"To screen or not to screen": Comparing the health and economic benefits of early peanut introduction strategies in five countries.

BACKGROUND: Early peanut introduction (EPI) in the first year of life is associated with reduced risk of developing peanut allergy in children with either severe eczema and/or egg allergy. However, EPI recommendations differ among countries with formal guidelines. METHODS: Using simulation and Markov modeling over a 20-year horizon to attempt to explore optimal EPI strategies applied to the US population, we compared high-risk infant-specific IgE peanut screening (US/Canadian) with the Australiasian Society for Clinical Immunology and Allergy (Australia/New Zealand) (ASCIA) and the United Kingdom Department of Health (UKDOH)-published EPI approaches. RESULTS: Screening peanut skin testing of all children with early-onset eczema and/or egg allergy before in-office peanut introduction was dominated by a no screening approach, in terms of number of cases of peanut allergy prevented, quality-adjusted life years (QALY), and healthcare costs, although screening resulted in a slightly lower rate of allergic reactions to peanut per patient in high-risk children. Considering costs of peanut allergy in high-risk children, the per-patient cost of early introduction without screening over the model horizon was $6556.69 (95%CI, $6512.76-$6600.62), compared with a cost of $7576.32 (95%CI, $7531.38-$7621.26) for skin test screening prior to introduction. From a US societal perspective, screening prior to introduction cost $654 115 322 and resulted in 3208 additional peanut allergy diagnoses. Both screening and nonscreening approaches dominated deliberately delayed peanut introduction. CONCLUSIONS: A no-screening approach for EPI has superior health and economic benefits in terms of number of peanut allergy cases prevented, QALY, and total healthcare costs compared to screening and in-office peanut introduction.

Feasibility of mobile cancer screening and prevention.

Many areas have high cancer mortality rates and medically underserved populations. This study describes the feasibility (acceptability and costs) of an urban multiphasic (multiple cancers) screening van. Feasibility was evaluated by literature review and informant interviews. Costs were estimated by resource use from urban mobile screening units; decision analysis estimated the costs per cancer detected for breast, cervix, colorectal, and prostate cancer screening. Acceptability of a multiphasic van varied by the informant's perspective. Feasibility and costs were most sensitive to four parameters: age, prior screening history, risk factors, and volume of simultaneous examinations. Subsidized mobile screening facilities may have the potential to reduce cancer morbidity and mortality if they target hard-to-reach underscreened groups, maintain high volume, coordinate with primary care providers, and build on an infrastructure that provides diagnostic and treatment services regardless of ability to pay. It is unclear whether the investment required will translate into a reasonable cost per year of life saved.

Some ethical and design challenges of screening programs and screening tests.

BACKGROUND: There are many examples of inadequate screening studies because of design faults and consent problems. ISSUES: Informed consent is the right of each person engaged in a clinical interaction, including service and research involvement in presymptomatic screening. Any screening approach must answer questions of efficacy, effectiveness, availability and efficiency. Accurate information, presented in clear language, must state a realistic assessment of the limitations, harms and benefits of the screening, including the consequences of false positive and false negative tests. There must be no coercive element in obtaining consent. Written and oral information should be presented. It is also important to recognize cultural differences between societies that emphasize individual autonomy and those in which autonomy derives from membership of a family, group or community, thus requiring different strategies to protect the vulnerable. Testing for genetic disorders presents additional challenges, partly due to the presence of relatively small numbers of affected individuals in the population, but also because of the complexity of counseling, confidentiality issues and the potential for social, insurance or employment discrimination. CONCLUSIONS: It is becoming increasingly difficult to present the data for many screening procedures in ways that can be understood by possible participants, and at the same time deal clearly with the costs to society and the efficacy and efficiency of the tests.

[Check-up studies at an internal medicine polyclinic: reasons, diagnostic tests, results and therapeutic consequences]. / Check-up-Untersuchungen an einer internistischen Poliklinik: Beweggründe, Abklärungen, Resultate und therapeutische Konsequenzen.

Data of an investigation on initial motives for and outcome of so-called diagnostic check-ups are presented. Over a period of about one year a total of 82 persons applying for such a check-up have been investigated. Concrete reasons for this step were not given initially, however, elucidated in 87% of cases after special interrogation. Mostly fear of carcinoma or HIV-infection because of unspecific symptoms or diseases of family members or friends was reported. Clinical status and additionally arranged investigations (laboratory and others) revealed as a rule no further relevant pathological findings, thus, acting mainly to exclude rather than prove a disease. If motives for such check-ups could be elucidated in time, a more focussed, cost-effective investigation could be initiated, with more benefit for the patient and higher satisfaction for the physician. Such a screening consultation might represent furthermore a good opportunity to communicate preventive aspects to the patient.

Economic evaluation of a Ninngen-dokku (medical checkup).

An economic evaluation of a medical checkup center (Ninngen-dokku, "human dry dock") was conducted from two perspectives: the cost for cancer checkup, and the cost for medical treatment after a diagnosis was obtained. We studied the cost of diagnosing cancer, compared with the cost required when cancer of an individual organ was detected through mass health testing, and studied the economics of a Ninngen-dokku according to Kawai's method of medical judgment. Assuming that the cost of death is more than the cost of saving the lives of persons who undergo the Ninngen-dokku, the Ninngen-dokku will be affordable. In the group undergoing the Ninngen-dokku compared with the group which did not, the estimated cost of medical treatment was reduced. The Ninngen-dokku carries advantages that cannot be quantified in financial terms; therefore, a multi-layered economic analysis of the Ninngen-dokku was required.

