Sustainability Of Cervical Cancer Screening In China

Objective:This study explores the program sustainability of cervical cancer screening from three dimensions including evaluation on screening capabilities provided by primary medical institution,estimating cost of cervical cancer screening,and establishing a proper and operational performance management system,based on health service system and the theory of sustainability.All of them above aim to provide decision support for building an institutionalized and standardized long-term mechanism for cervical cancer screening.Materials and methods:We estimated 20 primary health institutions in urban and township health centers in rural areas,where cervical cancer screening programs were piloted.And the 20 primary health institutions were sampled from 14 provinces included in seven regions(North China,Northeast China,East China,South China,Northwest China,Central China,and Southwest China)according to geographical location.1.A study on service capabilities of cervical cancer screening:(1)documents,executive plans and work records related to cervical cancer screening and breast cancer screening were checked to reflect the situation of project implementation.(2)a cross-sectional survey was executed about service capacities of 20 organizer and 310 implementation unit and hardware facilities et.al.(3)a key informant interview was executed on 20 officers from health authority and 20 managers from project implementation unit about how to implement,manage and cooperate et.al.2.Cost accounting on program of cervical cancer screening:(1)financial data items through the whole process,financial management documents were checked which helped to choose proper indicators for cost estimation.(2)we interviewed accountant,treasury supervisor about accounting title and implementation status.We also interviewed economist,project management expert on cost estimation.(3)time driven activity-based costing was executed on estimation of different cervical cancer screening methods,as well as project cost drivers of colposcopy and pathology used by 20 project chair unit.(4)sensitivity analysis of discount rate,national recommended colposcopy and cytology ratio,labor cost,training follow-up and other costs,HPV testing equipment cost which were used to explore factors affecting the cost of screening programs.3.Study on performance management of cervical cancer screening:(1)eligible articles including screening technology,service capabilities and project management were identified through searches of PubMed,Ovid?Web of science and were used to select proper indicators.(2)building a performance management assessment framework named balanced scorecard for cervical cancer screening programs,including finance,screening subjects,internal processes,and learning growth.(3)30 experts including national and provincial management experts,clinicians,researchers review and score the index and weight.(4)analytical hierarchy process was used to estimate on weight of the performance management assessment system.(5)compositive index method was used to comprehensively evaluate on performance management of research agencies.Results:1.Service capacities of cervical cancer screening program was mainly through the following several aspects.In terms of gynecological examination,cervical cytology examination,HPV examination,colposcopy,and histopathological examination:(1)the number of working days required to complete the same screening task were 263.46,1003.64,574.991,270.21,105.38 in urban areas,and 167.18,509.15,460.96,509.15,224.03 in rural areas.(2)proportion of medical staff meeting national cervical cancer screening standards was 70%,66.7%,76.9%,55.6%,70%in urban areas and 58.2%,22.7%,100%,44.7%,80%in rural areas.In terms of hardware equipment:(1)proportion of institutions with TCT filming machines,HPV testing equipment,electronic colposcopes,and pathological image analyzers was 50%,90%,100%,and 100%in urban areas,and 20%,70%,100%,20%in rural areas.(2)proportion of instit-utions with gynecological examination room,laboratory,PCR room and pathology room was 100%,100%,20%,70%and 100%,60%,0%,50%in urban areas.2.According to cost accounting,HPV testing with genotyping was conducted in urban areas with high economic developed level,at a cost of ?69.29 per person for one time.HPV testing Without genotyping was conducted in underdeveloped rural areas,at a cost of ?60.84 per person for one time,compared with cytology test's cost was ?59.1 1 per person for one time and VIA/VILI's test cost was ?18.52 per person for one time.Sensitivity analysis found that labor costs had the greatest impact on cytology and HPV costs in rural areas,and the price of HPV testing equipment has the biggest impact on HPV testing costs.3.A scientific,practical,quantitative,and easily accessible performance evaluation index system for cervical cancer screening projects based on balanced scorecards was established,which included 4 dimensions,8 secondary indicators,25 third-level indicators.The order of weight of the four dimensions is the screening target(0.3164),capacity building(0.2625),internal process(0.2194)and project funding(0.2007).Sorting all the indicators,the top five indicators of importance are early diagnosis rate,detection rate of precancerous lesion,treatment rate,pathological section review compliance rate and funding arrival rate.The evaluation index system was applied to compare the A institution and the B institution.The result showed that the management effect of the B institution in the implementation of the cervical cancer project was slightly higher than the former.However,A and B showed different advantages in different dimensions.The evaluation index system will help to find the problem and improve management.Conclusions:HPV testing without genotyping(costed ?60.84 per person)is recommended as the primary screening scheme in rural areas where the capability of cytology test is relatively insufficient.HPV testing with genotyping(costed ?93.67 per person)is recommended as the primary screening scheme in urban areas,and then Thinprep Cytologic test is recommended(costed ?69.29 per person).It is recommended to adjust the input structure such as compensate the manpower and project supporting costs under the existing financial input total both in urban and rural areas if HPV testing is conducted.It is recommended to giving priority to increasing human input and project supporting costs from financial resource,if cytology test is conducted.The evaluation index system established by balanced scorecards is comprehensive,balanced and long-term.The indicators which can be quantified and easily obtained in the application have good practicability.Performance evaluation will help to identify weak links in the implementation of the project,which provide scientific decision-making and management models,and promote the sustainable development of the project.