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Ishibashi F, Suzuki S, Kobayashi K, Tanaka R, Kawakami T, Mochida K, Nagai M, Ishibashi Y, Morishita T. Cost-effectiveness analysis of single colonoscopy versus single fecal test for colorectal cancer diagnosis and treatment. J Gastroenterol Hepatol 2024; 39:1328-1335. [PMID: 38348570 DOI: 10.1111/jgh.16509] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/11/2024] [Accepted: 01/25/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND AND AIM Regular endoscopy or fecal immunochemical test (FIT) is ideal for screening colorectal cancer. However, only a limited number of individuals undergo regular screening. This study aimed to compare the cost-effectiveness of a single colonoscopy with a single FIT performed for colorectal cancer screening. METHODS A microsimulation model was constructed based on real-world observational data collected from three institutions between 2019 and 2022 that compared colonoscopy-based screening with FIT-based screening. The total costs of diagnosis and treatment of the detected lesions using the two strategies were calculated. The incremental cost-effectiveness ratio (ICER) per life year gained (LYG) of the colonoscopy-based strategy was calculated. RESULTS Data from 11 407 patients undergoing colonoscopies and 59 176 patients undergoing FITs were used to establish a model. In the base case analysis of screening strategies, colonoscopy was more cost-effective than FIT (ICER 415 193 yen/LYG). The ICER of the colonoscopy-based strategy among 60- to 69-year-old patients was lowest at 394 200 yen/LYG, whereas that in 20- to 29-year-old patients was highest. Monte Carlo simulations showed that the colonoscopy-based strategy was more cost-effective than the FIT-based strategy (net monetary benefit [NMB]: 5 695 957 yen vs 5 348 253 yen). When the adenoma detection rate in the colonoscopy was over 30% or the positive FIT rate was lower than 8.6% in the FIT-based strategy, the NMB of the colonoscopy-based strategy exceeded that of the FIT-based strategy. CONCLUSION In the microsimulation model, colonoscopy is recommended as a one-time screening procedure in patients aged >60 years with >30% ADR or <8.6% positive FIT rate.
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Affiliation(s)
- Fumiaki Ishibashi
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
- Endoscopy Center, Koganei Tsurukame Clinic, Tokyo, Japan
| | - Sho Suzuki
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
| | | | - Ryu Tanaka
- Digestive Disease Center, Shinjuku Tsurukame Clinic, Tokyo, Japan
| | | | - Kentaro Mochida
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
- Endoscopy Center, Koganei Tsurukame Clinic, Tokyo, Japan
| | - Mizuki Nagai
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
| | - Yuichi Ishibashi
- Research and Development Initiative, Chuo University, Tokyo, Japan
| | - Tetsuo Morishita
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
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Ladabaum U, Mannalithara A, Weng Y, Schoen RE, Dominitz JA, Desai M, Lieberman D. Comparative Effectiveness and Cost-Effectiveness of Colorectal Cancer Screening With Blood-Based Biomarkers (Liquid Biopsy) vs Fecal Tests or Colonoscopy. Gastroenterology 2024; 167:378-391. [PMID: 38552670 DOI: 10.1053/j.gastro.2024.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/13/2024] [Accepted: 03/10/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) screening is highly effective but underused. Blood-based biomarkers (liquid biopsy) could improve screening participation. METHODS Using our established Markov model, screening every 3 years with a blood-based test that meets minimum Centers for Medicare & Medicaid Services' thresholds (CMSmin) (CRC sensitivity 74%, specificity 90%) was compared with established alternatives. Test attributes were varied in sensitivity analyses. RESULTS CMSmin reduced CRC incidence by 40% and CRC mortality by 52% vs no screening. These reductions were less profound than the 68%-79% and 73%-81%, respectively, achieved with multi-target stool DNA (Cologuard; Exact Sciences) every 3 years, annual fecal immunochemical testing (FIT), or colonoscopy every 10 years. Assuming the same cost as multi-target stool DNA, CMSmin cost $28,500/quality-adjusted life-year gained vs no screening, but FIT, colonoscopy, and multi-target stool DNA were less costly and more effective. CMSmin would match FIT's clinical outcomes if it achieved 1.4- to 1.8-fold FIT's participation rate. Advanced precancerous lesion (APL) sensitivity was a key determinant of a test's effectiveness. A paradigm-changing blood-based test (sensitivity >90% for CRC and 80% for APL; 90% specificity; cost ≤$120-$140) would be cost-effective vs FIT at comparable participation. CONCLUSIONS CMSmin could contribute to CRC control by achieving screening in those who will not use established methods. Substituting blood-based testing for established effective CRC screening methods will require higher CRC and APL sensitivities that deliver programmatic benefits matching those of FIT. High APL sensitivity, which can result in CRC prevention, should be a top priority for screening test developers. APL detection should not be penalized by a definition of test specificity that focuses on CRC only.
