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The Italian experience of monitoring the impact of
socioeconomic inequalities and of barriers related to ethnicity on
access to CRC screening
Carlo SENORE
MINISTRY OF
HEALTH
ANNUAL SURVEY OF SCREENING ACTIVITY
- FIRST PART : INVITATION AND EXAMINATION
COVERAGE
- SECOND PART: SCREENING PERFORMANCE
INDICATORS
- in collaboration with GISCoR
NATIONAL MONITORING PROCESS
Ministero della Salute
Centro Nazionale per la Prevenzione
e il Controllo delle Malattie
Carlo Senore
National survey based on phone interviews Performed every year since 2007 • Coverage: all Regions
• Standardized questionnaire administered to a random
sample (stratified by age) of subjects aged 18 to 69
• Response rate > 85%
PASSI survey
PASSI 2010-13
Proportion of 50-69 year-old people who had a
faecal occult blood test in the two years before
the interview or colonoscopy/ sigmoidoscopy in
the five years before the interview, within
screening programmes or spontaneously, by
region.
PASSI 2010-13
Screening coverage by educational level – subjects aged 50 to 69
2010
High education
Low education
PASSI 2010-13
2010
Screening coverage by self-reported economic difficulties Subjects aged 50 to 69
None
Major
Minor
Education and individuals preferences
Better educated subjects were more likely to accept sigmoidoscopy instead of TC colonography screening
Senore et al. submitted
People who accepted the invitation to choose between FS and FIT in the SCORE2 trial were better educated
(high school / university degree versus primary/intermediate degree OR: 3.86; 95% CI: 1.28– 11.65)
Senore et al. AJG 2009
Screening uptake by education and test
0,0%2,5%
5,0%7,5%
10,0%12,5%
15,0%17,5%
20,0%22,5%
25,0%27,5%
30,0%32,5%
35,0%
Low Intermediate High
FS FIT
Adesione corretta per Regione
96
11
2629 29
3639
30
34
42
51
35
10
2022
38
4347
4952
54 54
58
67
52
0
10
20
30
40
50
60
70
Sicilia
Abru
zzo
Laz
io
Sar
deg
na
Liguria
Umbria
Piemonte
Tosc
ana
Lombar
dia
Emilia Romag
na
Friuli V.G
iulia
Ven
eto
2013
x 1
00 invitati
Migranti
Italiani
PARTICIPATION RATE By region IMMIGRANTS
ITALIANS
Positività ai primi esami
per sesso e cittadinanza
6,0
4,9
6,2
4,2
0
1
2
3
4
5
6
7
Maschi Femmine
sesso
x 1
00
es
am
ina
ti
migranti
italiani
POSITIVITY RATE
INITIAL SCREENING
MEN
WOMEN
ITALIANS
IMMIGRANTS
Positività agli esami successivi per sesso e
cittadinanza
5,3
4,3
5,1
3,8
0
1
2
3
4
5
6
Maschi Femmine
sesso
x 1
00
es
am
ina
ti
migranti
italiani
POSITIVITY RATE
SUBSEQUENT SCREENING
IMMIGRANTS
ITALIANS
MEN
WOMEN
MEN
WOMEN
IMMIGRANTS
ITALIANS
IMMIGRANTS
Tasso di adesione corretta alla
colonscopia
81,880,5
0
10
20
30
40
50
60
70
80
90
stranieri italiani
x 1
00 p
osit
ivi
COMPLIANCE WITH COLONOSCOPY REFERRAL
ITALIANS IMMIGRANTS
Tassi di identificazione KA: primi esami
vs esami successivi
1,34
1,06
1,62
0,98
0,0
0,5
1,0
1,5
2,0
primi esami esami successivi
x 1
000 e
sam
inati
migranti
italiani
DETECTION RATE – CRC
BY SCREENING HISTORY
SUBSEQUENT SCREENING
INITIAL SCREENING
IMMIGRANTS
ITALIANS
IMMIGRANTS
ITALIANS
IMMIGRANTS
ITALIANS
Tassi di identificazione Ad.Av: primi
esami vs esami successivi
8,41
6,90
9,25
6,79
0
2
4
6
8
10
12
primi esami esami successivi
x 1
000 e
sam
inati
migranti
italiani
DETECTION RATE – ADVANCED ADENOMAS
BY SCREENING HISTORY
IMMIGRANTS
ITALIANS
SUBSEQUENT SCREENING
INITIAL SCREENING
SUBSEQUENT SCREENING
INITIAL SCREENING
IMMIGRANTS
ITALIANS
Exposure to interventions promoting screening participation by duration of stay in Italy
40
28
4126
17 18
35
1923
42
20
32
0
20
40
60
80
100
Lettera
dell'Asl
Consiglio
medico
Campagna
informativa
%
0-4 anni 5-9 anni 10+ anni Italiane
People aged 50-69
Invitation
letter
GP’s
counselling
Invitation
letter
Media
campaign
years Italians years years
PASSI 2010-13
Monitoring impact of inequalities on screening effectiveness
Metrics:
Individual level
Aggregated level
Education
Advantages:
stable over time;
often associated with income/ SES / social resources
Limitations: country specific;
association with income/status should be verified/validated,
Income
Limitations:
Rarely available; often inaccurate
Ethnicity
A combination of culture, education, income and accessibility to services (i.e. citizenship rules).
In the US, after adjusting for SES, ethnicity is no longer associated with screening coverage
Aggregated level
Census area
Post-code
Limitations:
ecological association
Advantages:
feasibility; standardization;
updated based on census and population surveys results
Outcomes
Usually: participation (i.e. access to screening)
But
Screening effectiveness depends also on access to high quality assessment and treatment
Compliance with referral for assessment
Quality of treatment received
Survival