Screening at any cost?

Can we increase screening participation, and if so, at what cost? These were the questions I asked myself while reading the article “Effect of provider and patient reminders, deployment of nurse practitioners, and financial incentives on cervical and breast cancer screening rates,” which appears on page e282 of this issue.1 Kaczorowski et al present the results of a large concerted effort that took place in Ontario from 2004 to 2005, which aimed to increase the number of screening participants in both Papanicolaou tests for cervical cancer and mammograms for breast cancer.1 The goal of the program, known as P-PROMPT (Provider and Patient Reminders in Ontario: Multi-strategy Prevention Tools), which was supported by the Primary Health Care Transition Fund, was to develop and evaluate a large-scale demonstration project aimed at increasing delivery of 4 targeted preventive care services by means of the newly created models of primary care (primary care networks [PCNs] and family health networks [FHNs]); the preventive care management program; recall and reminder systems; and deployment of nurse practitioners (NPs) to enhance delivery of preventive care services. Kaczorowski et al conducted a large study: 232 Ontario family physicians participated, representing 75% of those practising in PCNs and FHNs in southwestern Ontario.1 A total of 83 101 women aged 35 to 69 were targeted for Pap tests every 2 years and 39 780 women between the ages of 50 and 69 were targeted for mammograms every 2 years. Six NPs were deployed to the PCNs and FHNs, working specifically to reach the targets. Subsidies were given to doctors to encourage them to attain the prevention targets—yearly bonuses of up to $2200 were offered for meeting objectives, and expenses related to reminders were eligible for reimbursement—and thousands of letters and other specific reminders were sent to patients who “forgot.” Is all of this worth it? After 1 year, statistically significant increases of 6% for Pap test rates and 5% for mammogram rates were noted (P < .001 for both). Any measure that achieves an increase in preventive behaviour is certainly valuable, but are these results really significant? In fact, when we consider participation rates in cervical and breast cancer screening programs, we observe that they already oscillate between 60% and 70%.2 The women targeted by the program initially had high participation rates—70% already participated in breast cancer screening and almost 69% regularly had Pap tests. The P-PROMPT program increased participation from 70% to 75% for breast cancer screening and 69% to 75% for cervical cancer screening. Even if the results seem impressive, one must recognize that most women who did not subscribe to the initial screenings continued to resist participating. In fact, the program succeeded in convincing 5% of 39 279 women to undergo breast cancer screening and 6% of 74 283 women to undergo Pap tests, which corresponded to 2085 and 4664 women, respectively. On the other hand, 9682 and 18 429 women refused to undergo mammograms and Pap tests, respectively. Therefore, we cannot ignore the fact that 25% of the women chose not to participate in these widely recognized and well-established preventive measures. This study demonstrates that we can increase the participation rate for screening programs. It also demonstrates the limitations of our educational efforts. Even if we invest thousands of dollars in educational campaigns, put into place every imaginable computerized or personalized reminder service, hire a multitude of NPs, and subsidize preventive practices, there will always remain a substantial proportion of the population that will ignore our interventions. In our health care system, which shows cracks everywhere, we should seriously question where we want to invest our funds. Everyone will claim that their practices are essential. Radiologists will tell us how important it is to achieve a screening rate above 70% and gastroenterologists will say the same about colonoscopies; others will express the importance of wearing a helmet while cycling. In contrast, others will say, justifiably, that it makes no sense to be unable to find a family doctor, to wait in an emergency department for hours, to spend days on a gurney in a hallway, or to wait several months for major surgery. As human and financial resources are not unlimited, we will have to prioritize. At the risk of displeasing advocates of prevention at all cost, educational and preventive measures will have to, like all other measures, be the object of efficiency analysis.