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Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; Department of Medicine, Stanford University School of Medicine, Stanford, California.
| | - Ajitha Mannalithara
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Yingjie Weng
- Department of Medicine, Stanford University School of Medicine, Stanford, California; Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Robert E Schoen
- Division of Gastroenterology, Hepatology and Nutrition, Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason A Dominitz
- Veterans Administration Puget Sound Health Care System, Seattle, Washington; Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Manisha Desai
- Department of Medicine, Stanford University School of Medicine, Stanford, California; Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Sciences University, Portland, Oregon
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Fouladi A, Asadi A, Sherer EA, Madadi M. Cost-effectiveness Analysis of Colorectal Cancer Screening Strategies Using Active Learning and Monte Carlo Simulation. Med Decis Making 2024:272989X241258224. [PMID: 38907706 DOI: 10.1177/0272989x241258224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2024]
Abstract
INTRODUCTION Detection of colorectal cancer (CRC) in the early stages through available screening tests increases the patient's survival chances. Multimodal screening policies can benefit patients by providing more diverse screening options and balancing the risks and benefits of screening tests. We investigate the cost-effectiveness of a wide variety of multimodal CRC screening policies. METHODS We developed a Monte Carlo simulation framework to model CRC dynamics. We proposed an innovative calibration process using machine learning models to estimate age- and size-specific adenomatous polyps' progression and regression rates. The proposed approach significantly expedites the model parameter space search. RESULTS Two multimodal proposed policies (i.e., 1] colonoscopy at 50 y and fecal occult blood test annually between 60 and 75 y and 2] colonoscopy at 50 and 60 y and fecal immunochemical test annually between 70 and 75 y) are identified as efficient frontier policies. Both policies are cost-effective at a willingness to pay of $50,000. Sensitivity analyses were performed to assess the sensitivity of results to a change in screening test costs as well as adherence behavior. The sensitivity analysis results suggest that the proposed policies are mostly robust to the considered changes in screening test costs, as there is a significant overlap between the efficient frontier policies of the baseline and the sensitivity analysis cases. However, the efficient frontier policies were more sensitive to changes in adherence behavior. CONCLUSION Generally, combining stool-based tests with visual tests will benefit patients with higher life expectancy and a lower expected cost compared with unimodal screening policies. Colonoscopy at younger ages (when the colonoscopy complication risk is lower) and stool-based tests at older ages are shown to be more effective. HIGHLIGHTS We propose a detailed Markov model to capture the colorectal cancer (CRC) dynamics. The proposed Markov model presents the detailed dynamics of adenomas progression to CRC.We use more than 44,000 colonoscopy reports and available data in the literature to calibrate the proposed Markov model using an innovative approach that leverages machine learning models to expedite the calibration process.We investigate the cost-effectiveness of a wide variety of multimodal CRC screening policies and compare their performances with the current in-practice policies.
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Affiliation(s)
| | - Amin Asadi
- Data Science, AI, OR, and Logistics, University of Twente, Twente, Netherlands
| | - Eric A Sherer
- Chemical Engineering, Louisiana Tech University, Ruston, LA, USA
| | - Mahboubeh Madadi
- Marketing and Business Analytics, San Jose State University, San Jose, CA, USA
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Robertson DJ, Rex DK, Ciani O, Drummond MF. Colonoscopy vs the Fecal Immunochemical Test: Which is Best? Gastroenterology 2024; 166:758-771. [PMID: 38342196 DOI: 10.1053/j.gastro.2023.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 12/18/2023] [Accepted: 12/29/2023] [Indexed: 02/13/2024]
Abstract
Although there is no debate around the effectiveness of colorectal cancer screening in reducing disease burden, there remains a question regarding the most effective and cost-effective screening modality. Current United States guidelines present a panel of options that include the 2 most commonly used modalities, colonoscopy and stool testing with the fecal immunochemical test (FIT). Large-scale comparative effectiveness trials comparing colonoscopy and FIT for colorectal cancer outcomes are underway, but results are not yet available. This review will separately state the "best case" for FIT and colonoscopy as the screening tool of first choice. In addition, the review will examine these modalities from a health economics perspective to provide the reader further context about the relative advantages of these commonly used tests.
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Affiliation(s)
- Douglas J Robertson
- VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management, SDA Bocconi School of Management, Milan, Italy
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Diedrich L, Brinkmann M, Dreier M, Rossol S, Schramm W, Krauth C. Is there a place for sigmoidoscopy in colorectal cancer screening? A systematic review and critical appraisal of cost-effectiveness models. PLoS One 2023; 18:e0290353. [PMID: 37594967 PMCID: PMC10438011 DOI: 10.1371/journal.pone.0290353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/05/2023] [Indexed: 08/20/2023] Open
Abstract
INTRODUCTION Screening for colorectal cancer (CRC) is effective in reducing both incidence and mortality. Colonoscopy and stool tests are most frequently used for this purpose. Sigmoidoscopy is an alternative screening measure with a strong evidence base. Due to its distinct characteristics, it might be preferred by subgroups. The aim of this systematic review is to analyze the cost-effectiveness of sigmoidoscopy for CRC screening compared to other screening methods and to identify influencing parameters. METHODS A systematic literature search for the time frame 01/2010-01/2023 was conducted using the databases MEDLINE, Embase, EconLit, Web of Science, NHS EED, as well as the Cost-Effectiveness Registry. Full economic analyses examining sigmoidoscopy as a screening measure for the general population at average risk for CRC were included. Incremental cost-effectiveness ratios were calculated. All included studies were critically assessed based on a questionnaire for modelling studies. RESULTS Twenty-five studies are included in the review. Compared to no screening, sigmoidoscopy is a cost-effective screening strategy for CRC. When modelled as a single measure strategy, sigmoidoscopy is mostly dominated by colonoscopy or modern stool tests. When combined with annual stool testing, sigmoidoscopy in 5-year intervals is more effective and less costly than the respective strategies alone. The results of the studies are influenced by varying assumptions on adherence, costs, and test characteristics. CONCLUSION The combination of sigmoidoscopy and stool testing represents a cost-effective screening strategy that has not received much attention in current guidelines. Further research is needed that goes beyond a narrow focus on screening technology and models different, preference-based participation behavior in subgroups.
