Screening Evidence and practice

by Raffle, Angela E; Gray, J. A. Muir

• ISBN13: 9780199214495
• ISBN10: 0199214492
• Edition: 1st
• Format: Paperback
• Copyright: 2007-10-04
• Publisher: Oxford University Press

Summary

Screening is the routine testing of populations to identify individuals who may have a particular medical condition or disease. It is carried out by both government and private organisations with the aims of: better prognosis/outcome for individuals; to protect society from contagious disease; to allow rational allocation of resources; to allow selection of healthy individuals; and for research purposes. About L500 million is spent on screening each year in Britain alone, and it is an issue that has relevance in health systems and for the general public and media. For many years, screening was practised without debate, but in the 1960s serious challenges were raised about standard screening procedures. Benefits of screening must be judged against negative side-effects, and concern was raised about potential and actual harm arising when people without a health problem received dangerous and unnecessary investigations and treatments as a result of 'routine' screening tests. Controversy raged and only now 50 years later, is there widespread recognition that quality assured service delivery and proper consumer information are essential. In addition to debate over health risks, the cost-effectiveness of such results also has to be considered, making this a highly contested issue. This book serves as a non-technical, introductory guide to all aspects of screening. The first section deals with concepts, methodology and evidence, explaining what screening is and how to evaluate it. The second section describes practical management, for example how to make policy and how to deliver it to a high quality. It includes many examples and case histories, a glossary to make medical terms accessible to the non-medic, and each chapter concludes with a summary and self-test questions. Although reference is made to the UK NHS, a world leader in screening, the book remains internationally relevant as the principles, knowledge and skills of screening are applicable in any setting. The controversies, paradoxes, uncertainties and ethical dilemmas of screening are explained in a balanced way. Muir Gray and Angela Raffle have been at the forefront of achieving improvements in screening over recent years, and they bring their wealth of experience to this essential text.

Author Biography

Sir Muir Gray has been the driving force behind the transformation of screening in the UK. In the 1980s he secured L25,000 from the Department of Health to resolve the problematic cervical screening programme; by harnessing the experience and commitment of pathologists, public health physicians, and gynaecologists throughout the service he transformed it into the quality assured public health programme it is today. Muir also masterminded the implementation of a nationwide breast screening programme. He then turned his attention to wider screening, setting up the National Screening Programmes which brought evidence, order and effectiveness to a disparate set of public health risk reduction programmes. Muir has also established the National Library for Health, been instrumental in helping establish the Cochrane Collaboration, and has brought accessible evidence-based information to the fingertips and desktops of all clinicians by publications such as Clinical Evidence. Dr Angela Raffle became involved in screening in 1985 when she took on responsibility for the cervical screening programme in and around Bristol and Bath. Working with Dr Elisabeth Mackenzie, she analysed the screening records for the 250,000 women in the programme. The results were worrying, demonstrating the scale of overdetection and overtreatment inherent in cervical screening. She articulated her findings, not as a polemicist from outside the programme, but as a professional involved in screening, committed to serving the women who participated. Angela became part of the National Coordinating Network, has worked on a wide range of screening policy issues for the National Screening Programmes, and has continued her commitment to teaching nationally and internationally. In Bristol she is responsible for all aspects of cancer services including the cancer screening programmes. She has also been a major player in the Smoke-free Bristol campaign and palliative care services at the end of life.

Table of Contents

Foreword	p. ix
Preface	p. xi
Endorsements	p. xiii
Acknowledgements	p. xv
How screening started	p. 1
The aim of the chapter	p. 1
Pre-modern screening	p. 1
Modern screening	p. 9
Post-modern screening	p. 28
Summary points	p. 29
Test yourself	p. 30
What screening is, and is not	p. 33
The aim of the chapter	p. 33
Definitions and meanings	p. 33
What we mean by screening	p. 34
Formal definitions of screening	p. 35
Where screening fits in the disease pathway	p. 38
Other kinds of testing in people without signs or symptoms	p. 39
Screening is ethically different from clinical practice	p. 41
Principles of screening	p. 42
Genetics and screening	p. 52
Summary points	p. 55
Test yourself	p. 56
What screening does	p. 59
The aim of the chapter	p. 59
Putting people through the screening system	p. 60
The experience for those being screened	p. 70
The system and its outcomes	p. 76
Summary points	p. 81
Test yourself	p. 82
Measuring what screening does	p. 85
The aim of the chapter	p. 85
Three main sources of bias in screening evaluation	p. 86
Three main methods for evaluating screening	p. 97
Two additional sources of information	p. 111
Measures of test performance	p. 113
Summarizing all information on outcomes	p. 116
Summary points	p. 122
Test yourself	p. 124
Implementing screening	p. 127
The aim of the chapter	p. 127
Drivers for unplanned screening	p. 128
Implementing from scratch	p. 129
Creating order out of chaos	p. 149
Summary points	p. 153
Test yourself	p. 154
Quality assuring screening programmes	p. 155
The aim of the chapter	p. 155
Why quality assurance is essential in screening	p. 155
Some history	p. 156
Applying quality assurance to screening	p. 160
Summary points	p. 174
Test yourself	p. 175
Day to day management of screening for public health practitioners and programme managers	p. 179
The aim of the chapter	p. 179
Coping with demand for, or provision of, inappropriate screening	p. 181
Problem solving in existing national programmes	p. 192
Handling concerns about commercial sector screening	p. 196
Screening and the law	p. 198
Handling the media	p. 205
Summary points	p. 211
Test yourself	p. 212
Making screening policy	p. 215
The aim of the chapter	p. 215
Who makes policy decisions about screening?	p. 217
What kind of decisions have to be made?	p. 217
How screening decisions are made	p. 218
Evidence and resources	p. 218
Using evidence for policy making	p. 220
The importance of values	p. 231
The importance of beliefs	p. 235
The importance of commercial interests	p. 240
The ethics of policy making	p. 244
To conclude	p. 256
Summary points	p. 257
Test yourself	p. 259
Answers	p. 263
Glossary	p. 285
References	p. 297
Index	p. 313
Table of Contents provided by Ingram. All Rights Reserved.