OBJECTIVES:

A distributional cost-effectiveness analysis (DCEA) of cervical cancer screening strategies in England was developed to: 1) evaluate distributional impacts of different strategies on health differences by socioeconomic status and sex; 2) provide an informative case study for implementation of the DCEA method in this indication.

METHODS:

A cost-effectiveness analysis was developed to estimate incremental costs and health benefits (quality-adjusted life years [QALYs]) by 10 subgroups based on the Index of Multiple Deprivation (IMD) and sex for three actual and hypothetical cervical cancer screening strategies, compared to a baseline of no screening: 1) standard primary human papillomavirus (HPV) screening; 2) addition of a self-sampling HPV kit; 3) a targeted reminder for the two most deprived subgroups. Results were combined with estimates of baseline distribution of health and distribution of opportunity costs. The level-dependent Atkinson social welfare function was used for equity weighting. Sensitivity analysis explored the impact of differing levels of inequality aversion and scenario analysis explored input uncertainty.

RESULTS:

Compared to no screening, all three strategies had a positive health impact but increased inequality. Self-sampling provided the largest population health gains (24,800 QALYs more than the next best [targeted reminder]) but was associated with the greatest negative impact on equity as assessed by Atkinson index of inequality (A(ɛ)). Targeted reminder had the smallest negative equity impact. The greatest equity-weighted health benefit was provided by self-sampling and targeted reminder at an Atkinson inequality aversion parameter <6 and ≥6, respectively. Results were similar when assuming equally distributed opportunity costs. Main data challenges related to IMD-specific screening compliance, requiring derivation from local authority.

CONCLUSIONS:

In this analysis, cervical cancer screening strategies were found to be associated with a trade-off between health benefits and increased inequality; a targeted reminder strategy has potential to mitigate equity impacts. DCEA provides an important tool to identify and evaluate this trade-off.