Nurse Intervention in Cervical Screening Programs Essay

Nurses deliver care to patients in an ever-changing environment that revolves around changes in local and governmental policies as well as technology and pharmaceutical advancement for effective practice, (Ellis, 2016). According to Nursing and Midwifery Council (NMC) Code of Conduct (2015), nurses assess patients’ needs and deliver timely, efficient and effective patient care based on the best available evidence. Evidence Based Practice is the integration of best research evidence with nursing practice and patient needs and values to facilitate effective care, it also promotes quality, safe and cost-effective treatment for patients, families, healthcare providers and health care system, (Brown, 2014; Craig and Smyth 2012). This assignment aims to explore an area in nursing, identifying gaps between theory and practice. Using research and discussing strength of the literature and overcoming related issues in the specified area. Nurse Intervention in Cervical Screening Programs Essay

The assignment will focus on barriers to cervical screening and nurses’ intervention to improve screening programmes. Cervical cancer screening can be detected early and treatment of precancerous cells and cervical cancer, (White et al., 2015) continues to exist. Cervical cancer starts from a pre-invasive stage known as cervical intraepithelial neoplasia (CIN) however, it can be detected through cervical screening, (Foran et al., 2015). Cervical cancer is the second most common cancer among women globally after breast cancer, (World Health Organization, 2016). According to the Department of Health (DH) (2012a) detecting cervical cancer at an early stage can prevent around 75% from developing. World Health Organization (WHO) (2015a) asserts that prevention and early detection of cervical cancer is cost –effective and a long-term strategy.  Hoppenot et al (2012) points out that screening can reduce incidence and death rates. Research shows cervical screening is associated with improved treatment for invasive cervical cancer, (Andrea et al., 2012). This highlights the importance of cervical screening programmes. Nurse Intervention in Cervical Screening Programs Essay

Cervical screening reduces the occurrence of cervical cancer and research shows it prevents approximately 4500 deaths annually in Britain, (Bryant, 2012). In England, there is an invitation for screening for women aged 25-64.  Women aged 25-49 should attend screening appointment every three years and women aged 50-64 every five years, (Health and Social Care Information, 2012).  However, the last fifteen years has seen a gradual increase in more women being left unscreened for  five years or above, from 16% in 1999 to 22% in 2013 (Health and Social Care Information Centre, 2013). Research shows differences in screening is among women who are younger, lower income earners, less educated or women from minority ethnic background and sexually abused women, (Waller et al., 2012; Cadman et al.,2012; Marlow et al., 2015; Albrow et al., 2014). Nurse Intervention in Cervical Screening Programs Essay

A comprehensive search of databases for literature review namely, Medline, Science Direct, CINAHL, National Institute for Health and Care Excellence (NICE) and Cochrane. An advance search strategy including ‘Cervical Screening, Barriers to Cervical Screening, Early Detection Cervical Cancer and Cervical Screening Adherence’. The search was refined to literature in the past five years and incorporated international literatures from United Kingdom, Australia, Sweden and Korea to give an insight of those barriers from a global perspective. Nurse Intervention in Cervical Screening Programs Essay

Firstly, as regards discussion of non-attendance among women from minority ethnic background. Marlow et al (2015) conducted both qualitative and quantitative study titled ‘Understanding cervical screening non-attendance among ethnic minority women in England’. The study investigated and compared differences in attendance among 720 women from minority ethnic background and White British women. For clarification purpose, ethnic minority are black, Asian and minority ethnicity (BAME). The study found that BAME women were less likely to attend cervical screening with 44-71% non-attenders compared to 12% white British women. This highlights the need for more intervention by nurses to improve practice. Reducing inequality in cancer pathway particularly among minority ethnic groups is a policy priority (Dept. of Health 2011). Nurse Intervention in Cervical Screening Programs Essay