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Affiliation(s)
- Leonie Diedrich
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Melanie Brinkmann
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Maren Dreier
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Siegbert Rossol
- Department of Internal Medicine, Krankenhaus Nordwest, Frankfurt/M, Germany
| | - Wendelin Schramm
- GECKO Institute for Medicine, Informatics and Economics, Heilbronn University, Heilbronn, Germany
| | - Christian Krauth
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
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Guzauskas GF, Garbett S, Zhou Z, Schildcrout JS, Graves JA, Williams MS, Hao J, Jones LK, Spencer SJ, Jiang S, Veenstra DL, Peterson JF. Population Genomic Screening for Three Common Hereditary Conditions : A Cost-Effectiveness Analysis. Ann Intern Med 2023; 176:585-595. [PMID: 37155986 DOI: 10.7326/m22-0846] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND The cost-effectiveness of screening the U.S. population for Centers for Disease Control and Prevention (CDC) Tier 1 genomic conditions is unknown. OBJECTIVE To estimate the cost-effectiveness of simultaneous genomic screening for Lynch syndrome (LS), hereditary breast and ovarian cancer syndrome (HBOC), and familial hypercholesterolemia (FH). DESIGN Decision analytic Markov model. DATA SOURCES Published literature. TARGET POPULATION Separate age-based cohorts (ages 20 to 60 years at time of screening) of racially and ethnically representative U.S. adults. TIME HORIZON Lifetime. PERSPECTIVE U.S. health care payer. INTERVENTION Population genomic screening using clinical sequencing with a restricted panel of high-evidence genes, cascade testing of first-degree relatives, and recommended preventive interventions for identified probands. OUTCOME MEASURES Incident breast, ovarian, and colorectal cancer cases; incident cardiovascular events; quality-adjusted survival; and costs. RESULTS OF BASE-CASE ANALYSIS Screening 100 000 unselected 30-year-olds resulted in 101 (95% uncertainty interval [UI], 77 to 127) fewer overall cancer cases and 15 (95% UI, 4 to 28) fewer cardiovascular events and an increase of 495 quality-adjusted life-years (QALYs) (95% UI, 401 to 757) at an incremental cost of $33.9 million (95% UI, $27.0 million to $41.1 million). The incremental cost-effectiveness ratio was $68 600 per QALY gained (95% UI, $41 800 to $88 900). RESULTS OF SENSITIVITY ANALYSIS Screening 30-, 40-, and 50-year-old cohorts was cost-effective in 99%, 88%, and 19% of probabilistic simulations, respectively, at a $100 000-per-QALY threshold. The test costs at which screening 30-, 40-, and 50-year-olds reached the $100 000-per-QALY threshold were $413, $290, and $166, respectively. Variant prevalence and adherence to preventive interventions were also highly influential parameters. LIMITATIONS Population averages for model inputs, which were derived predominantly from European populations, vary across ancestries and health care environments. CONCLUSION Population genomic screening with a restricted panel of high-evidence genes associated with 3 CDC Tier 1 conditions is likely to be cost-effective in U.S. adults younger than 40 years if the testing cost is relatively low and probands have access to preventive interventions. PRIMARY FUNDING SOURCE National Human Genome Research Institute.
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Affiliation(s)
- Gregory F Guzauskas
- The CHOICE Institute, Department of Pharmacy, University of Washington, Seattle, Washington (G.F.G., S.J.)
| | - Shawn Garbett
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee (S.G., J.S.S.)
| | - Zilu Zhou
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee (Z.Z., J.A.G.)
| | - Jonathan S Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee (S.G., J.S.S.)
| | - John A Graves
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee (Z.Z., J.A.G.)
| | - Marc S Williams
- Department of Genomic Health, Geisinger, Danville, Pennsylvania (M.S.W.)
| | - Jing Hao
- Department of Genomic Health and Department of Population Health Sciences, Geisinger, Danville, Pennsylvania (J.H.)
| | - Laney K Jones
- Department of Population Health Sciences and Heart Institute, Geisinger, Danville, Pennsylvania (L.K.J.)
| | - Scott J Spencer
- Institute for Public Health Genetics, University of Washington, Seattle, Washington (S.J.S.)
| | - Shangqing Jiang
- The CHOICE Institute, Department of Pharmacy, University of Washington, Seattle, Washington (G.F.G., S.J.)
| | - David L Veenstra
- The CHOICE Institute, Department of Pharmacy, and Institute for Public Health Genetics, University of Washington, Seattle, Washington (D.L.V.)
| | - Josh F Peterson
- Department of Biomedical Informatics and Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (J.F.P.)
