1. Background
Each year about 1 million new cases of colorectal cancers are identified and more than half of them lead to patient deaths (1). In Iran the most prevalent type of digestive system cancer is colorectal cancer (2). Various interventions are used for prevention, diagnosis, and treatment of colorectal cancers (CRCs). There is also a wide range of tests that are commonly used for screening of CRC, especially in people with average and high risk of CRC (3, 4). Each screening test has its own advantages and disadvantages (5). It is therefore important to identify and select the best and the most effective screening test for each population group. This will help improve the compliance of people for these tests, which seems to be very low in many countries (6, 7). It is argued that there are a number of reasons for the low participation of individuals in the CRC screening programs including individual opinion that the tests are not useful, and might be lethal (7). In order to screen colon cancer, many countries use various diagnostic tests based on the local guidelines authorized (8). In Iran, no systematic program for delivering the screening services of colon cancer has been implemented so far (9, 10). People preferences are an important factor that influences the compliance of CRC screening tests. The preferences might be influenced by many other factors, including test type, location, accuracy, demographic and socio - economic characteristics of the individuals, and health insurance. It is argued that the type of insurance coverage could affect the preferences of people regarding the various characteristics of the screening tests. Usually, if people are covered by an insurance coverage the screening costs would be decreased and as a result the people selecting the screening tests would pay more attention to other aspects affecting their preferences such as the test accuracy, mortality, and pain (11-13). In Iran, a health sector reform was implemented in 2014. One of the goals defined for the government in this plan was to expand the basic insurance coverage for the population so that those having no insurance coverage would be covered by the free of charge health insurance (14). Basic Iranian health insurance schemes do not cover all CRC screening tests. Moreover, all costs of CRC screening tests are not covered by these schemes for all individuals. Therefore complementary health insurance might play an important role (15-18). The existence of an insurance coverage is one of the main factors affecting the people preferences for choosing the various types of health services, especially the preventive services (11, 12). In the present study, the preferences of population with an average CRC risk were identified and compared for different tests, after the implementation of the health sector reform in population that were covered and not covered by the complementary health insurance.
2. Methods
2.1. Study Design and Sample
This study was a cross-sectional survey that was carried out in Tehran. The study sample was 500 individuals within the ages of 50 to 75 who referred to a large governmental teaching hospital between September 2016 and January 2017.
2.2. Data Collection and Measurement
The participants' preferences about various attributes of the 6 selected CRC screening tests (total colonoscopy (TC), stool DNA test, fecal immunochemical test (FIT), guaiac - based fecal occult blood test (gFOBT), double contrast barium enema (DCBE), and flexible sigmoidoscopy (FS) were determined by discrete choice experiment (DCE) method. First, we reviewed literatures and selected 14 attributes of CRC screening tests. Then, a checklist was developed and based on the importance of these attributes for CRC screening users, a sample of 15 gastroenterologists (GI) specialists rated all these selected attributes on a scale of 1 (the attributes did not have importance for individuals in choosing CRC screening tests) to 5 (the attributes were of high importance for individuals in choosing CRC screening tests). In the next step, average score of attributes were computed and 9 attributes were selected. The optimum levels of each selected attribute were identified (Table 1). The final attributes were the process of the test, pain, place, frequency, preparation, complications risk, reduced mortality rate, sensitivity, and cost. In order to identify scenarios and reduce the number of them, an experimental design (that maximizes D - efficiency criteria) was constructed. Respondents selected from a generic choice set that was binary (Choice1: A vs. B). The optimal design included 36 choice sets. Choice sets of test preferences were divided into 5 blocks (4 blocks with 7 choice sets and 1 block with 8 choice sets). Each block was filled by 100 individuals. The final questionnaire had 2 parts (socio - demographic questions and test preference questions).
