title: An Out-of-Pocket Cost Removal Intervention on Fecal Occult Blood Test Attendance.
abstract: BACKGROUND
  To date, no comparative study has assessed the impact of a cost-removal intervention on fecal occult blood testing (FOBT). In 2012, the Japanese government introduced a nationwide project to remove out-of-pocket costs for FOBT. The study objective was to evaluate the differential impact of the intervention on FOBT attendance in the total population and various subgroups.
  
  
  METHODS
  This study analyzed 309,103 people in national, repeated cross-sectional studies, observed pre- and post-intervention (2010 and 2013), using covariate-adjusted difference-in-differences estimates to compare intervention and no-intervention groups. The outcome measure was uptake of FOBT attendance resulting from the intervention. Stratified analyses were conducted according to sociodemographic and health-related characteristics.
  
  
  RESULTS
  The intervention was associated with significantly positive uptake of FOBT in both genders, but the impact was greater in women than men: 6.7% (95% CI=5.2, 8.1) for women and 2.7% (95% CI=1.1, 4.3) for men in the covariate-adjusted models. Post-intervention, attendance increased in almost all subgroups in women. However, among men, some socially advantaged subgroups, such as high expenditure, high education, and public officers, showed no effect. Some subgroups such as current smokers and less than high school education were identified as hard-to-reach populations that may be less sensitive to the intervention, irrespective of gender.
  
  
  CONCLUSIONS
  This is the first comparative study of cost-removal intervention for uptake of FOBT. The intervention may increase FOBT attendance. However, the size of the effect is not great, especially in men, and differential effects occurred across subgroups including gender and socioeconomic differences.
authors.affiliation: Center for Cancer Control and Statistics, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan. Electronic address: tabuti-ta@mc.pref.osaka.jp.
authors.forename: Takahiro
authors.initials: T
authors.lastname: Tabuchi
authors.affiliation: Institute of Gerontology, The University of Tokyo, Tokyo, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Murayama
authors.affiliation: Department of Economics, Keio University, Tokyo, Japan.
authors.forename: Takahiro
authors.initials: T
authors.lastname: Hoshino
authors.affiliation: Center for Cancer Control and Statistics, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.
authors.forename: Tomio
authors.initials: T
authors.lastname: Nakayama
mesh_terms: D000328:Adult; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000517:prevention & control; D003430:Cross-Sectional Studies; D055088:Early Detection of Cancer / Q000191:economics* / Q000379:methods / Q000706:statistics & numerical data; D004522:Educational Status; D005260:Female; D005102:Health Expenditures / Q000331:legislation & jurisprudence*; D006291:Health Policy / Q000191:economics; D006801:Humans; D007564:Japan; D008297:Male; D008403:Mass Screening / Q000191:economics* / Q000379:methods / Q000706:statistics & numerical data; D008875:Middle Aged; D009780:Occult Blood; D010043:Outcome and Process Assessment, Health Care / Q000191:economics / Q000706:statistics & numerical data; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D012737:Sex Factors