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Jin X, Cai C, Zhao J, Huang L, Jin B, Jia Y, Lyu B. Opportunistic colonoscopy in healthy individuals: A non-trivial risk of adenoma. PLoS One 2023; 18:e0283575. [PMID: 37053293 PMCID: PMC10101387 DOI: 10.1371/journal.pone.0283575] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 03/11/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the second leading cause of cancer death worldwide. Opportunistic colonoscopy may be beneficial in reducing the incidence of CRC by detecting its precursors. AIM To determine the risk of colorectal adenomas in a population who underwent opportunistic colonoscopy, and demonstrate the need for opportunistic colonoscopy. METHODS A questionnaire was distributed to patients who underwent colonoscopy in the First Affiliated Hospital of Zhejiang Chinese Medical University from December 2021 to January 2022. The patients were divided into two groups, the opportunistic colonoscopy group who underwent a health examination including colonoscopy without intestinal symptoms due to other diseases, and the non-opportunistic group. The risk of adenomas and influence factors were analyzed. RESULTS Patients who underwent opportunistic colonoscopy had a similar risk to the non-opportunistic group, in terms of overall polyps (40.8% vs. 40.5%, P = 0.919), adenomas (25.8% vs. 27.6%, P = 0.581), advanced adenomas (8.7% vs. 8.6%, P = 0.902) and CRC (0.6% vs. 1.2%, P = 0.473). Patients with colorectal polyps and adenomas in the opportunistic colonoscopy group were younger (P = 0.004). There was no difference in the detection rate of polyps between patients who underwent colonoscopy as part of a health examination and those who underwent colonoscopy for other reasons. In patients with intestinal symptoms, abnormal intestinal motility and changes in stool characteristics were frequent (P = 0.014). CONCLUSION The risk of overall colonic polyps, advanced adenomas in healthy people undergoing opportunistic colonoscopy no less than that in the patients with intestinal symptoms, positive FOBT, abnormal tumor markers, and who accepted re-colonoscopy after polypectomy. Our study indicates that more attention should be paid to the population without intestinal symptoms, especially smokers and those older than 40 years.
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Affiliation(s)
- Xiaoliang Jin
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medical), Hangzhou, China
| | - Chang Cai
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medical), Hangzhou, China
| | - Jing Zhao
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medical), Hangzhou, China
| | - Liang Huang
- Department of Endoscopy Center, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medical), Hangzhou, China
| | - Bo Jin
- Department of Endoscopy Center, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medical), Hangzhou, China
| | - Yixin Jia
- Department of Gastroenterology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Bin Lyu
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medical), Hangzhou, China
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Gheysariyeha F, Rahimi F, Tabesh E, Hemami MR, Adibi P, Rezayatmand R. Cost-effectiveness of colorectal cancer screening strategies: A systematic review. Eur J Cancer Care (Engl) 2022; 31:e13673. [PMID: 35974390 DOI: 10.1111/ecc.13673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 04/30/2022] [Accepted: 06/24/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Colorectal cancer (CRC) is the second leading cause of death worldwide and the use of CRC screening tests can reduce the incidence and mortality of the disease by early detection. This study aims to review cost-effectiveness strategies in different ages and countries, systematically. METHODS We searched ProQuest, Web of Science, Scopus, Cochrane, PubMed and Embase for related studies between 2010 and 2020. Articles that reported costs per Quality-Adjusted Life Year or Life Year Gain and Incremental Cost-Effectiveness Ratios to compare the cost-effectiveness of CRC screening strategies in the average-risk population were included in our study. RESULTS The search strategies identified 426 records and finally 48 articles were included in the systematic review based on included and excluded criteria. We identified seven strategies for CRC screening. Most of the strategies were performed in aged 50-75. These studies were reported by cost per Quality-Adjusted life year (QALY)/Life Year Gain (LYG) based on methods and perspectives and the ICER of comparison of two-by-two strategies. CONCLUSION Most of the CRC screening strategies were cost-effective, but there was big heterogeneity between the cost-effectiveness analysis of CRC screening strategies because of different screening methods, perspectives and screening populations. So, it is important to consider this heterogeneity to compare the economic evaluation studies in this field.