Comparison of two pre-admission testing methods for elective surgery patients.

Patients admitted for elective surgery (inguinal hernia, varicose veins and hemorrhoids) were studied in order to evaluate the impact of performing pre-admission testing (PAT) by utilizing an automated multiphasic health testing (AMHT) technology on the rate of repeating the pre-operative routine laboratory tests during hospitalization. A slightly lower but statistically significant rate of repeated tests was found among patients who performed PAT by AMHTS compared with those who performed the tests via the conventional ambulatory system. This result suggests that performing routine tests before hospitalization in a single authorized AMHTS facility is preferred since it saves the patient time and reduces the need for repeated tests.

National statistics on multiphasic health testing (human dock and AMHTS)--especially for the annual-course change during the last five years.

We have gathered national statistics on multiphasic health testing since 1984, and especially analyzed annual-course changes of the past five years. 1) Subjects for questionnaire survey: Despite an increasing number of hospitals with human dock and institutions with automated multiphasic health testing and services (AMHTS), the reply rate to the questionnaire survey has also increased with the number of subjects for the survey being 900,000 in 1988. 2) In the survey of national statistics under the internal organ distinction, the detection rate of cancer of the stomach was the highest, followed by the rates of cancers of the large intestine and lung, in that order. The rate of cancer of the stomach to all the detected cancers decreased by 11.1% during these five years, whereas that of cancer of the large intestine increased to represent 40% of the rate of the stomach. The rate of early stage cancer for all cancers was high, for example, approximately 70% for the stomach and 75% for the large intestine, proving that multiphasic health testing provides excellent accuracy. 3) In the total results collected under item distinction, we examined six items (obesity, glucose tolerance failure, hepatic defficiency, hypertension, hypertriglyceridemia and hypercholesterolemia) which appear frequently and become sources of adult disease. We concluded that especially, hepatic deficiency and hyperlipidemia had increased each year, indicating a deterioration of health and also that regional differences showed a decreasing tendency. 4) The present analysis of the national statistics has apparently provided effective information as data of a preventive counterplan against adult disease.

Should medical screening of the elderly population be promoted?

This article reviews the history of screening in the elderly, the conditions that should be considered, whether or not screening in the elderly is of benefit, whether we should look for disability or diseases and where screening should take place. Thirteen conditions are discussed: hearing loss and anaemia in some detail. Both disability and precise diagnostic criteria are considered. The place where screening is best carried out depends on the mobility of the subject and the nature of the particular screening tests selected for the 13 conditions. The desirability of screening was assessed on the following criteria: prevalence of the condition, severity of the problem, acceptability by the patient of the screening test, false positive rate, consequences of making a false positive diagnosis, the false negative rate and the consequences of this error, the effect of treatment, the cost of the screening test and the burden on the health services produced by the screening test. The criteria were scored 1-5 on a scale defined for each assessment, with higher scores favouring screening. We provide evidence that screening may be worthwhile for: need for chiropody, varicose veins/ulcer, hearing loss, obesity, visual impairment, hypothyroidism, hypertension, anaemia and diabetes mellitus. However, the assessments discussed in this paper need to be tested prospectively in randomised controlled trials.

The sixth stool guaiac test: $47 million that never was.

In a 1975 paper, Neuhauser and Lewicki analysed a colorectal cancer screening policy approved by the American Cancer Society. Their analysis yielded an incremental cost per case detected in excess of $47 million. This vivid demonstration of the impact of marginal analysis is frequently cited by health economists and is often used for pedagogic purposes. The analysis is incorrect because of two fundamental errors. We have reanalysed the protocol in two stages. After correction for these errors, the $47 million disappears, the marginal cost is quite modest and the policy appears to be defensible on economic grounds.

A medical algorithm for detecting physical disease in psychiatric patients.

An algorithm for screening psychiatric patients for physical disease was empirically derived from a comprehensive assessment of 509 patients in California's mental health system. The first 343 patients were used to develop the algorithm, and the remaining 166 were used as a test group. Calculations were made for several versions of the algorithm, and the data were compared with the diagnoses listed in the patients' admission mental health record. The algorithmic procedure was more accurate and more cost-effective than the medical evaluation procedures used by the state mental health system. When applied to the test group, the algorithm detected up to 90 percent of patients who had an active, important physical disease at a cost of $156 per patient. The mental health system had detected 58 percent of test-group patients with a disease at a cost of $230 per patient.

Multiphasic health testing services: can they cure medicine of its ills?

Preventive medicine could be the answer to many of the problems facing medicine, the author says. However, to be cost effective, we need to merge this new type of care with the traditional treatment of the sick that has been the foundation of health care for centuries.

The cost-effectiveness of health checkups--an illustrative study.

An economic analysis of personal health maintenance is complicated by the great variability in the health care process, the large amount of missing data and the great range in analytic results. Accordingly, this study should be considered more illustrative than conclusive. Data are available on middle-aged adults that periodic health checkups can be effective in significantly lowering mortality from potentially postponable disease. Using these data, a net-cost analysis has been attempted for periodic health checkups. The findings suggest that their costs and effects on health depend on how they are provided, how often and to whom. Yet, periodic health checkups can reduce lost earnings capability of examinees and can be cost-effective by using efficient health examination methods. If policy decision makers require health checkups for the lowest income people to be cost-effective, then these checkups probably will continue to be limited to case finding by physicians as an expense already included in current medical practice.