The Effectiveness, Cost-effectiveness, and Budget Impact of Interventions to Improve the Delivery of Cervical Cancer Screening in Puerto Rico
试验速览
- 阶段
- 不适用
- 状态
- Enrolling By Invitation
- 发起方
- 入组人数
- 1,400
- 试验地点
- 1
- 主要终点
- Intervention Effectiveness
研究概览
简要总结
Cervical cancer incidence is increasing dramatically (2.5% per year) in Puerto Rico (PR), with increased occurrence of regional (1.7% per year) and distant (4.7% per year) stage cancer, which reflects a real increase and indicates missed screening opportunities. Unfortunately, 80% of cervical cancer cases diagnosed in PR occur among low-income women covered by Medicaid or Medicare, who also have a 70% greater likelihood of being diagnosed with cervical cancer. Cervical cancer screening uptake continues to decline in PR, particularly among low-income Medicaid enrollees, mainly seen by government clinics. Barriers to cervical cancer screening in PR are mainly due to personal (lack of transportation, obesity-related embarrassment) and environmental (repeated disaster events that hampered screening uptake and made recovery slow) factors. The absence of evidence on the effectiveness, cost-effectiveness, and budget impact of patient navigators has limited its adoption among government clinics in this US territory. Multicomponent interventions that can address common screening barriers and improve screening participation in clinic-based settings or avert the need for a clinical-based visit could help improve screening uptake and follow-up care. Our preliminary work suggests the feasibility and acceptability of Human Papillomavirus (HPV) self-sampling in PR. We now propose a hybrid type 1 effectiveness-implementation study using a four-arm multi-site randomized controlled trial (RCT) conducted within government OBGYN clinics in PR. We will assess the effectiveness of patient reminders plus patient navigation and HPV self-collection (individually and in combination) compared to patient reminders alone in increasing cervical cancer screening, timely colposcopy, and cervical precancer treatment (Aim 1). The secondary aim will evaluate key implementation outcomes, including patient and provider receptivity, reach, level of implementation and fidelity, and sustainment intentions. We will then develop an open-cohort micro-simulation model to evaluate the population impact, cost-effectiveness, and budget impact of alternative strategies (Aim 2) to inform their potential applicability at delivery organization, community, and territory levels. This study will provide much-needed knowledge that is necessary to successfully facilitate the adoption and sustained integration of optimal strategies that will improve cervical cancer screening participation and reduce magnifying disparities in Puerto Rico.
详细描述
Aim 1. Conduct a four-arm multi-site randomized controlled trial to evaluate the effectiveness of three interventions, including patient reminders plus patient navigation and self-collection of HPV test (individually and in combination), compared to patient reminders alone on:
1a. Cervical cancer screening (clinic-based pap test/HPV co-testing) uptake among women and completion of HPV self-collection kit.
- b. Timely colposcopy and high-grade squamous intraepithelial lesion (HSIL) treatment among women with abnormal screening results. Secondary analyses will examine implementation outcomes, including patient and provider receptivity, reach, level of implementation and fidelity, and sustainment intentions.
Aim 2. Evaluate the population impact, cost-effectiveness, and budget impact of each intervention strategy compared to patient reminders. 2. a. Develop an open-cohort micro-simulation model of cervical cancer natural history, screening, and treatment outcomes among women in PR and evaluate population impact (incidence and mortality trends) and the cost-effectiveness of alternative strategies.
2b. Evaluate the budget impact of implementing an optimal screening strategy compared to the current intervention mix (at a delivery organization, community, and territory levels).
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Prevention
- 盲法
- None
入排标准
- 年龄范围
- 25 Years 至 65 Years（Adult, Older Adult）
- 性别
- Female
- 接受健康志愿者
- 否
入选标准
- •25-65 years old
- •No history of cervical cancer or hysterectomy
- •Have not had a Pap test in the past 3 years or more, an HPV test in the past 5 years or more, or a combination of a Pap test and an HPV test in the past 5 or more years (co-testing).
- •Must have a record at the study clinics (at least 2 previous visits).
排除标准
- •Women with no telephone contact information
- •Being pregnant*
- •Living with HIV, Lupus, or Crohn's*
- •Active on immunotherapy treatment*
- •History of organ transplants*
- •Will be excluded as cervical cancer screening guidelines differ for them.
研究组 & 干预措施
Arm 1: Patient reminder (Control Arm)
Participants who are due or past recommended cervical cancer screening will be contacted through a scripted telephone call by trained research staff to remind them to schedule an appointment for screening and to provide them with the contact information of the clinic.
Arm 2: Patient reminder and patient navigator
A patient navigator will call the participants to remind them of their cervical cancer screening, assess any screening barriers that they may have, explain the importance of cervical cancer screening, and help them schedule their appointment at the study sites. The patient navigator will also coordinate follow-up colposcopy and treatments as needed.
干预措施: Arm 2: Patient Navigator (Behavioral)
Arm 3: Patient Reminder and Mailed HPV Test for Self-collection
Research staff will contact the participants and remind them to schedule an appointment for cervical cancer screening and will provide them with the contact information of the clinic. She/he will also explain to the participant the role of HPV infection in the development of cervical cancer, provide the participant with information about HPV self-collection, and send them the HPV-self-collection through the mail. The kit will include written instructions on how to collect the cervical sample and mail it back to the study site.
干预措施: HPV self-collection kit (Behavioral)
Arm 4: Patient reminder, patient navigator, and mailed HPV test for self-collection
A patient navigator will remind the participant that it is time for their cervical cancer screening, assess any screening barriers that they may have, explain the importance of cervical cancer screening, and help them schedule their appointment at study sites. She/he will also explain to the participant the role of HPV infection in the development of cervical cancer, provide the participant with information about HPV self-collection, and send them the HPV-self-collection through the mail. The patient navigator will coordinate cytology visits if it is the preference of the participant and any follow-up appointment for cytology and other triage tests, colposcopy and treatments as needed.
干预措施: Arm 2: Patient Navigator (Behavioral)
Arm 4: Patient reminder, patient navigator, and mailed HPV test for self-collection
A patient navigator will remind the participant that it is time for their cervical cancer screening, assess any screening barriers that they may have, explain the importance of cervical cancer screening, and help them schedule their appointment at study sites. She/he will also explain to the participant the role of HPV infection in the development of cervical cancer, provide the participant with information about HPV self-collection, and send them the HPV-self-collection through the mail. The patient navigator will coordinate cytology visits if it is the preference of the participant and any follow-up appointment for cytology and other triage tests, colposcopy and treatments as needed.
干预措施: HPV self-collection kit (Behavioral)
结局指标
主要结局
Intervention Effectiveness
时间窗: Within 6 months after a patient is recruited
Proportion of women who complete cervical cancer screening (attending in-clinic cervical cancer screening) and the proportion of women who completed/returned HPV self-collection kit (Arms 3 and 4).
次要结局
- Screening Adherence after abnormal results(Within 18 months after a patient is recruited.)
研究者
Ana P. Ortiz Martinez
Principal Investigator
University of Puerto Rico Comprehensive Cancer Center