2.3. Statistical Analyses
Conditional logit model was applied to explore test attributes (e.g. pain, place) on individual’s utility from the tests for both insured and uninsured groups. The basic theory of experimental designs is the random utility theory. This theory supposes that the utility of every individual (i) is function from the choice of a hypothetical scenario “j”. Modelling individual preferences through this theory provides a well - established conceptual framework. In this framework, the utility of a certain scenario defines based on its attributes:
Uij= Vij + ɛij
The utility of individual (i) from scenario (j) is represented by U. The estimation of coefficients for various levels of every attributes was shown with β. These coefficients indicate the importance that a certain respondent gives to a specific level. The effect of immeasurable variables on a specific scenario (j) for the person (i) was specified by Ɛ, which is the random parameter.
A total of 95% is considered as the significant interval. Analyses were conducted using SAS version 9.4.
The study protocol was approved by Ethics Committee of Tehran University of Medical Sciences.
Table 1.Final Set of Attributes and Associated Levels Used in DCE Survey
| Attribute | Levels |
|---|---|
| Process | 1 stool sample |
| 2 stool samples | |
| 3 stool samples | |
| A flexible tube that has a little camera is inserted into your rectum and through your colon; the test do not has sedation | |
| A flexible tube that has a little camera is inserted into your rectum and through your colon, the test has sedation | |
| Air and a white liquid are injected into your colon through a tube that is inserted into your rectum and through your colon and as the liquid moves through your colon X - rays are taken | |
| Pain | Little pain or discomfort able |
| No pain or discomfort able | |
| Place | Home |
| Hospital | |
| Frequency | Every year |
| Every 5 years | |
| Every 10 years | |
| Preparation | No preparation |
| Avoid certain foods and medications | |
| Laxative | |
| Enema | |
| Mortality Reduction | Mortality risk won’t change |
| 10 out of 100 people can be survived | |
| 40 out of 100 people can be survived | |
| Sensitivity | 3 out of 10 people with cancer |
| 5 out of 10 people with cancer | |
| 7 out of 10 people with cancer | |
| Complication Risk | No one |
| 1 out of 1000 people | |
| 10 out of 1000 people | |
| Cost | 800000 Rials |
| 2000000 Rials | |
| 4000000 Rials |
3. Results
3.1. Socio - Demographic Results
The mean age of insured and uninsured participants was 61.68 and 59.25 years, respectively. A total of 65.2 (163 out of 250) insured respondents were men. Other socioeconomic characteristics of respondents are shown in Table 2.
Table 2.Characteristics of the Surveyed Population (N = 500)
| Characteristics | Number | Mean/Percent | Std. Err. (95% Conf. Interval) | ||
|---|---|---|---|---|---|
| Sex | Insured | Male | 163 | 65.2 | - |
| Female | 87 | 34.8 | - | ||
| Uninsured | Male | 120 | 55.81 | - | |
| Female | 95 | 44.19 | - | ||
| Age | Insured | 250 | 61.68 | 7.30 | |
| Uninsured | 215 | 59.25 | 7.52 | ||
| Marriage | Insured | Married | 209 | 83.6 | - |
| Divorced - widow | 34 | 13.6 | - | ||
| Single | 7 | 2.8 | - | ||
| Uninsured | Married | 183 | 85 | - | |
| Divorced - widow | 25 | 12 | - | ||
| Single | 7 | 3 | - | ||
| Education | Insured | 250 | 8.75 | 5.17 | |
| uninsured | 215 | 5.07 | 4.77 | ||
3.2. Conditional Logit Analysis of Preferred Attributes of Two Insurance Groups
