Suchergebnisse

BACKGROUND: Mammography screening programs in Europe revealed a 25–30% breast cancer mortality reduction in women between 50 and 74 years. Early cancer detection and less radical treatment in dedicated multidisciplinary breast centers have improved breast cancer care. Breast population-based screening (persons are individually identified and personally invited to attend screening) is intended to detect breast cancer at an early stage to enable lower mortality rates. METHODS: The status of implementation of cancer screening programs among European countries, quality parameters and possible differences will be reviewed. RESULTS: Implementation of the recommended maximum age range was adopted in most programs. Almost all the European countries established digital mammography as the method of screening instead of screen-film mammography. Inequalities in implementation of cancer screening in the European Union have been observed. CONCLUSION: Improvement of data quality and mortality registries linked to the screening programs are needed.

Enthält: Engl. Text. - 6 S. Französ. Text u.d.T.: Le programme de filtrage de securite du governement canadien. - 6 S

The dissertation deals with the ethics of mammography screening programs and related individual women's decision-making regarding whether to participate the program. While, on the one hand, mammography screening is proven beneficial in reducing breast cancer mortality at the population level, on the other hand routine screening also entails potential harmful outcomes for individuals such as false positive results and overdiagnosis. Intrinsic difficulties in evaluating the magnitude of benefits and harms of mammography, as well as in the identification of the target population, gave rise to a tremendous scientific, political and social debate. The latest up-to-date Western countries' guidelines recognize the complexity of assessing the net benefit of routine mammography screening, especially for women aged 40 to 49 who, nevertheless are eligible to participate programs on the basis of their personal evaluation and preferences. This dissertation argues that shared decision-making constitutes the most effective way of respecting women's autonomy and incorporating their values in the decision-making process. Among different ethical theories, the dissertation claims that care ethics represents the most suitable normative ethical approach to justify and provide a concrete guide to SDM, which can also be applied to the inquiry of older women's mammography screening as well as to other clinical contexts. Finally, in order to provide physicians with a practical tool for eliciting women's values and preferences, the major themes of women experiencing breast cancer identified through a critical interpretative literature review are systematically presented and proposed as a basis for an empirical qualitative research on the issue.

The provision of mass mammographic screening programs for all women over the age of 50 years in Australia has received widespread support from the popular press, politicians and society in general. However health professionals have expressed doubts about the desirability of implementing such programs before their broader efficacy has been properly assessed. This paper asserts that consideration of the opinions, experiences and attitudes of women has been largely neglected in both the popular media and medical circles. The symbolic meanings surrounding high technology, cancer and the body are discussed with reference to the mammography issue. It is argued that the psychological costs to women who are induced to enter a mammogram program require greater attention. Of particular importance is the case of those women who are forced to undergo further medical investigation when a suspicious lesion is discovered. It is concluded that the interests of women are not necessarily served by the Australian government's decision to use scare resources to fund mass mammographic screening programs.

Screening programs for genetic diseases and characteristics have multiplied in the last 50 years. 'Genetic Screening: Programs, Principles, and Research' is the report of the Committee for the Study of Inborn Errors of Metabolism (SIEM Committee) commissioned by the Division of Medical Sciences of the National Research Council at the National Academy of Sciences in Washington, DC, published in 1975. The report is considered a classic in the field worldwide, therefore it was thought appropriate 30 years later to present the Committee's modus operandi and bring the Committee's recommendations to the attention of those involved in genetics, including organizational, educational, legal, and research aspects of genetic screening. The Committee's report anticipated many of the legal, ethical, economic, social, medical, and policy aspects of genetic screening. The recommendations are current, and future committees should be familiar with them. In 1975 the Committee stated: 'As new screening tests are devised, they should be carefully reviewed. If the experimental rate of discovery of new genetic characteristics means an accelerating rate of appearance of new screening tests, now is the time to develop the medical and social apparatus to accommodate what later on may otherwise turn out to be unmanageable growth.' What a prophetic statement that was. If the Committee's recommendations had been implemented on time, there would be today a federal agency in existence, responsive and responsible to carry out the programs and support research on various aspects of genetic screening, including implementation of a federal law that protects consumers from discrimination by their employers and the insurance industry on the basis of genetic information.