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Affiliation(s)
- Fatemeh Gheysariyeha
- Department of Health Economics, School of Management and Medical Information Sciences Isfahan University of Medical Science, Isfahan, Iran
| | - Farimah Rahimi
- Pharmacoeconomics and Pharma Management, Research Assistant Professor, Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elham Tabesh
- Gastroenterology and Hepatology, Isfahan Gastroenterology and Hepatology Research Center (IGHRC), Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Payman Adibi
- Gastroenterology and Hepatology, Isfahan Gastroenterology and Hepatology Research Center (IGHRC), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reza Rezayatmand
- Health Economics, Health Management and Economics Research Center Isfahan University of Medical Sciences, Isfahan, Iran
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van Dover TJ, Kim DD. Do Centers for Medicare and Medicaid Services Quality Measures Reflect Cost-Effectiveness Evidence? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1586-1591. [PMID: 34711358 DOI: 10.1016/j.jval.2021.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/22/2021] [Accepted: 03/22/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Despite its importance of quality measures used by the Centers for Medicare and Medicaid Services, the underlying cost-effectiveness evidence has not been examined. This study aimed to analyze cost-effectiveness evidence associated with the Centers for Medicare and Medicaid Services quality measures. METHODS After classifying 23 quality measures with the Donabedian's structure-process-outcome quality of care model, we identified cost-effectiveness analyses (CEAs) relevant to these measures from the Tufts Medical Center CEA Registry based on the PICOTS (population, intervention, comparator, outcome, time horizon, and setting) framework. We then summarized available incremental cost-effectiveness ratios (ICERs) to determine the cost-effectiveness of the quality measures. RESULTS The 23 quality measures were categorized into 14 process, 7 outcome, and 2 structure measures. Cost-effectiveness evidence was only available for 8 of 14 process measures. Two measures (Tobacco Screening and Hemoglobin bA1c Control) were cost-saving and quality-adjusted life-years (QALYs) improving, and 5 (Depression Screening, Influenza Immunization, Colon Cancer Screening, Breast Cancer Screening, and Statin Therapy) were highly cost-effective (median ICER ≤ $50 000/QALY). The remaining measure (Fall Screening) had a median ICER of $120 000/QALY. No CEAs were available for 15 measures: 10 defined by subjective patient ratings and 5 employed outcome measures without specifying an intervention or process. CONCLUSIONS When relevant CEAs were available, cost-effectiveness evidence was consistent with quality measures (measures were cost-effective). Nevertheless, most quality measures were based on subjective ratings or outcome measures, posing a challenge in identifying supporting economic evidence. Refining and aligning quality measures with cost-effectiveness evidence can help further improve healthcare efficiency by demonstrating that they are good indicators of both quality and cost-effectiveness of care.
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Affiliation(s)
- Timothy J van Dover
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - David D Kim
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA; Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA.
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Zahnd WE, Josey MJ, Schootman M, Eberth JM. Spatial accessibility to colonoscopy and its role in predicting late-stage colorectal cancer. Health Serv Res 2021; 56:73-83. [PMID: 32954527 PMCID: PMC7839638 DOI: 10.1111/1475-6773.13562] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To better determine the relationship between spatial access to colonoscopy and colorectal cancer (CRC) outcomes, our objective was to examine the agreement of the classic, enhanced, and variable two-step floating catchment area (2SFCA) methods in evaluating spatial access to colonoscopy and to compare the predictive validity of each method related to late-stage CRC. 2SFCA methods simultaneously consider supply/demand of services and impedance (ie, travel time). DATA SOURCES Colonoscopy provider locations were obtained from the South Carolina Ambulatory Surgery Database. ZIP code tabulation area (ZCTA) level population estimates and area-level poverty level were obtained from the American Community Survey. Rurality was determined by the United States Department of Agriculture's Rural-Urban Commuting Area codes. Individual-level CRC data were obtained from the South Carolina Central Cancer Registry. STUDY DESIGN Using the classic, enhanced, and variable 2SFCA methods, we calculated ZCTA-level spatial access to colonoscopy. We assessed agreement between the three methods by calculating Spearman's rank coefficients and weighted Kappas (Κ). Global and Local Moran's I were used to assess spatial clustering of accessibility scores across 2SFCA methods. We performed multilevel logistic regression analyses to examine the association between spatial accessibility to colonoscopy, area- and individual-level factors, and late-stage CRC. PRINCIPAL FINDINGS We found strong agreement (Weighted Κ = 0.82; 95% CI = 0.79-0.86) and identified similar clustering patterns with the classic and enhanced 2SFCA methods. There was negligible agreement among the classic/enhanced 2SFCA and the variable 2SFCA. Across all 2SFCA methods, regression models showed that spatial access to colonoscopy, rurality, and poverty level were not associated with greater odds of late-stage CRC, though Black race was associated with late-stage CRC across all models. CONCLUSIONS None of the 2SFCA methods showed an association with late-stage CRC. Future studies should explore which elements (spatial or nonspatial) of access to care have the greatest impact on CRC outcomes.
