Highlight
- Direct mailing of HPV self-sampling kits is more effective and cost-saving compared to usual care and other outreach methods among both screening adherent and overdue individuals.
- An opt-in approach is generally more cost-effective than usual care for individuals with unknown screening histories.
- Program budget impact declines rapidly over four years, with the fastest reductions seen in the screening adherent subgroup.
- The study supports mailed HPV self-sampling as an efficient, affordable strategy to increase cervical cancer screening uptake in diverse populations.
Study Background and Disease Burden
Cervical cancer is a significant public health concern, with human papillomavirus (HPV) infection as the primary etiologic factor. Screening programs utilizing Pap tests, HPV testing, or co-testing have markedly reduced cervical cancer incidence and mortality. However, subpopulations remain underscreened due to barriers including accessibility, awareness, and healthcare engagement. HPV self-sampling kits mailed to patients are emerging as a promising intervention to increase screening rates, addressing barriers such as clinic visit availability and patient discomfort.
Though prior studies have indicated that mailed HPV self-testing kits effectively improve screening rates in underscreened populations and may be cost-effective, there has been a gap in understanding the cost-effectiveness across individuals with varying screening histories, such as those adherent to guidelines, overdue, or with unknown screening status. Evaluating economic outcomes across these groups is critical for informed health policy decisions and optimal allocation of resources within integrated healthcare systems.
Study Design
This study was a cost-effectiveness analysis (CEA) and budget impact analysis (BIA) following a randomized clinical trial (RCT) conducted within Kaiser Permanente Washington, an integrated healthcare system. The trial enrolled 31,355 female members aged 30 to 64 years identified via electronic medical records. Participants were stratified by screening history:
– Screening Adherent: Received usual care (UC), patient reminders, clinician electronic health record (EHR) alerts, education (UC plus mailed educational materials), direct mail (UC, education, and mailed self-sampling kit), or opt-in (UC, education, plus invitation to request kit).
– Overdue for Screening: Assigned to UC, education, or direct mail.
– Unknown Screening History: Assigned to UC, education, or opt-in.
Primary outcome was screening completion within 6 months postrandomization. Economic analyses, calculated from Kaiser Permanente and Medicare perspectives, incorporated delivery costs and visit types (wellness vs. screening-only). The BIA evaluated annual program implementation costs over four years.