Marlow et al (2015) found that women from ethnic minority viewed that they were not sexually active so they did not have to do the test. This is an important aspect for nurses to educate in order to improve practice and to promote attendance with educational materials in various languages for better interpretation. The study also found 65% women from minority ethnic background believed they do not need to attend smear test in the absence of any symptoms compared to 6% white British women. These barriers are primarily associated with lower education and lower socio- economic status, (Fang and Baker, 2013).  It is surprising that women are still not aware of cervical cancer screening when people should have received letters and leaflets as part of the NHS programme, this highlights that women who have never attended screening had not read any information, (Kobayashi, 2016). Furthermore Benito et al. (2014) argued that nursing activities were mainly in areas namely health education and promotion, clinical, research, training, and program evaluation. Nurses’ intervention to educate thereby improving knowledge and understanding of cervical cancer and the benefits of screening is essential. Nurse Intervention in Cervical Screening Programs Essay

In addition, participants had deep-seated personal opinions including fear and embarrassment. Ethnic minority women were more likely to be fearful and preferred female health practitioner. To improve practice support groups in the community may be a good avenue to discuss about screening. These interventions should lay emphasis on the efficacy of cervical screening and address concerns regarding shame and embarrassment. The main strength of this study is information from a large population that makes it a relevant and reliable study to improve cervical cancer screening programme. Nurse Intervention in Cervical Screening Programs Essay

A qualitative study conducted by Cadman et al (2012) titled ‘Barriers to cervical screening in women who have experienced sexual abuse; an exploratory study.  Women from the age of twenty and above who visit the Website of the National Association for People Abused in Childhood (NAPAC), a United Kingdom Charity who provide support and information for people from abusive background were invited to complete a web-based survey of their opinions and experiences of cervical screening. This survey included closed questions assessing social class, screening history and past records of abuse. Participants indicated the type of abuse they had experienced either physical, sexual, emotional, neglect, spiritual or any other form of abuse. Study shows women who have a history of sexual abuse are at risk of gynaecological problems and cervical neoplasia compared to women who have not. Women who have been sexually abused are more likely to smoke, take drugs and consume alcohol. The study revealed that a number of barriers impeded their attendance and adherence to cervical screening including embarrassment, lack of trust on meeting someone for the first time, gender of smear taker, pain, tension, fear and anxiety. The findings indicated that some study participants made remarks about the intrusive nature of the test. Some participants mentioned they were not comfortable with interventions performed while on their backs.  The argument suggest that women who have history of sexual abuse may be fearful and anxious because of triggering memories of the trauma so they may avoid such responses which is true therefore this study is valid and reliable. In relation to evaluation and analysis of the study, the findings also revealed that further training should be provided to increase nurses’ knowledge and sensitivity.  NMC Code (2015) points out that health care providers respect individual choices and deliver care without delay.  In an event of a sensitive discussion, nurses are required to ask patient preference and should remain professional not expressing any sign of shock. Fujimori et al. (2014) argues that to attain effective communication, nurses should inquire patients’ preferences and expectations at the start of the screening process. To improve this skill can be taught in communications skills training which has proven to be an effective approach. Nurses could show empathy by explicitly asking women about their expectations of the screening encounter and whether they have any concerns. This may help to surface issues that the nurse and patient could tackle together to minimise anxiety and fear. For example, it could be to provide the option of a female practitioner for the cervical screening appointment, maintain dignity and sensitivity. Effective communication between nurses and patients is essential. To achieve this, however, nurses must be sensitive to their specific needs and demonstrate empathy. Having nurses who are adequately trained with special knowledge of abuse is essential. There should be interventions such as counselling and support activities as part of ways of ensuring that they attend screening. This is particularly important at cervical screening appointments for sexually abused patients to deliver safe and sensitive practice. Nurse Intervention in Cervical Screening Programs Essay

The Waller et al (2012) conducted a qualitative study evaluating differences to barriers among women from different ages. The study  interviewed practitioners working in the screening programme and other related charities as well as women who never attended screening focusing on their views on how age can influence non- attendance and non-adherence in cervical screening. The study found that women were classified into two distinct groups, which were those who wanted to go for screening but did not attend which consisted younger women and others who had decided not to attend were mainly older women. Wardle (2016) argues that nurses’ intervention at improving uptake could be beneficial by considering different approaches for various age groups to improve practice. Nurse Intervention in Cervical Screening Programs Essay