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Affiliation(s)
- Whitney E. Zahnd
- Rural & Minority Health Research CenterArnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
- Big Data Health Science CenterArnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
| | - Michele J. Josey
- Department of Epidemiology and BiostatisticsArnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
| | - Mario Schootman
- SSM HealthDepartment of Clinical AnalyticsCenter for Clinical ExcellenceSt. LouisMissouriUSA
| | - Jan M. Eberth
- Rural & Minority Health Research CenterArnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
- Big Data Health Science CenterArnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
- Department of Epidemiology and BiostatisticsArnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
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Crosby RA, Mamaril CB, Collins T. Cost of Increasing Years-of-Life-Gained (YLG) Using Fecal Immunochemical Testing as a Population-Level Screening Model in a Rural Appalachian Population. J Rural Health 2020; 37:576-584. [PMID: 33078439 DOI: 10.1111/jrh.12514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Given the innovation of fecal immunochemical testing (FIT) to detect polyps in the rectum and colon for removal by colonoscopy, it is important to determine the cost per Life-Year Gained (LYG) when using FIT as a population-level screening model. This is particularly true for medically underserved rural populations. Accordingly, the purpose of this study was to make this determination among rural Appalachians experiencing isolation and economic challenges. METHODS The study occurred in an 8-county area of southeastern Kentucky. Kits were distributed to 1,424 residents. Seven hundred thirty-two kits (51.4%) were completed and returned. A Markov decision-analytic model was developed using PrecisionTree 7.6. FINDINGS Reactive test results occurred for 144 of the completed kits (19.7%). Thirty-seven colonoscopies were verified, with 15 of these indicating precancerous changes or actual cancer. Program costs were estimated at $461,952, with the average cost per person screened estimated at $324. Cost per LYG was $7,912. CONCLUSIONS In contrast to an average cost per LYG of $17,200, our findings suggest a highly favorable cost-effectiveness ratio for this population of medically underserved rural residents. Cost-benefit analyses suggest that the screening program begins to yield positive net benefits at the stage when project recipients undergo colonoscopy, suggesting that this is the key step for behavioral intervention and intensified outreach.
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Affiliation(s)
- Richard A Crosby
- College of Public Health, University of Kentucky, Lexington, Kentucky
| | - Cesar B Mamaril
- College of Public Health, University of Kentucky, Lexington, Kentucky
| | - Tom Collins
- College of Public Health, University of Kentucky, Lexington, Kentucky
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12
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Khalili F, Najafi B, Mansour-Ghanaei F, Yousefi M, Abdollahzad H, Motlagh A. Cost-Effectiveness Analysis of Colorectal Cancer Screening: A Systematic Review. Risk Manag Healthc Policy 2020; 13:1499-1512. [PMID: 32982508 PMCID: PMC7490076 DOI: 10.2147/rmhp.s262171] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/22/2020] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Colorectal cancer (CRC) is a significant health problem with an increasing incidence worldwide. Screening is one of the ways, in which cases and deaths of CRC can be prevented. The objective of this systematic review was to evaluate the cost-effectiveness of the different CRC screening techniques and to specify the efficient technique from a cost-effectiveness perspective. METHODS The economic studies of CRC screening in general populations (average risk), aged 50 years and above were reviewed. Two reviewers independently reviewed the titles, abstracts, and full-texts of the studies in five databases: Cochrane, Embase, Scopus, Web of Science and PubMed. The disagreements between reviewers were resolved through the authors' consensus. The main outcome measures in this systematic review were the incremental cost-effectiveness ratio (ICER) of screening versus no-screening and then in comparison with other screening techniques. The ICER is defined by the difference in cost between two possible interventions, divided by the difference in their effect. RESULTS Eight studies were identified and retained for the final analysis. In this study, when screening techniques were compared to no-screening, all CRC screening techniques showed to be cost-effective. The lowest ICER calculated was $PPP -16265/quality-adjusted life-year (QALY) (the negative ICERs were between purchasing power parity in US dollar ($PPP) -16265/QALY to $PPP -1988/QALY, whereas the positive ICERs were between $PPP 1257/QALY to $PPP 55987/QALY). For studies comparing various screening techniques, there was great heterogeneity in terms of the structures of the analyses, leading to diverse conclusions about their incremental cost-effectiveness. CONCLUSION All CRC screening techniques were cost-effective, compared with the no-screening methods. The cost-effectiveness of the various screening techniques mainly was dependent on the context-specific parameters and highly affected by the framework of the cost-effectiveness analysis. In order to make the studies comparable, it is important to adopt a reference-based methodology for economic evaluation studies.
