Objectives Risk stratification has so far been evaluated under the assumption that women fully adhere to screening recommendations. However, the participation in German cancer screening programs remains low at 54%. The question arises whether risk-stratified screening is economically efficient under the assumption that adherence is not perfect. Method We have adapted a micro-simulation Markov model to the German context. Annual, biennial, and triennial routine screening are compared with five risk-adapted strategies using thresholds of relative risk to stratify screening frequencies. We used three outcome variables (mortality reduction, quality-adjusted life years, and false-positive results) under the assumption of full adherence vs. an adherence rate of 54%. Strategies are evaluated using efficiency frontiers and probabilistic sensitivity analysis (PSA). Results The reduced adherence rate affects both performance and cost; incremental cost-effectiveness ratios remain constant. The results of PSA show that risk-stratified screening strategies are more efficient than biennial routine screening under certain conditions. At any willingness-to-pay (WTP), there is a risk-stratified alternative with a higher likelihood of being the best choice. However, without explicit decision criteria and WTP, risk-stratified screening is not more efficient than biennial routine screening. Potential improvements in the adherence rates have significant health gains and budgetary implications. Conclusion If the participation rate for mammographic screening is as low as in Germany, stratified screening is not clearly more efficient than routine screening but dependent on the WTP. A more promising design for future stratified strategies is the combination of risk stratification mechanisms with interventions to improve the low adherence in selected high-risk groups.
BackgroundThe increasing number of patients co-affected with Diabetes and TB may place individuals with low socio-economic status at particular risk of persistent poverty. Kyrgyz health sector reforms aim at reducing this burden, with the provision of essential health services free at the point of use through a State-Guaranteed Benefit Package (SGBP). However, despite a declining trend in out-of-pocket expenditure, there is still a considerable funding gap in the SGBP. Using data from Bishkek, Kyrgyzstan, this study aims to explore how households cope with the economic burden of Diabetes, TB and co-prevalence.MethodsThis study uses cross-sectional data collected in 2010 from Diabetes and TB patients in Bishkek, Kyrgyzstan. Quantitative questionnaires were administered to 309 individuals capturing information on patients’ socioeconomic status and a range of coping strategies. Coarsened exact matching (CEM) is used to generate socio-economically balanced patient groups. Descriptive statistics and logistic regression are used for data analysis.ResultsTB patients are much younger than Diabetes and co-affected patients. Old age affects not only the health of the patients, but also the patient’s socio-economic context. TB patients are more likely to be employed and to have higher incomes while Diabetes patients are more likely to be retired. Co-affected patients, despite being in the same age group as Diabetes patients, are less likely to receive pensions but often earn income in informal arrangements. Out-of-pocket (OOP) payments are higher for Diabetes care than for TB care. Diabetes patients cope with the economic burden by using social welfare support. TB patients are most often in a position to draw on income or savings. Co-affected patients are less likely to receive social welfare support than Diabetes patients. Catastrophic health spending is more likely in Diabetes and co-affected patients than in TB patients.ConclusionsThis study shows that while OOP are moderate for TB affected patients, there are severe consequences for Diabetes affected patients. As a result of the underfunding of the SGBP, Diabetes and co-affected patients are challenged by OOP. Especially those who belong to lower socio-economic groups are challenged in coping with the economic burden.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1369-7) contains supplementary material, which is available to authorized users.
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