The conditional logit results revealed that insured individuals preferred all modalities of CRC screening over a CRC screening test that required 1 sample of stool. The highest odds ratio was related to Enema test (OR = 1.84, 95% CI: 1.84, 2.30, P =< 0.0001). This means that the odds of taking the enema test was 84% more than 1 sample FOBT. The odds ratio of taking the tube test with a sedative drug was 1.61 (95% CI: 1.30, 2.01, P =< 0.0001) compared to 1 sample FOBT. In the next level insured individuals preferred 2 samples of stool, tube test without sedative drug, and finally 3 samples of stool, respectively. In insured individuals, doing the test at the hospital leaded to decrease odds ratio of test acceptability (OR = 0.78, 95% CI: 0.69, 0.87, P =< 0.0001). For this group, non-modalities of preparation actions had a significant effect on these individuals’ utility. The positive signs of coefficients for reduction of the mortality due to early detection of CRC through screening and sensitivity indicated that participants preferred a test that had a high mortality reduction and had a high accuracy (OR = 1.004, 95% CI: 1.0002, 1.008, P = 0.04 & OR = 1.15, 95% CI: 1.11, 1.20, P =< 0.0001). Further increase of the complication due to doing the test through screening was associated with a significant decrease in the likelihood of acceptance of a test (OR = 0.96, 95% CI: 0.95, 0.97, P =< 0.0001). Individuals were willing to accept a decrease in the likelihood of undergoing a procedure to lower the risk of complication by CRC screening test. Free pain screening test have a statistically significant influence on insured individuals utility compared with a painful one. The frequency and cost attributes did not have a statistically significant impact on the utility of insured individuals from CRC screening test (Table 3).
However, individuals without insurance coverage did not show any difference between various screening modalities except for tube test with sedative drug, which significantly influence preferences of these participants. At the confidence interval of 95%, other significant attributes for this group of respondents were preparation action that involved enema, reduced mortality rate, sensitivity, and price of CRC screening test. However, by increase of confidence interval to 90%, frequency of testing and process of testing that involved tube test without sedative drug had a significant effect on selection of a CRC screening test (Table 4).
Table 3.Insured Individuals’ Preferences for CRC Screening Test Using Conditional Logit Model
| Attributes | Β Coefficient | SE | P Value | Odds Ratio | 95% Confidence Limit |
|---|---|---|---|---|---|
| Process | |||||
| Enema test | 0.61 | 0.11 | < 0.0001 | 1.84a | 1.48 – 2.30 |
| Tube test with sedative drug | 0. 48 | 0.11 | < 0.0001 | 1.61a | 1.30 – 2.01 |
| Tube test without sedative drug | 0.32 | 0. 12 | 0.009 | 1.38a | 1.08 – 1.75 |
| Three sample | 0.30 | 0.11 | 0.005 | 0.35 | 1.09 - 1.67 |
| Two sample | 0.43 | 0.11 | < 0.0001 | 1.54a | 1.23 - 1.92 |
| One sample | 0 | - | - | - | - |
| Place | |||||
| Hospital | -0.25 | 0.06 | < 0.0001 | 0.78a | 0.69 - 0.87 |
| Home | 0 | - | - | - | - |
| Preparation | |||||
| Diet | 0.08 | 0.09 | 0.37 | 1.09 | 0.91 - 1.30 |
| Enema | - 0.11 | 0.09 | 0.22 | 0.90 | 0.76 - 1.07 |
| Laxative | 0.12 | 0.09 | 0.22 | 1.12 | 0.93 - 1.35 |
| Nothing | 0 | - | - | - | - |
| Frequency | - 0.004 | 0.009 | 0.63 | 0.99 | 0.98 - 1.01 |
| Mortality reduction | 0.004 | 0.002 | 0.04 | 1.004a | 1.0002 - 1.008 |
| Sensitivity | 0.14 | 0.02 | < 0.0001 | 1.15a | 1.11 - 1.20 |