The findings of the following analysis identified barriers that included many described in other studies namely fear of discomfort, pain, embarrassment and lack of education. There is a reliable argument that providing support with when, where and booking an appointment is effective. Additionally one of the key themes emerging from the study is that older women are more conscious about their bodies as they age. For example, one participant discussed about changes in her self-image as she grew older and how it has affected her self-esteem and how she feels reluctant to undergo invasive procedures.  Nurses could encourage action by  reassuring older women and  to remind them of the importance and benefits of cervical screening. Sabatino et al (2012) argued that effective communication improves cervical screening. Nurse Intervention in Cervical Screening Programs Essay

This systematic review by Albrow et al (2014) found similar findings with Waller et al (2012) further evaluated the influence of intervention in cervical screening evidence uptake amongst women less than 35 years. The findings from the study increased validity and reliability from the argument that younger women are less likely to attend cervical screening. Ninety-two records were screened and four studies investigated. One of the studies evaluated the use of invitation letters and reported no significant increase compared to standard invitation. Three studies investigated the effect of reminder letters. Study participants described how screening was yet another demand on their time and often competed with work and childcare, which are of higher priority. For others, they could not attend due to inconvenient location, fear, discomfort and embarrassment, (Waller et al., 2012). There was a widely view among 30 year old women as sickness was associated with old age and felt they had no reason to attend screening (Blomberg, 2011). Analysis of the findings  indicate an increase in the number of women attending cervical screening after receiving reminder letters compared to those that were not given, however the increase was relatively small. For this reason, cervical screening programmes need to look beyond the use of invitation and reminder letters among younger women and to develop other interventions to overcome as many barriers. Another study reported no increase amongst women aged 20-24, although in some places these women are below the age threshold. However, the same study reported an increase among 25-29 (95%) and 30-34 that also reported (95%) increase. It could be argued that there is some evidence to suggest that reminder letters had positive effects on adherence to cervical screening programmes. The results also showed that telephone reminder from a female nurse, which had 6.3% and 21.7% increase. The study also reported 2.4% increase after a physician reminder. In evaluation of how nurses can improve practice among these, age group there is a need to remove practical barriers and provide other incentive methods that includes mass media campaigns and educational intervention. There are so many users of social media especially within this age group and if used properly it will play a significant role in creating awareness and educating patients (Merolli et al., 2013). Concerning low perceived risk, this may relate to misperceptions of the purpose of the screening programmes with patients focusing on detection rather than prevention of cervical cancer.  Again, patients should be empowered through social support in the community.  In addition, nurses can educate, giving information regarding importance and benefits of cervical screening. Lastly, the review of GP incentive such as nurses providing flexibility in appointment times and out of clinic days will improve practice. Nurse Intervention in Cervical Screening Programs Essay

In conclusion, cervical cancer is preventable and relatively easy to diagnose. Several barriers upon women’s decision to attend cervical screening programme have been identified. Given this, there is a need for how women view cervical cancer and make screening decision. This assignment collates available evidence in order to investigate potential psychosocial influences on women from different perspectives. It is essential that patients adhere to nurses’ advice and educational interventions. In order to improve cervical cancer patient experience, there is a need that nurses receive adequate training and develop skills that can improve practice. One possible strategy is being sensitive to the screening process as a result of its intimate nature combined with effective communication. Nurses can play an important role in treating patients with dignity, respect and showing empathy. This can make a difference to all women most especially women who have experienced sexual abuse. Another contributing factor is to respect patients’ choice; an example is providing preferred gender of the sample taker. This could encourage more attendance and adherence to the cervical screening programme. Nurse Intervention in Cervical Screening Programs Essay