BACKGROUND: Newborn screening tests have been designed to identify infants with severe disorders that are relatively prevalent and treatable or controllable. Comparing to other countries, the incidence of these diseases are very high in Turkey where the rate of consanguineous marriage is high. METHODS: In this article, it is aimed to evaluate the development and organization of newborn screening programs in Turkey which include phenylketonuria, congenital hypothyroidism and biotinidase deficiency screenings. The point reached today, limitations of the program, expectations and projects for the future are discussed. RESULTS: Today, the point reached in screening programs of the country is appreciable. While the screening rate of the live born babies was 4,7% in 1987, this rate reached to 95% by 2008. Predicted target for newborn screening program at the strategic plan of Ministry of Health for 2010–2014 was to enhance this rate above 95% by the end of 2012. It seems that the envisaged goal has been reached. CONCLUSION: National newborn screening program appears to be conducted successfully and extensively as a result of political determination and performance of health care workers who are in charge of this program. Nevertheless, limited numbers of the nutrition and metabolism clinics and specialists on these branches have caused some access difficulties, waste of time, and financial loss. Therefore, special planning to improve quality and the number of the clinics would be useful.

Setting. Coors Brewing Company is a self-insured corporation of 10,600 employees located in Golden, Colorado. Management has long believed in the value of a healthy workforce and has instituted ongoing health and wellness programming since 1981. Program design. Coorscreen was started in September 1985 to create an ongoing awareness of breast cancer screening and prevention for all female employees, spouses, and retirees and to lower the health care costs for the company through early detection of breast cancer. Program impact. From 1985 through 1993, 12,210 mammograms were completed on 3729 employees, spouses, and retirees. The participation rate was 83%. Forty-seven malignant conditions were confirmed during the first 8 years. Pathology reports confirmed 43 early detections (10 employees) and four late detections (two employees). The 10 cases of malignant disease detected early among employees cost an average of $12,388 in terms of direct medical costs, short-term disability, temporary replacement, and ongoing benefits. The two cases detected late among employees cost an average of $143,398. Among spouses, cases of malignant disease detected late have cost an average of $69,230 more than cases detected early. On the basis of early detection for 10 employees and 26 spouses, the total savings are estimated to be $3,110,000. Discussion. The Coorscreen program cost savings for the first 8 years were $3,110,080 because of the lower cost of early versus late detection. Total screening and procedural costs to the company have equaled $668,690. Thus the company has realized a total cost savings of $2,441,190.

Screening to detect diseases early is attractive as it can improve the prognosis and decrease costs, but it is often a problematic concept and there are several pitfalls. Many healthy individuals have to be investigated to avoid a disease in a few, which results in a dilemma because to save a few, many are exposed to a procedure that could potentially harm them. Other examples of problems associated with screening are latent diseases and over-treating. The question of optimal design of a screening program is another source of uncertainty for decision-makers, as a screening program may potentially be implemented in very different ways. This highlights the need for structured analyses that weigh benefits against the harms and costs that occur as consequences of the screening. The aim of this thesis is, therefore, to explore, develop and implement methods for health economic evaluations of screening programs. This is done to identify problems and suggest solutions to improve future evaluations and in extension policy making. This aim was analysed using decision analytic cost-effectiveness analyses constructed as Markov models. These are well-suited for this task given the sequential management approach where all relevant data are unlikely to come from a single source of evidence. The input data were in this thesis obtained from the published literature and were complemented with data from Swedish registries and the included case studies. The case studies were two different types of screening programs; a program of screening for unknown atrial fibrillation and a program to detect colorectal cancer early. Further, the implementation of treatment with thrombectomy and novel oral anticoagulants were used to illustrate how factors outside the screening program itself have an impact on the evaluations. As shown by the result of the performed analyses, the major contribution of this thesis was that it provided a simple and systematic approach for the economic evaluation of multiple screening designs to identify an optimal design. In both the included case studies, the screening was considered costeffective in detecting the disease; unknown atrial fibrillation and colorectal cancer, respectively. Further, the optimal way to implement these screening programs is dependent on the threshold value for cost-effectiveness in the health care sector and the characteristics of the investigated cohort. This is because it is possible to gain increasingly more health benefits by changing the design of the screening program, but that the change in design also results in higher marginal costs. Additionally, changes in the screening setting were shown to be important as they affect the cost-effectiveness of the screening. This implies that flexible modelling with continuously updated models are necessary for an optimal resource allocation.

