Methods to increase participation in organised screening programs: a systematic review.

BACKGROUND: The European Community recommends the implementation of population-based screening programmes for cervical, breast, and colorectal cancers. This recommendation is supported by many observational studies showing that organised programmes effectively reduce mortality and control the inappropriate use of screening tests. We conducted a systematic review of studies assessing the efficacy of interventions to increase participation in organised population-based screening programs. METHODS: We included all studies on interventions aimed at increasing screening participation published between 1/1999 and 7/2012. For those published before 1999, we considered the Jepson et al. (2000) review (Health Technol Assess 4:1-133, 2000). RESULTS: Including studies from the Jepson review, we found 69 with quantitative information on interventions in organised screening: 19 for cervical, 26 for breast, 20 colorectal cancers, and 4 for cervical and breast cancer together.Effective interventions were: postal (breast RR = 1,37 95% Confidence Interval (95% CI): 1.25-1.51; cervical RR = 1.71 95% CI: 1.60-1.83; colorectal RR = 1.33 95% CI: 1.17-1.51) and telephone reminders (with heterogeneous methods for implementation); GP's signature on invitation letter (breast RR = 1.13 95% CI: 1.11-1.16; cervical RR = 1.20 95% CI: 1.10-1.30; colorectal RR = 1.15 95% CI: 1.07-1.24); scheduled appointment instead of open appointment (breast RR = 1.26 95% CI: 1.02-1.55; cervical RR = 1.49 95% CI: 1.27-1.75; colorectal RR = 1.79 95% CI: 1.65-1.93). Mailing a kit for self-sampling cervical specimens increased participation in non-responders (RR = 2.37 95% CI: 1.44-3.90). CONCLUSION: Although some interventions did prove to be effective, some specific variables may influence their effectiveness in and applicability to organised population-based screening programs.

[Methods to increase participation in cancer screening programmes]. / Metodi per aumentare la partecipazione ai programmi di screening oncologici.

OBJECTIVE: to synthesize scientific evidences about methods to increase cervical, breast and colorectal cancer screening participation. METHODS: a multidisciplinary working group has been set up to define the scope of the report and to conduct the evaluation. The scope and the final evaluation have been submitted to a stakeholder committee, including the Ministry of Health, the National Screening Observatory, regional screening program coordinators, scientific societies, and Lega Italiana Lotta ai Tumori, for comments and integrations. A systematic review of the principal biomedical and social literature databases was conducted to identify experimental and observational studies, updating the existing review by Jepson and coll. (Health Technol Assess. 2000;4(14):i-vii, 1-133). RESULTS: 5900 have been identified, 900 relevant for the topic.Among those, 148 reported quantitative information on intervention efficacy, other 90 came from the previous review. Organised screening programmes, based on invitation letter or on GP involvement,were consistently effective in increasing participation compared to spontaneous screening. Interventions are classified according to their target: individual, community, test simplification, health operators, health service organization. The report presents meta-analyses on efficacy, analyses of cost-effectiveness, impact on organisation and social inequality, and ethical and legal issues, of all the intervention reported in the literature. CONCLUSIONS: there are several interventions consistently effective in any context, some of them have minimal impact on costs and health service resources.

Changing doctors' behaviours: an educational program to disseminate a new clinical pathway for the hospital management of hip fractures in elderly patients in the Lazio Region, Italy.

RATIONALE AND AIMS: Concerns with patient safety have increased interest in approaches to improving doctors' performance, yet dissemination of clinical guidelines and conventional continuing medical education have often failed. This study investigated the effects of an educational program based on reflection upon experience on the quality of care for patients with hip fracture in Lazio, Italy. METHODS: Five hospitals participated. The study consisted of the development of a clinical pathway, a preparatory phase and the educational intervention itself, which comprised a course followed by monthly audits with reflection on practice, guided by analysis of patients' charts. Data on the quality of care for patients with hip fracture were collected from the routine information system for the period before and after the intervention. RESULTS: There was a significant increase in the proportion of patients who underwent surgery within 48 hours of admission (from 7% in 2006 to 26.4% in 2007) and a significant reduction in the average length of hospital stay (from 18.8 to 16.4 days). Some process indicators of quality of care were high after the intervention, though non-recommended practices were still routinely used (e.g. urinary catheterization in 72.2% of patients). There were differences in the changes when comparing hospitals. CONCLUSION: An educational intervention that combined the dissemination of a clinical pathway with external auditing geared to reflection upon practice was effective in promoting changes in doctors' behaviours. The persistence of non-recommended practices and the variation among hospitals indicate that multiple factors influence performance and affect the effectiveness of interventions.

The role of education in improving physicians' professional use of economic evaluations of health interventions: some evidence from a cross-sectional survey in Italy.

