| ObjectivesUpper gastrointestinal cancer(UGC)is one of the high-incidence cancers in China.Screening is one of the most realistic and effective measures for cancer prevention and control.Endoscopy followed by indicative biopsy is the gold standard for screening and diagnosis of UGC,which has been written into guidelines and expert consensus as the preferred screening method.However,with a short time and less practice of endoscopic screening,China has limited realiable evidence on how to formulate screening strategies suitable for different rural regions.The study aimed to comprehensively analyze the effectiveness,cost and economics and experience of UGC endoscopic screening under Triple Aim framework,to provide decisionmaking evidence for the optimizing of UGC endoscopic screening strategy within the goals of"Good cost-effectiveness,Affordable to the society and Acceptable to the mass",and to promote the efficiency and benefit of UGC endoscopic screening.MethodsBased on the Triple Aim framework,this study adopted a combination design of model long-term prediction and cross-sectional analysis.A total of 10 measurement indicators were determined after introducing the concept of health economic evaluation and preference analysis.A specific Markov decision model for UGC joint endoscopic screening was constructed to analyze the long-term trend of population health dimension and cost dimension indicators.Discrete Choice Experiment(DCE)was used to measure residents’ preference of endoscopic screening,and then the screening experience were explored by the obtained preference.Thereafter,the study achieved a comprehensive analysis of UGC joint endoscopic screening strategy.Jinan City and Weifang City in the East,Jining City and Tai’an City in the Middle,Liaocheng City and Binzhou City in the West of Shandong Province were selected as the sample areas in which certain county-level administrative regions were extracted to carry out a twostage data collection and questionnaire survey.In the first stage,Pingyin,Linqu,Qufu,Feicheng,Dongchangfu and Wudi were selected as sample counties,and 90000 screening cases were analyzed,5 medical institutions,171 screening participants and 1117 patients with upper gastrointestinal diseases were investigated.In the second stage,2-5 villages were randomly chosen from Linqu,Feicheng and Dongchangfu.Villagers aged 40-70 who had never been diagnosed with cancer were randomly investigated.A total of 986 participants was complished the DCE survey.Results1.A total of 86183 villagers was screened by endoscopy in sample areas,and 1823 positive cases were detected in the year 2015 to 2020.The overall detection rate,early diagnosis rate and treatment rate were 2.12%,82.17%and 91.11%,respectively,but there were differences between regions,age groups and sex groups.A total of 8773 in 11700 cases were followed-up,with a follow-up rate of 74.98%.368 positive cases were detected in the follow-up period,with a detection rate of 2 times higher than that of primary screening.An obvious same direction change trend between the follow-up rate and the early diagnosis rate was observed,that is,the early diagnosis rate was also higher in the areas with high follow-up rate.2.The Markov prediction results were in line with the actual given that the differences were within the interpretable range,so the Marokv model in the study was stable and reliable.Within the population health dimension,screening could effectively reduce the UGC cumulative morbidity(range,3.63-5.42%)and mortality(range,2.68-4.04%),and improve life expectancy(LE),life year(LY)and quality-adjusted life year(QALY)of the population.When the screening intervals were 1,2 or 5 years,the earlier the screening starting age,the better the effectiveness.When the intervals were 10 or 15 years,the starting age of 40 with follow-up could obtain the best health benefit,and the starting age of 55 or 45 without follow-up were the worst ones.In the case of screening once in a lifetime,a later screening starting age would be better choice for more effectiveness,conversely.In the cost and economic dimension,8 dominant options were found out by the incremental cost-effectiveness ratio(ICER)and the incremental cost-utility ratio(ICUR),respectively.Compared with none screening,the ICER and ICUR of each dominant option were less than￥40000/LY and ￥35000/QALY,respectively.Compared with adjacent options,most of ICER and ICUR were below ￥30000/LY and ￥20000/QALY,with the highest value of ￥85799.40/LY and ￥66764.06/QALY,respectively.With a ￥30000/LY(QALY)willingness to pay threshold,the option that screening every 5 years,starting at age 40 and with follow-up could obtain the maximum net benefit.As the threshold increasing,the net benefit of options with shorter screening interval and earlier starting age would gradually elevate accordingly.When the threshold reached above ￥100000/LY or ￥70000/QALY,the option that screening once a year from age 40 could produce the maximum net benefit.3.DCE results were used as proxy