagner TH (HERC and Stanford)
Engelstad LP (Alameda County Medical Center, Oakland CA)
McPhee SJ (UCSF)
Pasick RJ (UCSF)

Follow-up among women who have had an abnormal Papanicolaou (Pap) smear is often poor in public hospitals that serve women at increased risk for cervical cancer. In this study, we evaluated the cost-effectiveness of a tailored outreach intervention.

In a randomized controlled trial, 348 women with abnormal Pap smear results were assigned to intervention or usual care. In the intervention, outreach workers provided culturally tailored information and helped patients navigate the system as a supplement to the clinic’s usual care. The comparison group was usual care alone (typically a letter mailed to the woman's home). All women were seen at a county hospital in Oakland, CA serving a disproportionate number of low income and multi-ethnic women. We calculated the incremental cost per follow-up within six months of the abnormal test result. Bootstrapping was done to create confidence regions. Sensitivity analyses were done to test the robustness of the results. Long-term follow-up was not feasible because women in the control arm were assigned to the intervention group (i.e., rescued) after six months.

The intervention cost a total of $34,507 for 178 women served. The intervention was associated with a 28% increase in the rate of 6-month follow-up. The incremental cost per follow-up was $685 (95% CI $410-$959). The intervention dramatically improved follow-up for women with a high-grade squamous intraepithelial lesion (HGSIL). These women have precancerous cells and face an increased risk that the abnormality will progress to invasive cancer. There were 15 women with an HGSIL in the intervention group and 14 in the control group. After the intervention, 14 (93%) and 6 (43%) in the intervention group and control group, respectively, had documented follow-up at six months.

A tailored counseling intervention is effective at increasing abnormal Pap smear follow-up. A break even analysis shows that this program would be more cost effective than usual care (at a ratio of $50,000 per QALY) if the program yielded between 0.35-0.69 quality adjusted life years (QALY), on average.

Emergency departments should consider an outreach intervention if they have low rates of abnormal Pap smear follow-up, especially among women with HGSIL.