Decision Model and Cost-Effectiveness Analysis of Colorectal Cancer Screening and Sureillance Guidelines for Average-Risk Adults

Center for Outcomes and Effectiveness Research, Agency for Healthcare Research and Quality, Rockville, MD 20852-3813, USA.
International Journal of Technology Assessment in Health Care (Impact Factor: 1.31). 02/2001; 16(03). DOI: 10.1017/S0266462300102077
Source: CiteSeer


Objectives: Guidelines on colorectal cancer screening and surveillance in people at average risk and at increased risk have recently been published by the American Gastroenterological Association. The guidelines for the population at average risk were evaluated using cost-effectiveness analyses. Methods: Since colorectal cancers primarily arise from precancerous adenomas, a state transition model of disease progression from adenomatous polyps was developed. Rather than assuming that polyps turn to cancer after a fixed interval (dwell time), such transitions were modeled to occur as an exponential function of the age of the polyps. Screening strategies included periodic fecal occult blood test, flexible sigmoidoscopy, double-contrast barium enema, and colonoscopy. Screening costs were estimated using Medicare and private claims data, and clinical parameters were based on published studies. Results: Cost per life-year saved was $12,636 for flexible sigmoidoscopy every five years and $14,394 for annual fecal occult blood testing. The assumption made for polyp dwell time critically affected the attractiveness of alternative screening strategies. Conclusions: Sigmoidoscopy every five years and annual fecal blood testing were the two most cost-effective strategies, but with low compliance, occult blood testing was less costeffective. Lowering colonoscopy costs greatly improved the cost-effectiveness of colonoscopy every ten years.

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    • "CTC was often compared with existing technologies that have emerged in the recent years. Evidence and recommendations on the use of BE remain inconsistent thus BE was considered as one of the current modalities in some studies [20,27,51,56] but excluded in others [47,52]. "
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    ABSTRACT: This paper aims to systematically review the cost-effectiveness evidence, and to provide a critical appraisal of the methods used in the model-based economic evaluation of CRC screening and subsequent surveillance. A search strategy was developed to capture relevant evidence published 1999-November 2012. Databases searched were MEDLINE, EMBASE, National Health Service Economic Evaluation (NHS EED), EconLit, and HTA. Full economic evaluations that considered costs and health outcomes of relevant intervention were included. Sixty-eight studies which used either cohort simulation or individual-level simulation were included. Follow-up strategies were mostly embedded in the screening model. Approximately 195 comparisons were made across different modalities; however, strategies modelled were often simplified due to insufficient evidence and comparators chosen insufficiently reflected current practice/recommendations. Studies used up-to-date evidence on the diagnostic test performance combined with outdated information on CRC treatments. Quality of life relating to follow-up surveillance is rare. Quality of life relating to CRC disease states was largely taken from a single study. Some studies omitted to say how identified adenomas or CRC were managed. Besides deterministic sensitivity analysis, probabilistic sensitivity analysis (PSA) was undertaken in some studies, but the distributions used for PSA were rarely reported or justified. The cost-effectiveness of follow-up strategies among people with confirmed adenomas are warranted in aiding evidence-informed decision making in response to the rapidly evolving technologies and rising expectations.
    Preview · Article · Sep 2013
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    • "High rates of participation has been consistently associated with screening efficacy in terms of mortality reduction as well as costeffectiveness [10]. This assumption is particularly certain in the case of FOBT-based screening in which recommended intervals are shorter than for other screening strategies (every 1 or 2 years) [11] [12]. "
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    ABSTRACT: Colorectal cancer (CRC) is a major health problem worldwide. Although population-based CRC screening is strongly recommended in average-risk population, compliance rates are still far from the desirable rates. High levels of screening uptake are necessary for the success of any screening program. Therefore, the investigation of factors influencing participation is crucial prior to design and launches a population-based organized screening campaign. Several studies have identified screening behaviour factors related to potential participants, providers, or health care system. These influencing factors can also be classified in non-modifiable (i.e., demographic factors, education, health insurance, or income) and modifiable factors (i.e., knowledge about CRC and screening, patient and provider attitudes or structural barriers for screening). Modifiable determinants are of great interest as they are plausible targets for interventions. Interventions at different levels (patient, providers or health care system) have been tested across the studies with different results. This paper analyzes factors related to CRC screening behaviour and potential interventions designed to improve screening uptake.
    Full-text · Article · Jan 2012 · Gastroenterology Research and Practice
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    • "Baseline costs per life year (in USD at 2000 price levels) relative to a no screening strategy for both the one-off and repetitive screening vary considerably. Seven studies reported costs per life year of $20,000 or more [49,58-60,69-71], eight reported in the range $10,000 - $19,999 [47,48,56-59,62,70], three between $5,000 - $9,999 [55,57,58] and three between $0-$4999 [56,64,88]. Some models even indicated incremental cost-savings (alongside effectiveness gains), both for one-off [72] and repeated screening interventions [56,72]. "
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    ABSTRACT: Regional generalized cost-effectiveness estimates of prevention, screening and treatment interventions for colorectal cancer are presented. Standardised WHO-CHOICE methodology was used. A colorectal cancer model was employed to provide estimates of screening and treatment effectiveness. Intervention effectiveness was determined via a population state-transition model (PopMod) that simulates the evolution of a sub-regional population accounting for births, deaths and disease epidemiology. Economic costs of procedures and treatment were estimated, including programme overhead and training costs. In regions characterised by high income, low mortality and high existing treatment coverage, the addition of screening to the current high treatment levels is very cost-effective, although no particular intervention stands out in cost-effectiveness terms relative to the others.In regions characterised by low income, low mortality with existing treatment coverage around 50%, expanding treatment with or without screening is cost-effective or very cost-effective. Abandoning treatment in favour of screening (no treatment scenario) would not be cost effective.In regions characterised by low income, high mortality and low treatment levels, the most cost-effective intervention is expanding treatment. From a cost-effectiveness standpoint, screening programmes should be expanded in developed regions and treatment programmes should be established for colorectal cancer in regions with low treatment coverage.
    Full-text · Article · Mar 2010 · Cost Effectiveness and Resource Allocation
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