Abdominal aortic aneurysm screening attendance: Effect of removing the examination fee

Abstract

Objectives

The organized population-based screening programme for abdominal aortic aneurysm in Stockholm, Sweden, started in 2010. An examination fee was initially charged, but later removed because of a policy change. We examined the effect on screening attendance of removing the fee.

Methods

The periods before and after removing the examination fee were compared with regard to screening attendance, overall, by municipality and by district.

Results

Screening attendance was 79.2% in the period with an examination fee and 79.9% in the period without an examination fee (p = 0.1787), with no significant change in screening attendance between the periods.

Conclusions

Although removing examination fees has been shown to have a positive impact on attendance in other screening programmes, we did not find this association in our study.

Introduction

Population-based national screening programmes for abdominal aortic aneurysm (AAA) have been implemented in England and Sweden. In the United States, screening is recommended by Medicare to selected risk groups (those aged 65–75 with a history of smoking or a family history of AAA), but coverage is unknown.^1,2 Regional screening programmes and screening within the context of randomized trials exist in several countries.

Screening for AAA has gradually been implemented in Sweden’s 21 counties since 2006, reaching full national coverage in 2016. ³ In August 2010, AAA screening of mean aged 65 commenced in Stockholm. More than 81,000 men have since been invited to a one-time ultrasound examination of their aorta in this programme. The Stockholm region has a population of almost 2.1 million and includes both densely populated and more rural counties. Approximately 12,000 men turn 65 each year. The Swedsh population register, updated daily, is used to identify all men at age 65 and extract their addresses for individual invitations.

During the first 18 months of the Stockholm screening programme, the region charged an examination fee of 140 SEK (14€). The fee was removed in January 2012 in accordance with policy changes in the breast cancer screening programme. In screening programmes with multiple screening rounds, such as cervical cancer and breast cancer screening, the removal of the fee was associated with an increased attendance in the breast cancer screening programme, especially in hard to reach areas, but a study on cervical screening in a hard to reach area did not demonstrate any effect on the attendance rate.^4,5 In a large meta-analysis from 2002, removing or reducing fees was found to be the second most effective intervention to improve overall screening attendance. ⁶ We here present the effect of removing the examination fee on the attendance rate in AAA screening in the Stockholm programme.

Methods

For this analysis, screening attendance in the 18-month period before (30 June 2010–31 December 2011) and after (1 January 2012–30 June 2013) removing the examination fee was compared. Screening attendance was measured as the proportion of men who attended screening following invitation among all men invited in the period. The Stockholm region includes 26 municipalities, and within the metropolitan municipality of Stockholm, there are 28 districts. Screening attendance was reported and compared by 18-month period and reported separately for the 10 municipalities and districts with the highest and lowest attendance rates before the examination fee was removed. A Chi-square test of proportions was used to compare the attendance between periods.

Results

In the first period, 23,958 men were invited to screening and 18,980 (79.2%) attended, and in the second period, 23,294 men were invited and 18,560 (79.7%) attended (no significant change, p = 0.1787). The attendance did not change significantly between periods among the 10 municipalities and districts that had the lowest attendance in the first period (74.1% in the first period and 75.2% in the second, p = 0.2548). Among the 10 municipalities and districts with the highest attendance in the first period, a significant decrease in screening attendance was observed following the removal of the examination fee (−2.1%, p = 0.0223).

Discussion

The screening attendance rate remained unchanged after the removal of examination fee in the AAA screening programme. The 10 municipalities and districts with the lowest attendance in the first period represent areas of lower socio-economic status, whereas the 10 municipalities and districts with the highest attendance are areas with higher socio-economic status. Even when examining these areas separately, no meaningful differences in screening attendance were observed. Unlike most other adult screening programmes, AAA screening is conducted as a one-time examination. Men receive a personal invitation with a prescheduled time and place for the examination. Information regarding the examination fee was provided in the invitation letter. This information was replaced with a notice that the examination was free of charge after the policy change. As individuals are only invited once, awareness of the change in examination fee would be low.

Previous evidence suggests that removing the fee for screening can have a positive effect on attendance, as has been observed in breast cancer screening. ⁵ However, women are invited to breast cancer screening every two years for several decades, which would make a change in fees noticeable from one round to the next. There is regional variation with regard to the examination fee in Sweden. In England, where the average AAA screening attendance rate is 78.1%, AAA screening is free of charge. ¹

European guidelines for colorectal cancer screening recommend that screening should be free of charge to the individual. ⁷ Similarly, guidelines for cervical cancer screening highlight the need to remove any financial barriers to screening to increase attendance, ⁸ and surveys have shown that the majority of countries do not charge a fee for cervical screening.^9,10

Although removing examination fees has been shown to have a positive impact on attendance in other screening programmes, we did not find this association in our study.