PART 2

Reflective practice is essential to nursing profession. My search for the best evidence for cervical cancer screening interventions began by doing literature search. Designing a research study is an advanced and complex skill that requires clinical experience as well as analysing and evaluating the research design. While doing my research I focused on the needs of patients and effectiveness of nursing interventions. The result of my search enabled me acquire knowledge and skills in patient care by extensive literature search using electronic databases and advanced search with combined words. Discovering how to refine my search using full text and finding up to date evidence in the last five years.  My skills have greatly improved using electronic databases. This was done in order to obtain relevant up to date search. NMC (2015) requires nurses use up to date evidence and competent to practice. Such insight in itself is relevant to nursing competency and can help to improve patient care.  I read and understood articles relevant to nursing practice, clinical expertise and understanding patient values. Reading the research articles and reflecting on each one, identifying assumptions, key concepts and methods and determined whether the conclusions were based on their findings. Appraising the steps of the research process in order to critically analyse and use it to inform practice. This developed my assessment skills and I was able to identify valid and reliable studies. Reviews and ratings of the evidence resulted in recommendations for practice. According to National Institute of Nursing Research (NINR) 2013, nursing research is defined as research that involves and develops nursing care in order to promote patient healthcare. Nurses play an important role in the National Health Service (NHS) they provide front line services, support patients and contribute to health research. Furthermore, research generates knowledge for nurses and contribute towards health care (Parahoo, 2014). I am more enlightened about the importance of analysing and evaluating research studies, which helps nurses to acquire more knowledge and be up to date with evidence thereby promoting patient care. It is evident that evidence base practice will continue to have great impact on the professional practice of nursing. Evidence based practice is important in nursing because it improves patient outcomes, care is delivered more effectively and efficiently and it minimises error, (Houser,  2016). I have acquired more knowledge, skills during the duration of this evidence based practice assignment and recognised my strengths, and areas that I needed to improve on. Nurse Intervention in Cervical Screening Programs Essay

Cervical cancer is the fourth most common malignancy affecting women worldwide, accounting for nearly 10% of all cancers (excluding non-melanoma skin cancers) and about 265,700 deaths annually (7.5% of all female cancer deaths) (1). This burden of disease exists in spite of cervical cancer being one of the most preventable cancers (2). Nurse Intervention in Cervical Screening Programs Essay

The causal association between cervical cancer and Human Papilloma Virus (HPV) is one that is well established (3)(4)(5). Thus, prevention strategies are largely targeted at preventing HPV infection or preventing disease progression for those who are infected. There are 2 types of preventive measures available to reduce incidence and mortality from cervical cancer: i.) Vaccination and ii.) Screening. While vaccination is a primary preventive measure (providing protection against the incidence of illness), screening is a secondary preventive measure aiming to diagnose illness early and prevent its progression. Combining screening and vaccination against HPV should potentially provide the best protection against cervical cancer as neither option alone offers 100% protection. At present, screening strategies for cervical cancer have not been altered for females who are HPV vaccinated (6). Screening vaccinated women is arguably still a requirement because of the limitations of current HPV vaccines both in their lack of therapeutic effect (not protecting women with ongoing neoplastic processes) and in their coverage of limited number of HPV types (leaving to evolve some 25–30% of cervical cancer cases related to HPV types other than 16 or 18 strains). Consequently, for health economists, the question regarding the most cost-effective combination of screening strategies along with vaccination arises. The economic impact of screening HPV vaccinated populations is analytical information that health policy makers require for the formulation of effective, evidence-based strategies. Nurse Intervention in Cervical Screening Programs Essay

The purpose of this literature review is to collect and collate the best possible evidence available to answer this question. This review aims to systematically analyze health economic studies on HPV vaccination to provide integrated evidence and recommendations based on its cost–effectiveness when combined with differing cervical cancer screening strategies. Nurse Intervention in Cervical Screening Programs Essay

CAVEAT:

Prior Knowledge:

During the search conducted in July 2017, it was noted that a systematic review by Mendes et al (7) on CEA of prevention strategy combinations against HPV infection, was published on March 28th 2017 (after the preliminary literature review search was conducted by the author). Upon examining this paper, it was found that:

i) No quality appraisal of the papers included in the review was carried out.