| Complication | -0.04 | 0.007 | < 0.0001 | 0.96a | 0.95 - 0.97 |
| Cost | -0.001 | 0.001 | 0.3 | 0.99a | 0.99 - 1.00 |
| Pain | |||||
| Yes | -0.14 | 0.07 | 0.04 | 0.87 | 0.76 - 0.99 |
| No | 0 | - | - | - | - |
| Model statistics | |||||
| Number of responses | 3668 | ||||
| Number of respondents | 250 | ||||
| Log likelihood | -1500.10 | ||||
aP ≤ 0.05
Table 4.Uninsured Individuals’ Preferences for CRC Screening Test Using Conditional Logit Model
| Attributes | Β Coefficient | SE | P Value | Odds Ratio | 95% Confidence Limit |
|---|---|---|---|---|---|
| Process | |||||
| Enema test | 0.02 | 0.14 | 0.9 | 1.02 | 0.78 - 1.33 |
| Tube test with sedative drug | 0. 34 | 0.13 | 0.01a | 1.41 | 1.09 - 1.81 |
| Tube test without sedative drug | 0.23 | 0. 14 | 0.09b | 1.26 | 0.97 - 1.65 |
| Three sample | 0.17 | 0.12 | 0.16 | 1.19 | 0.93 - 1.52 |
| Two sample | 0.18 | 0.14 | 0.19 | 1.20 | 0.91 - 1.58 |
| One sample | 0 | - | - | - | - |
| Place | |||||
| Hospital | -0.23 | 0.06 | < 0.0001 | 0.79a | 0.7 - 0.90 |
| Home | 0 | - | - | - | - |
| Preparation | |||||
| Diet | - 0.002 | 0.10 | 0.98 | 0.99 | 0.81 - 1.22 |
| Enema | - 0.23 | 0.10 | 0.02 | 0.8a | 0.62 - 0.97 |
| laxative | 0.02 | 0.11 | 0.83 | 1.02 | 0.83 - 1.26 |
| Nothing | 0 | - | - | - | - |
| Frequency | 0.02 | 0.01 | 0.06 | 1.02b | 0.99 - 1.04 |
| Mortality reduction | 0.007 | 0.002 | 0.001 | 1.007a | 1.003 - 1.01 |
| Sensitivity | 0.11 | 0.02 | < 0.0001 | 1.12a | 1.07 - 1.18 |
| Complication | - 0.06 | 0.008 | < 0.0001 | 0.99a | 0.93 - 0.95 |
| Cost | - 0.006 | 0.001 | < 0.0001 | 0.99a | 0.992 - 0.996 |
| Pain | |||||
| Yes | - 0.06 | 0.07 | 0.38 | 0.94 | 0.81 - 1.08 |
| No | 0 | - | - | - | - |
| Model statistics | |||||
| Number of responses | 3034 | ||||
| Number of respondents | 215 | ||||
| Log likelihood | - 1126.80 |
aP ≤ 0.05
bP ≤ 0.1
4. Discussion
To our knowledge, in this study, we provide the first DCE assessment of the Iranian population preferences for CRC screening tests between different insurance groups. Our study demonstrated that the test characteristics that significantly influenced individual preferences were different between insured and uninsured groups.
The results of our study showed that respondents with complementary insurance coverage had utility from all CRC screening modalities over a test that involved 1 sample of fecal; however, those without a complementary insurance coverage only desired the procedure that involved tube test with sedative drug over 1 sample stool. The importance attached to enema test by Insured respondents was the most significant. In the next level they preferred the tube test with the sedative drug, 2 samples of stool, tube test without sedative drug, and finally 3 samples of stool, respectively. Another study reported similar results to our findings. In their study, the state policy of mandates CRC screening coverage with health insurance was associated with probability of endoscopy (colonoscopy and sigmoidiscopy) utilizations among US adults aged 50 to 64 (11). In another study, insurance coverage caused a gap in CRC screening among different Medicare beneficiaries. Their results revealed those individuals without a usual source of care had a lower CRC screening rate compared with other groups. Their findings suggested that expansion of access to CRC screening tests through insurance program could increase tests utilization (12). Wolf et al., (2006) revealed different results. In their study insurance fully covered all tests. Their result showed an overwhelming preference for FOBT (19).