indicators to reflect the experience and participation rate.Overall,the respondents preferred the screening program with a high-risk reduction of UGC-related mortality,shorter interval,follow-up,less pain,and lower out-of-pocket cost.The screening technique attribute had the most important impact on residents(accounted for 43.61%),followed by out-of-pocket costs and screening interval.Satisfying preferences can improve the screening experience,but there was preference heterogeneity in different populations.When converting endoscopy to painless endoscopy,the respondents were willing to pay ￥686.01.Theoretically,if regular follow-up was not provided,the respondents should be compensated ￥57.02.In the scenario prediction,the participation rate would decrease accordingly as out-of-pocket costs increase,and it would increase by 89.94%if painless endoscopy was used.Even if the out-of-pocket costs were ￥300 and ￥500,participation rates could reach to 92.72%and 83.99%by adjusting and optimizing other attributes.Conclusions and ImplicationsThe Triple Aim provides a novel framework for the evaluation and optimization of cancer screening strategies.But the performance of different screening options varied in three dimensions.A screening option with good effectiveness might not be economical,and a lowcost and economical option might not perform well in effectiveness and experience.Based on the Triple Aim,the formulation of UGC endoscopic screening strategies should firstly clarify the weights and priorities of the three dimensions and followed the principle of "adapting to local conditions" and "being able to vary from person to person".After taking painless endoscopy and regular follow-up as essential components,areas with good economic level and sufficient screening resources should pay more attention to population health and experience and could perform screening at age 40 with a 1 year or 2 years screening interval.Areas with medium economic levels should properly considered the affordability of screening,which can adopt a starting age of 40 or 45 and a screening interval of 5 or 10 years.Areas with poor economic level and limited resources can perform cancer screening for target population once in their lifetime,but the starting age should be raised to 50 or 55.But the health benefits and experience will be negatively affected under these circumstances.In addition,varied screening intervals can be set for different age groups within certain regions.Pluralistic screening financing mechanisms shoule be explored and a classified 10-30%co-pay rate could be set for people with different incomes,which will help for the sustainable development of cancer screening.According to the above conclusions,the following policy recommendations were proposed:1)To strengthen government responsibility to ensure that cancer screening measures are implemented.2)The determination of UGC endoscopic screening strategies should adhere to the goals of "Good cost-effectiveness,Affordable to the society and Acceptable to the mass",It is necessary not only to pay attention to the effectiveness and economics of the screening,but also to improve the experience and participation rate of the target population and to make tradeoffs according to the availability of resources.3)Reasonable multi-party funding and costsharing mechanism of cancer screening should be explored.4)Various measures should be taken to improve cancer screening capabilities in various regions,and to promote the standardization and homogeneity of screening.5)Supporting scientific studies to provide quantitative evidences for the timely adjustment and continuous optimization of screening strategies.Innovations and LimitationsInnovations:1)This study firstly introduced the Triple Aim into the evaluation and optimization of UGC screening,and then put forward the optimization goals of "Good costeffectiveness,Affordable to the society and Acceptable to the mass" and the improvement ideas of "adapting to local conditions,being able to vary from person to person",which provided a new perspective for the formulation and evaluation of public health interventions.2)A specific Markov model for UGC joint screening was constructed,which avoided the issues of enlarging cost or reducing effectiveness when prevous studies only evaluated a single cancer.3)This was the first DCE study to measure the preference of residents’ endoscopic screening in China,which overcame the problems that traditional attitude survey can not achieve trade-offs and quantitative analysis of attributes.Limitations:A part of Markov model parameters came from literature and second-hand data which lower the model’s localization level and might affect the accuracy of the prediction results.Recalling bias and sampling bias might be exsit in the questionnaire survey.Whether the stated preference obtained through DCE was consistent with the actual behavior and screening experience still need to be confirmed by further research. |
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