The effectiveness, cost-effectiveness, and budget impact of interventions to improve the delivery of cervical cancer screening in Puerto Rico.

项目总结 在波多黎各(PR)，宫颈癌发病率急剧上升(每年2.5%)，而且 地区性(每年1.7%)和远处(每年4.7%)期癌症的发生率，这反映出实际增加 并表明错过了筛查机会。不幸的是，80%的宫颈癌病例是在PR中诊断的 发生在医疗补助或医疗保险覆盖的低收入女性中，她们患癌症的可能性也高出70% 被诊断出患有宫颈癌。在PR中，宫颈癌筛查的接受率继续下降，特别是 在低收入医疗补助参与者中，主要由政府诊所查看。宫颈癌的障碍 PR中的筛查主要是由于个人原因(缺乏交通工具、肥胖相关的尴尬)和 环境因素(反复发生的灾难事件阻碍了筛查的接受并使恢复缓慢)。 缺乏关于患者导航器的有效性、成本效益和预算影响的证据 限制了它在这个美国领土上的政府诊所中的采用。多成分干预，可以 解决常见的筛查障碍，提高以诊所为基础的环境中的筛查参与度，或避免 需要以临床为基础的访问可以帮助改善筛查、吸收和后续护理。我们的前期工作 提示人乳头瘤病毒自检在公关中的可行性和可接受性。我们现在提出一种混合类型1 有效性--采用四臂多部位随机对照试验(RCT)进行的实施研究 在PR的政府妇产科诊所内。我们将评估患者提醒和患者提醒的有效性 导航和HPV自我收集(单独和组合)与单独的患者提醒在 增加宫颈癌筛查、及时阴道镜检查和宫颈癌前病变治疗(目标1)。这个 次要目标将评估关键实施成果，包括患者和提供者的接受度、覆盖范围、 实施水平和保真度，以及维持意图。然后我们将开发一个开放的队列 评估替代方案的人口影响、成本效益和预算影响的微观模拟模型 战略(目标2)告知其在交付组织、社区和地区层面的潜在适用性。 这项研究将提供非常必要的知识，这是成功促进采用和 持续整合最佳策略，以提高宫颈癌筛查的参与度并减少 扩大波多黎各的贫富差距。

PROJECT SUMMARY 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 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 microsimulation 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.