At confidence interval 90%, both groups showed a significant disutility regarding the place of taking a certain CRC screening test at the hospital. Testing at the hospital had a negative influence on the likelihood of test selection by these groups.
In our study, uninsured participants did not prefer a test that needed preparation action like enema. In contrast to uninsured individuals, the insured ones did not show any significant difference toward various preparation modalities (CI = 95%). Inconsistent with a previous study regarding CRC screening preferences, our uninsured respondents were not interested in bowel preparation (20, 21).
One of the key drivers of individuals’ preferences for CRC screening tests of both groups was reduction of CRC mortality. Further risk reduction of CRC mortality leaded more utility. Our result revealed that insured and uninsured participants considered the scientific information about different CRC screening tests. Presenting information like this may increase CRC screening uptake based on our finding. The results of the other study proved our findings (22).
Our study demonstrated that the likelihood of selecting a CRC screening test that could correctly detect more individuals with CRC, was more in both groups.
Unlike individuals with insurance coverage, free pain screening test did not have a different influence on uninsured individuals compared with painful one.
At P - value of 0.05, the frequency attribute did not significantly have an impact on the individuals’ preferences. However, at confidence interval 90%, uninsured participants preferred a certain test that had a longer interval. In other words, uninsured individuals took into account the time interval of testing. It is consistent with the previous research. Insured individuals compared to uninsured respondents were significantly more likely to have undertaken screening within the recommended time of intervals (23). There could be some explanation for our finding. Barriers related to availability of CRC screening tests may be a reason. Another reason may be the cost nature (time and money consuming) associated with insurance coverage of this group.
Complications of CRC screening test had a statistically significant influence on participants with insurance coverage and without insurance coverage. Further increase of individuals who had complication due to taking a test was associated with a statistically significant decrease in the likelihood of acceptance of a test.
Cost of CRC screening modalities had a statistically significant effect on uninsured individuals. However, this effect for this group was low. Our results are in contrast with other studies findings (24, 25). Pignone et al., (2014) found that cost of CRC screening test was considered a very important attribute (24).
Our study revealed that CRC screening preferences varied significantly with the complementary insurance status of respondents. The comparison of insured participations’ and uninsured participations’ preferences for CRC screening tests indicated that they had a high degree of disagreement.
Interestingly, respondents with complementary insurance coverage were more likely to have all CRC screening modalities over 1 sample. The uninsured people tend to use cheaper screening CRC tests, therefore, costs should be considered in designing insurance coverage for covering CRC screening test in order to reach optimal uptake of CRC screening program. Furthermore, expansion of insurance coverage for a CRC screening program will be optimal if effectiveness (reduction of mortality by early detection of CRC) and sensitivity (the power of test in cancer detection) of the test is high. Insurance coverage of CRC screening modality, which is taking place at home, and tests without preparation action like laxative may improve acceptability of tests.
Taken together, our results suggest that a critical factor for improving screening rates among average - risk individuals is health insurance coverage. It should be acknowledged that different insurance coverage may lead to heterogeneity of preferences for CRC screening tests. Therefore, In this case, the preferences of health insurance beneficiaries should be used as the main argument to encourage CRC screening. As noted, one of the most crucial considerations in how to design and develop a program effectively is incorporating how individuals value different healthcare interventions. Therefore, CRC screening tests that are included in a certain insurance scheme should be designed based on the individuals’ preferences. Lack of awareness regarding the preferences of health insurance beneficiaries may influence effectiveness and acceptance of covered CRC screening tests. Considering preferences of target individuals will likely increase the uptake of CRC screening program in the years to come.
4.1. Study Limitations
Our study had some limitations. Firstly, it was carried out in the city of Tehran and preferences of other cities were not examined, therefore, the study results must be interpreted with caution. Second, the limitation of our study was that we did not determine preferences of CRC screening tests provider. Several factors may be a potential barrier in CRC screening. As another study carried out in Iran showed, providers’ recommendation was one of them (9). This means that eliciting preferences of this group is necessary.
