Gerald F. Kominski

Authors randomized 48 primary care pediatric practices to online communication training vs. usual care. Online communication training reduced missed opportunities (MOs) for initial human papillomavirus (HPV) vaccination at well-child care (WCC) visits by 6.8 percentage points among children aged 11–17 years. The current study estimated implementation costs of the communication training intervention at WCC visits.

Authors analyzed monthly surveys completed by intervention practice lead clinicians to track clinician plus office staff personnel hours devoted to implementing the intervention. They converted personnel time into 2019 U.S. dollars using national median hourly wages for physicians and other health care workers; they tracked nonpersonnel costs. Authors calculated costs per practice (overall and by practice size) and estimated costs per averted MO for HPV vaccine initiation using an effectiveness estimate determined by grouped logistic regression at the practice level.

Findings: Practices varied from 1 to 24 clinicians and from 241 to 8,866 visits during the 6-month intervention. Total intervention costs varied substantially across the 24 intervention practices from $370 to $6,653, with a mean of $2,003 and median of $1,305. The incremental cost per averted MO for HPV vaccine initiation at WCC visits averaged $110 ($212 in practices with 1 or 2 physicians and $94 in practices with 3 or more physicians).

The implementation cost per averted MO for HPV vaccine initiation at WCC visits of this online communication training intervention was modest, particularly among larger pediatric practices.

The Inflation Reduction Act of 2022 (IRA) included additional federal subsidies to make health insurance more affordable in the individual market, but these expire at the end of 2025. If Congress does not extend the expanded subsidies and levels revert to those in the original Affordable Care Act, all 2.37 million Californians in the individual market — including those not receiving subsidies — would face higher health insurance premiums and be forced to choose between more expensive coverage, less generous coverage, or forgoing coverage altogether and going uninsured. Under this scenario, authors project that in 2026:

• 1,558,000 Californians would pay an average of $967 more per year but maintain coverage despite having their subsidies reduced or eliminated;
• 740,000 Californians enrolled in unsubsidized coverage would pay an average of $253 more per year due to the worse risk-mix of the individual market if the IRA subsidies were eliminated;
• 69,000 additional Californians would become uninsured.

Authors conclude that maintaining IRA-level subsidies in the individual market would protect 2.37 million Californians from insurance premium increases and keep 69,000 Californians covered. For these subsidies to continue, Congress must act in 2024 or 2025. In early 2025, insurers will develop their rates for the 2026 coverage year, and rates will be finalized by the middle of 2025. Congressional action before then could help avoid premium increases.

In 2012, updated American Society for Colposcopy and Cervical Pathology (ASCCP) management guidelines for abnormal cervical cytology recommended observation rather than immediate referral to colposcopy for low-grade abnormalities in women ages 21–24. Researchers evaluated the impact of these guidelines on changes in colposcopy procedure rates among young women. They analyzed administrative and claims data from the largest statewide family planning program between July 2011 and June 2015. Using a difference-in-differences approach, researchers estimated changes in colposcopy procedure rates among women ages 21–24 years before and after the 2012 ASCCP management guidelines, relative to a comparison group of women ages 25–44.

Findings: The analysis included 333,977 women from 216 primary care provider sites. After publication of the 2012 ASCCP management guidelines, colposcopy rates significantly declined from 6.70% to 3.94% among women ages 21–24 and from 4.35% to 3.53% among women over 24 years. These declines correspond to a 1.93 percentage point reduction in colposcopy rate among women 21–24 vs. over 24 years, or a two-fold relative reduction.

Among women ages 21–24, colposcopy receipt was associated with speaking primarily English vs. non-English, having a cervical cytology test within the past year vs. not, and receiving care from a public vs. private provider.

Colposcopy procedure rates among young women significantly declined following publication of the 2012 management guidelines, which has implications for reducing potential harms of overtreatment.
 

Recently updated global guidelines for cervical cancer screening incorporated new technologies-most significantly, the inclusion of Human papillomavirus (HPV) DNA detection as a primary screening test-but leave many implementation decisions at countries' discretion. Authors sought to develop recommendations for Malawi as a test case since it has the second-highest cervical cancer burden globally and high HIV prevalence. They incorporated updated epidemiologic data, the full range of ablation methods recommended, and a more nuanced representation of how HIV status intersects with cervical cancer risk and exposure to screening to model outcomes of different approaches to screening.

Using a Markov model, authors estimated the relative health outcomes and costs of different approaches to cervical cancer screening among Malawian women. The model was parameterized using published data, and focused on comparing "triage" approaches-i.e., lesion treatment (cryotherapy or thermocoagulation) at differing frequencies and varying by HIV status. Health outcomes were quality-adjusted life years (QALYs) and deaths averted. 

Findings: Thermocoagulation was more cost-effective than cryotherapy at all screening frequencies. Screening women once per decade would avert substantially more deaths than screening only once per lifetime, at relatively little additional cost. Moreover, at this frequency, it would be advisable to ensure that all women who screen positive receive treatment (rather than investing in further increases in screening frequency): for a similar gain in QALYs, it would cost more than four times as much to implement once-per-5 years screening with only 50% of women treated versus once-per-decade screening with 100% of women treated. Stratified screening schedules by HIV status was found to be an optimal approach.

These results add new evidence about cost-effective approaches to cervical cancer screening in low-income countries. At relatively infrequent screening intervals, if resources are limited, it would be more cost-effective to invest in scaling up thermocoagulation for treatment before increasing the recommended screening frequency. In Malawi or countries in a similar stage of the HIV epidemic, a stratified approach that prioritizes more frequent screening for women living with HIV may be more cost-effective than population-wide recommendations that are HIV status neutral.