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Affiliation(s)
- Farhad Khalili
- Department of Health Economics, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Behzad Najafi
- Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fariborz Mansour-Ghanaei
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Mahmood Yousefi
- Department of Health Economics, Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hadi Abdollahzad
- Research Center for Environmental Determinants of Health, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ali Motlagh
- National Cancer Control Secretariat, Ministry of Health and Medical Education, Tehran, Iran
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Smith H, Varshoei P, Boushey R, Kuziemsky C. Simulation modeling validity and utility in colorectal cancer screening delivery: A systematic review. J Am Med Inform Assoc 2020; 27:908-916. [PMID: 32417894 PMCID: PMC7309251 DOI: 10.1093/jamia/ocaa022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 02/13/2020] [Accepted: 03/06/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE This study sought to assess the impact and validity of simulation modeling in informing decision making in a complex area of healthcare delivery: colorectal cancer (CRC) screening. MATERIALS AND METHODS We searched 10 electronic databases for English-language articles published between January 1, 2008, and March 1, 2019, that described the development of a simulation model with a focus on average-risk CRC screening delivery. Included articles were reviewed for evidence that the model was validated, and provided real or potential contribution to informed decision making using the GRADE EtD (Grading of Recommendations Assessment, Development, and Evaluation Evidence to Decision) framework. RESULTS A total of 43 studies met criteria. The majority used Markov modeling (n = 31 [72%]) and sought to determine cost-effectiveness, compare screening modalities, or assess effectiveness of screening. No study reported full model validation and only (58%) reported conducting any validation. Majority of models were developed to address a specific health systems or policy question; few articles report the model's impact on this decision (n = 39 [91%] vs. n = 5 [12%]). Overall, models provided evidence relevant to every element important to decision makers as outlined in the GRADE EtD framework. DISCUSSION AND CONCLUSION Simulation modeling contributes evidence that is considered valuable to decision making in CRC screening delivery, particularly in assessing cost-effectiveness and comparing screening modalities. However, the actual impact on decisions and validity of models is lacking in the literature. Greater validity testing, impact assessment, and standardized reporting of both is needed to understand and demonstrate the reliability and utility of simulation modeling.
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Affiliation(s)
- Heather Smith
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
- Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peyman Varshoei
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
| | - Robin Boushey
- Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Craig Kuziemsky
- Office of Research Services, MacEwan University, Edmonton, Alberta, Canada
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14
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Zhong GC, Sun WP, Wan L, Hu JJ, Hao FB. Efficacy and cost-effectiveness of fecal immunochemical test versus colonoscopy in colorectal cancer screening: a systematic review and meta-analysis. Gastrointest Endosc 2020; 91:684-697.e15. [PMID: 31790657 DOI: 10.1016/j.gie.2019.11.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/19/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The fecal immunochemical test (FIT) and colonoscopy are the most commonly used strategies for colorectal cancer (CRC) screening worldwide. We aimed to compare their efficacy and cost-effectiveness in CRC screening in an average-risk population. METHODS PubMed, Embase, and National Health Services Economic Evaluation Database were searched. Risk ratio (RR) was used to evaluate the differences in detection rates of colorectal neoplasia between FIT and colonoscopy groups. A random-effects model was used to pool RRs. Incremental cost-effectiveness ratios (ICERs) were calculated to evaluate the cost-effectiveness of FIT versus colonoscopy. RESULTS Six randomized controlled trials and 17 cost-effectiveness studies were included. The participation rate in the FIT group was higher than that in the colonoscopy group (41.6% vs 21.9%). In the intention-to-treat analysis, FIT had a detection rate of CRC comparable with colonoscopy (RR, .73; 95% confidence interval, .37-1.42) and lower detection rates of any adenoma and advanced adenoma than 1-time colonoscopy. Most included cost-effectiveness studies showed that annual (13/15) or biennial (5/6) FIT was cost-saving (ICER < $0) or very cost-effective ($0 < ICER ≤ $25000/quality-adjusted life-year) compared with colonoscopy every 10 years. CONCLUSIONS FIT may be similar to 1-time colonoscopy in the detection rate of CRC, although it has lower detection rates of any adenoma and advanced adenoma than 1-time colonoscopy. Furthermore, annual or biennial FIT appears to be very cost-effective or cost-saving compared with colonoscopy every 10 years. These findings indicate, at least partly, that FIT is noninferior to colonoscopy in CRC screening in an average-risk population. Our findings should be treated with caution and need to be further confirmed.
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Affiliation(s)
- Guo-Chao Zhong
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei-Ping Sun
- Department of Gastrointestinal Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lun Wan
- Department of Hepatobiliary Surgery, the People's Hospital of Dazu district, Chongqing, China
| | - Jie-Jun Hu
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fa-Bao Hao
- Pediatric Surgery Center, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, Shandong, China
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15
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Mendivil J, Appierto M, Aceituno S, Comas M, Rué M. Economic evaluations of screening strategies for the early detection of colorectal cancer in the average-risk population: A systematic literature review. PLoS One 2019; 14:e0227251. [PMID: 31891647 PMCID: PMC6938313 DOI: 10.1371/journal.pone.0227251] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/16/2019] [Indexed: 12/18/2022] Open
Abstract
Background Colorectal cancer (CRC) screening has proven effective in reducing CRC mortality. This study aimed to systematically review, and evaluate the reporting quality, of the economic evidence regarding CRC screening in average-risk individuals. Methods Databases searched included Medline, EMBASE, National Health Service Economic Evaluation, Database of Abstracts of Reviews of Effects, Cost-Effectiveness Analysis registry, EconLit, and Health Technology Assessment database. Eligible studies were cost-effectiveness and cost-utility analyses comparing CRC screening strategies in average-risk individuals, published in English or Spanish, between January 2012 and November 2018. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Results Of 1,993 publications initially retrieved, 477 were excluded by duplicate review, 1,449 by title/abstract review, and 34 by full-text review. Finally, 33 publications were included in the qualitative synthesis. Most studies were conducted in Europe (36,4%), followed by United States (24,2%) and Asia (24,2%). The main screening modalities considered were fecal immunochemical tests (70%), colonoscopy (67%), guaiac fecal occult blood test (42%) and flexible sigmoidoscopy (30%). In most studies, CRC screening was deemed cost-effective compared to no screening. Sensitivity analyses indicated that cost of CRC screening tests, adherence to screening, screening test sensitivity, and cost of CRC treatment had the greatest impact on cost-effectiveness results across studies. The majority of studies (73%) adequately reported at least 50% of the items included in the CHEERS checklist. Least well reported items included setting, study perspective, discount rate, model choice, and methods to identify effectiveness data or to estimate resource use and costs. Conclusions CRC screening is an efficient alternative to no screening. Nevertheless, it is not possible to conclude which strategy should be preferred for population-based screening programs. Although we observed an overall good adherence to CHEERS recommendations, there is still room for improvement in economic evaluations reporting in this field.
