Mind the Gaps: Reducing the Inequalities & Research Implementation Gaps in the English National Health Service Dr Rosalind Raine Professor & Head of Department of Applied Health Research University College London, UK
The NHS is free for everyone regardless of ability to pay But - widespread socio-economic gradients in use of and outcomes from care eg National Bowel Cancer Screening Programme: overall uptake 54% but varies 61-35% (affluent-> deprived) We aimed to reduce the: - gradient (rather than the gap) in inequality - research-> implementation gap
Colorectal cancer Survive for Preventable New bowel Bowel cancer 10 or more bowel cancer cancer cases deaths (2012) years (2010) cases (2012) In the UK: • 2nd leading cause of cancer death (16 000 people die p.a.) & • 4th most common cancer (41 000 cases p.a.) • Accounts for 12% of all cancer cases
NHS Bowel Cancer Screening Programme • If diagnosed early, more than 90% of bowel cancer cases can be treated successfully • NHS Screening Programme rolled out 2008 • Aged 60-74 • Biennial Faecal Occult Blood Testing - Small sample of faeces onto test card - 3 times over two weeks - 16% relative risk reduction (population level)
Identifying source of inequality Faecal Occult Blood Test (FOBT) uptake 54% uptake overall 61% in least deprived 35% in most deprived von Wagner et al., IJE 2011 Subsequent Colonoscopy: Overall uptake 88.4% Variation by deprivation (86.4% to 89.5%) Morris et al. BJC 2012
GP endorsed letter development Practice names only appeared on letters sent to patients randomly allocated to the ‘GP endorsement’ group
Enhanced Reminder letter
Interventions Usual Practice ASCEND Study Interventions Bowel Cancer Screening System RCT 3 RCT 1 RCT 2 3 - 28 June 2013 5 - 16 November 2012 4 - 15 March 2013 GP endorsed NARRATIVE GIST leaflet Week 0 Invitation Letter (S1) invitation leaflet Week 1 Kit letter (S9) RCT 4 1 July - 2 August 2013 Enhanced Reminder Letter Week 5 Reminder (S10)
Gold Standard Methods…in routine practice - Large, national, cluster RCTs of each intervention - RCTs didn't disrupt usual delivery of NHS service - consent from 80% of primary care practitioners (GPs) nationally - Included everyone (60 – 74 years) eligible for screening in England - Blinding of individuals not possible, but minimal possibility of bias due to no direct contact with participants - Effect of interventions analysed by logistic regression, taking account of cluster randomisation - Applied published data on screening positivity rates, uptake of further investigations, and investigation outcomes to predict impact of GP endorsement and enhanced reminders on bowel cancer/ polyp detection in NHS BCSP
Gold Standard Methods…in routine practice - The primary outcome was the proportion of people adequately screened and its variation by quintile of Index of Multiple Deprivation (IMD) - We also calculated average marginal effects of GP endorsement and the enhanced reminder from the RCTs and used these to predict their impact on the detection of colorectal adenomas and cancer by the BCSP
GP endorsement RCT N=265 434 Increased odds of overall uptake by 7% (adjusted OR: 1·07, 95% CI 1·04 – 1·10, p<0·0001) but no effect on the socio-economic gradient If GP endorsement were implemented nationally, 39,766 extra people would be screened per annum. detect up to 165 more people with high / intermediate risk polyps and 61 people with a colorectal cancer each year.
Enhanced Reminder RCT N=168 480 Significant interaction with socio-economic status gradient (p=0·005), with a stronger effect in the most deprived quintile (adj OR 1·11, 95% CI 1·04 – 1·20, p=0·003) than in the least deprived (adj 1·00, 0·94 – 1·06, p=0·98). 3.6% relative increase in overall uptake (adj OR 1·07, 1·03 – 1·11, p=0·001). If enhanced reminder were implemented nationally, 19,298 extra people would be screened per annum. detect up to 80 more people with high / intermediate risk polyps and 30 people with a colorectal cancer each year.
Costs and Impact GP endorsement and enhanced reminder incurred a one-off cost to modify the standard invitation and reminder letters = £78,000 . This would not need to be incurred again on national implementation. No additional costs were incurred per person invited to screening. Hence the average marginal cost per GPE screening invitation and enhanced reminder = £0 . Up to 59000 more people might take a bowel cancer test p.a ….leading to an additional 91 people who have bowel cancer being identified & 245 high or medium-risk polyps p.a.
Implementation
{ no title: give entire slide over to screen shots of newspaper articles eg in the Mail}
Research implementation: Spring 2016 The BCSP nationally have agreed to implement the enhanced reminder and BCSP London Hub are preparing to implement GP endorsement
Monitoring over time Measur ures Invited: count of people invited to participate of FOBt screening by the BCSP Adequate: count of people reaching a definitive gFOBt outcome ( normal or abnormal ) Abnormal: count of people reaching a definitive gFOBt outcome of abnormal Specialist Screening Practitioner (SSP) Invites: Count of people who have been invited for a SSP appointment SSP Attendance: Count of people who attended SSP appointment Diagnostic Test Invited: Count of people who have been invited for a diagnostic test (colonoscopy OR CT colonography) Diagnostic Test Attendance: Count of people who have attended their diagnostic test All by: socioeconomic deprivation, age, sex, geographical region, screening round ( first prevalent (first invite), prevalent (previous non-responders) and incident (at least one round of previous screening))
DEDICATED TO THE MEMORY OF PROFESSOR JANE WARDLE PhD, FBA, FMedSci OCTOBER 30 TH 1950 – OCTOBER 20 TH 2015
ASCEND Study Team UCL Queen Mary, University of London Professor Rosalind Raine Professor Jane Wardle Wendy Atkin Dr Christian von Wagner Rosemary Howe Dr Sam Smith Ines Kralj-Hans Dr Cecily Palmer NHS Bowel Cancer Screening Dr Leslie McGregor Programme Dr Nick Counsell Professor Allan Hackshaw Stephen Halloran Dr Gemma Vart Helen Seaman Professor Steve Morris Steve Smith Dr Francesca Solmi Richard Logan Julia Snowball Imperial College London Graham Handley Professor Stephen Duffy Sandra Rainbow Professor Sue Moss
r.raine@ucl.ac.uk
Recommend
More recommend
