Purpose: Follow-up among women who have had an abnormal Papanicolaou (Pap) smear is often poor in public hospitals that serve women at increased risk for cervical cancer. In this study, we evaluated the cost-effectiveness of a tailored outreach intervention.

Methods: In a randomized controlled trial, 348 women with abnormal Pap smear results were assigned to intervention or usual care. In the intervention, outreach workers provided culturally tailored information and helped patients navigate the system as a supplement to the clinic's usual care. The comparison group was usual care alone (typically a letter mailed to the woman's home). All women were seen at a Highland Hospital, a county hospital in Oakland, CA serving a disproportionate number of low income and multi-ethnic women. We calculated the incremental cost per follow-up within six months of the abnormal test result. Bootstrapping was done to create confidence regions. Sensitivity analyses were done to test the robustness of the results. Long-term follow-up was not feasible because women in the control arm were assigned to the intervention group (i.e., rescued) after six months.

Results: The intervention cost a total of $34,507 for 178 women served. The intervention was associated with a 28% increase in the rate of 6-month follow-up. The incremental cost per follow-up was $685 (95% CI $410-$959). The intervention dramatically improved follow-up for women with a high-grade squamous intraepithelial lesion. These women have precancerous cells and face an increased risk that the abnormality will progress to invasive cancer. There were 15 such women in the intervention group and 14 in the control group. After the intervention, 14 (93%) and 6 (43%) in the intervention group and control group, respectively, had documented follow-up at six months.

Conclusions: A tailored counseling intervention is effective at increasing abnormal Pap smear follow-up. Programs that serve higher risk populations would find this to be more cost effective than usual care (at a ratio of $50,000 per QALY) if the program yields between 0.35-0.69 quality adjusted life years (QALY), on average. Because of the intervention's effect on women with high-grade squamous intraepithelial lesion, achieving these benefits seems possible.