ii) No papers analyzing the cost effectiveness of screening strategies in populations vaccinated with the non-avalent (9-valent) vaccine (8) were included

iii) The search was finalized in April 2014 resulting in the exclusion of all papers since 2014 till July 2017

iv) The study focused only on studies based in Austria, Belgium, Switzerland, Czech Republic, Germany, Denmark, Spain, Finland, France, Greece, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Sweden, Slovenia, and the UK, the US, Canada and Australia excluding relevant studies from other parts of the world

Contribution from this literature review: Nurse Intervention in Cervical Screening Programs Essay

i) Complete appraisal of all papers using the recommended CHEERS checklist for economic evaluations (9)

ii) A crucial CEA conducted on screening strategies within cohorts vaccinated with the nonavalent or 9-valent vaccine (10)

iii) Studies published after April 2014 were added to this literature review (8) (10)(11)

iv) Relevant studies carried out in Africa (12), Thailand (13), Laos (14), China (15), Taiwan (16) , Israel (17) have been included and reviewed

HPV and Cervical Cancer:

HPV (Human Papilloma Virus) is currently the most common sexually transmitted virus (3). It is passed on primarily through genital contact (such as vaginal and anal sex) and also by skin-to-skin contact (3). Over 100 types of HPV have been identified and more than 40 of these infect the genital area. Although there are several high-risk HPV types, the infection of 2 particular HPV types: 16 and 18 are found to be responsible for 70%–75% of all cervical cancers and 40%–60% of its precursors (18). Among the cancer-related outcomes of HPV infection, cervical cancer is the most important outcome, with over 5,00,000 new cases and 2,75,000 attributable deaths world-wide in 2008 (19). The high-risk (cancer causing) types of HPV include: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68 (20). Women who are infected with HPV may have their infection clear, progress or persist. Persistence is the most significant determinant of whether or not a HPV-infected woman will develop a clinically significant sequelae (4). Nurse Intervention in Cervical Screening Programs Essay

Primary Prevention – Vaccines:

Currently 2 first generation HPV vaccines have enabled prevention against the two most common types of human papillomavirus infection – strains 16, 18 (Bivalent) and also 6 and 11 (Quadrivalent). Clinical trials have provided evidence that the bivalent vaccine was 100% [95% confidential interval (CI) 47–100%, N = 1113] effective against HPV types 16 and 18, and the quadrivalent vaccine 98% [95% CI 86–100%, N = 10,565] (21) (22). These vaccines, have been made available in several countries since their international approval and we are now in the phase of possibly of utilising the second generation of ‘non-avalent’ HPV vaccines (23). These newer vaccines have potential for protection against persistent infection from HPV types 6/11/16/18/31/33/45/52/58 (which together cause ~90% of cervical cancers, globally) (5). Nurse Intervention in Cervical Screening Programs Essay

Secondary Prevention – Cervical Cancer Screening Tools:

Persistent HPV infection can cause pre-cancerous cervical lesions and invasive cervical cancer thereafter. With regular cervical cancer screening and appropriate follow-up, most cervical cancer precursors can be identified and treated, interrupting progression to the severe disease stage. Screening programs can reduce cancer risk among those who do not receive the vaccine, those infected by non-vaccine targeted HPV types, and those who demonstrate reduced vaccine efficacy, providing insurance at the population level, given the uncertainties surrounding vaccine performance. The screening tools available include (24): Nurse Intervention in Cervical Screening Programs Essay

a.) Cervical Cytology:

Evidence suggests that cervical cancer screening using cytology is one of the most successful public health prevention programs, particularly when implemented in a mass strategy (25). This method involves the collection of exfoliated cells from the cervix followed by microscopic examination of the same after staining, for cellular abnormalities. Based on these abnormalities, further investigation is required to arrive at a diagnosis. There are two cytological screening methods:

i) Conventional PAP smear

ii) Liquid Based Cytology (LBC)