Aim was to study the epidemiologic indicators of uptake and characteristic colonoscopic findings in the Croatian National Colorectal Cancer Screening Program. Colorectal cancer (CRC) was the second leading cause of cancer mortality in men (n = 1063, 49.77/100 000), as well as women (n = 803, 34.89/100 000) in Croatia in 2009. The Croatian National CRC Screening Program was established by the Ministry of Health and Social Welfare, and its implementation started in September, 2007. The coordinators were recruited in each county institute of public health with an obligation to provide fecal occult blood testing (FOBT) to the participants, followed by colonoscopy in all positive cases. The FOBT was performed by hypersensitive guaiac-based Hemognost card test (Biognost, Zagreb). The test and short questionnaire were delivered to the home addresses of all citizens aged 50-74 years consecutively during a 3-year period. Each participant was required to complete the questionnaire and send it together with the stool specimen on three test cards back to the institute for further analysis. About 4% FOBT positive cases are expected in normal risk populations. A descriptive analysis was performed. A total of 1 056 694 individuals (born between 1933-1945 and 1952-1957) were invited to screening by the end of September 2011. In total, 210 239 (19.9%) persons returned the envelope with a completed questionnaire, and 181 102 of them returned it with a correctly placed stool specimen on FOBT cards. Until now, 12 477 (6.9%), FOBT-positive patients have been found, which is at the upper limit of the expected values in European Guidelines for Quality Assurance in CRC Screening and Diagnosis [European Union (EU) Guidelines]. Colonoscopy was performed in 8541 cases (uptake 66%). Screening has identified CRC in 472 patients (5.5% of colonoscopied, 3.8% of FOBT-positive, and 0.26% of all screened individuals). This is also in the expected range according to EU Guidelines. Polyps were found and removed in 3329 (39% of colonoscopied) ...

Purpose: We evaluated the rate of hyperlipidemia identified during workplace screening in previously undiagnosed individuals, the association between workplace hyperlipidemia screening and use of medical care during follow-up, and changes in lipid profile among individuals with hyperlipidemia at screening. Design: Nonexperimental longitudinal study. Setting: Employees who participated in a workplace health screening. Participants: A total of 18 993 individuals from 39 self-insured employers in the United States. Measures: Total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides were measured during screening. A claims-based algorithm was used to identify hyperlipidemia cases. Analysis: Discrete-time survival analysis was used to estimate monthly rates of new hyperlipidemia diagnoses or prescriptions. Paired t tests were used to evaluate 1-year changes in lipid profile. Results: A total of 1872 (9.9%) individuals had hyperlipidemia at screening. Among all individuals, a significantly greater rate of new hyperlipidemia diagnoses was observed during the first month after screening, compared to the 3 months before screening (odds ratio [95% CI]: 2.99 [2.66-3.36]). Among the 987 individuals who were followed up 1 year later, significant improvements were observed in total cholesterol (−8.5% ± 13.6%) and LDL levels (−10.2% ± 19.3%). Conclusion: Workplace health screenings in an insured population were associated with a subsequent increase in physician visits and prescriptions for hyperlipidemia. After 1 year, significant improvements in total cholesterol and LDL levels were observed among individuals who screened positive for hyperlipidemia.