A cross-sectional survey was carried out on a random sample of Italian physicians through a self-administered questionnaire to describe knowledge, attitudes, and professional behavior toward economic evaluations of health interventions. A response rate of 74.1% was achieved (760 questionnaires). Although many physicians show a positive attitude toward cost-minimization and, to a lesser extent, to cost-effectiveness analysis, they rated their methodological knowledge as unsatisfactory, and the professional use of the economic evaluations of the health interventions in clinical practice is quite low. Multiple logistic regression analysis showed that adequate knowledge and positive attitudes are associated with increased physicians' use of health economic evaluations, as well as time dedicated to continuing medical education and previous training experience about health economics and management. Education and specific training may play an important role in promoting a more cost-conscious behavior of physicians.

Epidemiology and costs of cervical cancer screening and cervical dysplasia in Italy.

BACKGROUND: We estimated the number of women undergoing cervical cancer screening annually in Italy, the rates of cervical abnormalities detected, and the costs of screening and management of abnormalities. METHODS: The annual number of screened women was estimated from National Health Interview data. Data from the Italian Group for Cervical Cancer Screening were used to estimate the number of positive, negative and unsatisfactory Pap smears. The incidence of CIN (cervical intra-epithelial neoplasia) was estimated from the Emilia Romagna Cancer Registry. Patterns of follow-up and treatment costs were estimated using a typical disease management approach based on national guidelines and data from the Italian Group for Cervical Cancer Screening. Treatment unit costs were obtained from Italian National Health Service and Hospital Information System of the Lazio Region. RESULTS: An estimated 6.4 million women aged 25-69 years undergo screening annually in Italy (1.2 million and 5.2 million through organized and opportunistic screening programs, respectively). Approximately 2.4% of tests have positive findings. There are approximately 21,000 cases of CIN1 and 7,000-17,000 cases of CIN2/3. Estimated costs to the healthcare service amount to 158.5 million euro for screening and 22.9 million euro for the management of cervical abnormalities. CONCLUSION: Although some cervical abnormalities might have been underestimated, the total annual cost of cervical cancer prevention in Italy is approximately 181.5 million euro, of which 87% is attributable to screening.

Physicians' knowledge, attitudes and professional use of RCTs and meta-analyses: a cross-sectional survey.

BACKGROUND: Familiarity with Randomized Control Trials (RCTs) and meta-analyses is essential to practice Evidence Based Medicine (EBM). The aims of this study were to describe knowledge, attitudes and professional behavior of physicians towards methods to evaluate the efficacy of health interventions, particularly meta-analysis and to find out their possible associated factors. METHODS: A cross-sectional survey was carried out on a random sample of Italian physicians through a self-administered questionnaire. RESULTS: A response rate of 70.1% was achieved (654 questionnaires). Despite satisfactory knowledge and substantial positive attitudes, Italian physicians have not integrated the use of RCTs and meta-analyses into their practice to a large extent, because they infrequently read and use RCTs and meta-analyses to make decisions in clinical practice. There is a high correlation between knowledge, attitudes and professional use of RCTs and meta-analyses. Moreover, the results of our multivariate analysis show that the probability of an appropriate professional use, that is higher for doctors who know the English language, have internet access and dedicate a proper amount of time to continuing medical education, increases significantly with a previous exposure to meta-analysis during graduate/post-graduate training (OR 2.25, 95% CI 1.44-3.52), and with the attendance of post-graduate courses about EBM (OR 1.75, 95% CI 1.09-2.82). Finally, Italian physicians demonstrate a high level of interest in further training. CONCLUSIONS: The association between the EBM educational background of doctors and the appropriate professional use of RCTs and meta-analyses suggest that EBM training may promote a more evidence-based practice among physicians.

[Prevalence of Staphylococcus aureus nasal colonization in injection drug users]. / La colonizzazione nasale di Staphylococcus aureus nei tossicodipendenti: risultati di uno studio di prevalenza comprendente la tipizzazione genotipica dei ceppi isolati.

A prevalence study was conducted to evaluate Staphylococcus aureus nasal colonization in two groups of injection drug users recruited at two drug addiction treatment centres in Rome and Frosinone (Italy). Prevalence of Staphylococcus aureus nasal colonization in the 181 subjects included in the study was 8.83%. Significantly increased carriage rates were found among drug users in Frosinone with respect to those in Rome. No other significant determinants of colonization were identified through multiple logistic regression analysis. Only 2 of 16 Staphylococcus aureus strains (12.5%) were found to be methicillin resistant. Genomic DNA restriction pattern analysis, through SmaI digestion and pulsed field gel electrophoresis, demonstrated wide genetic heterogeneity among the isolates. Although the great majority of PFGE patterns were found in single isolates, in some cases common patterns were identified in isolates obtained from different drug users, clearly indicating the possibility of interhuman transmission of Staphylococcus aureus in this population.