These 2 methods have been extensively compared and it is found that LBC is significantly advantageous in terms of sensitivity and possibility for ‘reflex testing’ of HPV infection without new sample requirements. (26)(27)(28)

b.) Visual Inspection: Nurse Intervention in Cervical Screening Programs Essay

Visual inspection of the cervix continues to be implemented as a screening tool for low-resource settings, despite its limited specificity and poor positive predictive value (PPV), as it is economical and can provide immediate results. This method involves direct visual examination for abnormalities or lesions in the cervix after staining with acetic acid or Lugol’s iodine referred to as Visual Inspection with Acetic Acid (VIA) or Visual Inspection with Lugol’s Iodine (VILI), respectively. (29)

c.) HPV DNA Testing:

Similar to Cytology, HPV DNA testing is done on sample cells collected from the cervix and is used to confirm the presence of infection by the HPV Virus (3)(25). This test has shown higher sensitivity and reproducibility of results than Cytology, for detecting high-grade cervical intraepithelial neoplasia (CIN), (although lower specificity) (30)(31). Unfortunately, the high cost of this option has limited its availability in Low and Middle income countries of the world (32). Nurse Intervention in Cervical Screening Programs Essay

Economic Evaluation:

With the costs of healthcare increasing worldwide, there is advancing pressure to ration and efficiently use limited resources. Economic evaluations are utilized to identify, measure, and compare health care intervention costs and benefits, to aid in efficient resource allocation (33).

Economic evaluation, as per the Drummond et. al definition, refers to “the comparative analysis of alternative courses of action in terms of both their costs and consequences” (34). The basic types of economic evaluation include:

1. Cost-benefit analysis (CBA):

CBA measures the benefits and costs of outcomes achieved from an intervention in purely monetary terms. This means that expected years of life gained or expected improvements in health and wellbeing are valued in terms of currency. There is much controversy surrounding CBAs on account of ethical and practical reliability questions on how one may accurately express health outcomes in monetary terms. Nurse Intervention in Cervical Screening Programs Essay

2. Cost-effectiveness analysis (CEA):

To overcome the limitations of CBA, CEA was developed as an alternative, more practical approach to healthcare decision-making. It assesses the net cost of a project or service relative to the outcomes generated. CEA is used where the need for a project has already been established, but uncertainty remains over the best method for achieving it (35). The purpose of cost effectiveness analysis is to identify the best method to spend a set budget to achieve a particular goal (36).

3. Cost-utility analysis (CUA):

CUA is often seen as a special form of CEA that introduces measures of benefits that reflect individuals’ preferences over the health consequences of alternative programs that affect them. CUAs use a global measure of health outcome, such as quality-adjusted life-years (QALYs) by undertaking one program instead of another, and the results are often expressed as a cost per QALY gained. (37) This enables the comparison of different types of programs, which makes CUA more practical for decision-makers. Nurse Intervention in Cervical Screening Programs Essay

4. Cost-Minimization Analysis (CMA):

Sometimes a cost-minimization analysis is performed if the alternatives under evaluation are considered to achieve the identical health outcomes and carried out in terms of net cost comparisons (38). This specificity of outcome measure reduces its application across health fields, thereby limiting its utilization in evaluation studies. Nurse Intervention in Cervical Screening Programs Essay

Source:https://www.ispor.org/PEguidelines/source/Guidelines_Austria.pdf

Economic Modelling:

Full economic analyses of interventions can be carried out by the following approaches:

1. Trial-based studies:

As randomized clinical trials are a necessary condition for the successful licensing of pharmaceuticals, relevant economic data are often obtained alongside the trials for economic evaluations. This method provides internal validity, while the main limitation is that the results may suffer from external generalizability (39).

