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

项目摘要 在波多黎各（PR），宫颈癌发病率急剧增加（每年2.5%）， 区域（每年1.7%）和远处（每年4.7%）阶段癌症的发生率，反映了真实的增加 并指示错过的筛选机会。不幸的是，80%的宫颈癌病例在PR诊断 发生在医疗补助或医疗保险覆盖的低收入妇女中，她们也有70%的可能性 被诊断出患有宫颈癌宫颈癌筛查的PR持续下降，特别是 在低收入的医疗补助登记者中，主要是政府诊所。宫颈癌的治疗方法 在公关筛选主要是由于个人（缺乏交通，肥胖相关的尴尬）， 环境因素（反复发生的灾害事件阻碍了筛查的开展，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的政府诊所中的采用。多成分干预措施， 解决常见的筛查障碍，提高临床环境中的筛查参与率，或避免 对基于临床的访问的需求可能有助于提高筛查的吸收和后续护理。我们的前期工作 建议的可行性和可接受的HPV自我采样在PR。我们现在提出一个混合型1 使用四组多中心随机对照试验（RCT）进行的有效性实施研究 我们将评估病人提醒的有效性， 导航和HPV自我收集（单独和组合）与单独的患者提醒相比， 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）。的 次要目标将评估关键实施结果，包括患者和提供者的接受性，覆盖范围， 执行和忠实程度，以及维持意图。然后我们将开发一个开放队列， 微观模拟模型，以评估人口的影响，成本效益，和预算的影响， 战略（目标2），以告知其在交付组织，社区和地区层面的潜在适用性。 这项研究将提供急需的知识，这是必要的，以成功地促进采用， 持续整合最佳战略，提高宫颈癌筛查的参与率， 波多黎各的贫富差距不断扩大。

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.