2. Decision analytic modeling:

This approach brings together a range of evidence sources and allows the expansion of the comparators considered in the analysis and an expansion of the time horizon beyond that of a trial period. Further, decision analytic modeling provides a framework for informing specific decision-making under conditions of uncertainty by allowing more convenient assessment of modeling assumptions, modeling structural uncertainty, and different patient subgroups (heterogeneity) (37). Important model types include: Nurse Intervention in Cervical Screening Programs Essay

i) Decision Trees: This is the simplest form of decision analytical modelling in economic evaluation. The pathways in decision trees follow each intervention or process option in a series of logically ordered alternative events, denoted by branches emanating from chance nodes (circular symbols). The alternatives at each chance node must be mutually exclusive and their probabilities sum exactly to one. The end points of each pathway, denoted by terminal nodes (triangular symbols), are assigned values or pay-offs, such as costs, life years, or quality adjusted life years (QALYs). Once the probabilities and pay-offs have been entered, the decision tree is “averaged out” and “folded back” (or rolled back), allowing the expected values of each option to be calculated. Nurse Intervention in Cervical Screening Programs Essay

ii) Markov Model: An alternate form of modelling is the Markov model. Unlike decision trees, which represent sequences of events as a large number of complex pathways, Markov models involve simpler and more flexible sequencing of outcomes, including recurring outcomes, through time. Patients are assumed to reside in one of a finite number of health states at any point in time and make transitions between those health states over a series of discrete time intervals or cycles. The probability of staying in a state or moving to another one in each cycle is determined by a set of defined transition probabilities. The definition and number of health states and the duration of the cycles will be governed by the decision problem (40). The final stage is to assign values to each health state, typically costs and health utilities (41)(40). Most commonly, such models simulate the transition of a hypothetical cohort of individuals through the Markov model over time, allowing the analyst to estimate expected costs and outcomes. This simply involves, for each cycle, summing costs and outcomes across health states, weighted by the proportion of the cohort expected to be in each state, and then summing across cycles (42). If the time horizon of the model is over one year, discounting (34) is usually applied to generate the present values of expected costs and outcomes. Nurse Intervention in Cervical Screening Programs Essay

iii) Microsimulation models: These models simulate the progression of individuals rather than hypothetical cohorts. They track the progression of potentially heterogeneous individuals with the accumulating history of each individual determining transitions, costs, and health outcome. Unlike Markov models, they can simulate the time to next event rather than requiring equal length cycles and can also simulate multiple events occurring in parallel.

iv) Discrete event simulations: They describe the progress of individuals through healthcare processes or systems, affecting their characteristics and outcomes over unrestricted time periods. These simulations are not restricted to the use of equal time periods or the Markovian assumption and, unlike patient level simulation models, allow individuals to interact with each other.

v) Dynamic models: These models allow internal feedback loops and time delays that affect the behaviour of the entire health system or population being studied. They are particularly valuable in studies of infectious diseases, where analysts may need to account for the evolving effects of factors such as herd immunity on the likelihood of infection over time, and their results can differ substantially from those obtained from static models. Nurse Intervention in Cervical Screening Programs Essay

Economic Evaluation Outcomes and Decision rule:

The results of an economic evaluation of an intervention are typically expressed in terms of an ICER – Incremental Cost Effectiveness Ratio. ICERs (measured most often in cost per QALY gained) reflect the incremental cost required to sustain one unit of benefit gained from a particular intervention compared to another. It applies to a decision rule based on a threshold cost effectiveness ratio. This decision rule states that any intervention with a price per unit effectiveness above a fixed threshold, would not be implemented and any program with an ICER below the threshold would be implemented. The threshold that this decision rule is applied to differs between economic settings. The threshold recommended by WHO involves utilizing a value which is a multiple of the GDP of the country under study (43) for cost effectiveness acceptability. An alternative to this is to cite the cost–effectiveness of an intervention that has previously been implemented in the country under study and to utilize the same as a benchmark for acceptable cost–effectiveness. The latter, however, is an approach used mainly in High income countries(43). Nurse Intervention in Cervical Screening Programs Essay

AIMS:

The aim of this systematic literature review is to present the comprehensive results of all available international evidence on the cost-effectiveness analysis of different cervical screening strategies for HPV vaccinated populations.