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Affiliation(s)
- Joan Mendivil
- Outcomes Research and Epidemiology, Shire International GmbH, a Takeda Company, Zug, Switzerland
- * E-mail:
| | | | - Susana Aceituno
- Health Economics department, Outcomes’ 10 SLU, Castellon, CS, Spain
| | - Mercè Comas
- Epidemiology and Evaluation Department, IMIM (Hospital del Mar Medical Research Institute); Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barcelona, Spain
| | - Montserrat Rué
- Departament of Basic Medical Sciences, Universitat de Lleida, Lleida, Spain
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16
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Heavener T, McStay FW, Jaeger V, Stephenson K, Sager L, Sing J. Assessing adherence and cost-benefit of colorectal cancer screening for accountable providers. Proc AMIA Symp 2019; 32:490-497. [PMID: 31656403 DOI: 10.1080/08998280.2019.1647702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/11/2019] [Accepted: 07/18/2019] [Indexed: 01/07/2023] Open
Abstract
The objective of this study was to assess adherence and costs-benefits of colorectal cancer (CRC) screenings from an accountable care organization/population health perspective. We performed a retrospective review of 94 patients (50-75 years of age) in an integrated safety net system for whom fecal CRC screening was abnormal for the period of June 1, 2014, to June 1, 2016. A cost-benefit model was constructed using Medicare payment rates and a sensitivity analysis. Most patients included in the study (64/94, 68%) received or were offered a colonoscopy. Of those receiving a colonoscopy, 24 of 45 (53%) had an abnormal finding. Total direct medical costs avoided by screening the patient panel was $32,926 but could have exceeded $63,237 had more patients received follow-up colonoscopies. A sensitivity analysis with 1000 patients demonstrated total monetary benefits between $2.2 million and $8.16 million when follow-up and colonoscopy rates were allowed to vary. Although the resulting rates of follow-up were within the range reported in the literature, there is room for improvement, especially considering the monetary benefit that could be used on other diseases. Health systems and payers should work cooperatively to structure payment models to better incentivize CRC screenings.
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Affiliation(s)
- Trace Heavener
- Department of Internal Medicine, Baylor Scott & White Medical Center-TempleTempleTexas
| | - Frank W McStay
- Center for Healthcare Policy, Baylor Scott & White Medical Center-TempleTempleTexas
| | - Victoria Jaeger
- Department of Internal Medicine, Baylor Scott & White Medical Center-TempleTempleTexas
| | - Kristen Stephenson
- Department of Internal Medicine, Baylor Scott & White Medical Center-TempleTempleTexas
| | - Lauren Sager
- Office of Biostatistics, Baylor Scott & White Medical Center-TempleTempleTexas
| | - James Sing
- Department of Gastroenterology, Baylor Scott & White Medical Center-TempleTempleTexas
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17
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Josey MJ, Odahowski CL, Zahnd WE, Schootman M, Eberth JM. Disparities in Utilization of Medical Specialists for Colonoscopy. Health Equity 2019; 3:464-471. [PMID: 31501806 PMCID: PMC6729104 DOI: 10.1089/heq.2019.0052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: Colonoscopy is the preferred screening modality for colorectal cancer (CRC) prevention. The quality of the procedure varies although medical specialists such as gastroenterologists and colorectal surgeons tend to have better outcomes. We aimed to determine whether there are demographic and clinical differences between those who received a colonoscopy from a specialist versus those who received a colonoscopy from a nonspecialist. Methods: Using the population-based South Carolina Outpatient Ambulatory Surgery Database, we looked retrospectively to obtain patient-level endoscopy records from 2010 to 2014. We used multilevel logistic regression to model whether patients saw a specialist for their colonoscopy. The primary variables were patient race and insurance type, and an interaction by rurality was tested. Results: Of the 392,285 patients included in the analysis, 81% saw a specialist for their colonoscopy. County of residence explained 30% of the variability in the outcome. Non-Hispanic black (OR=0.65; confidence interval [95% CI]: 0.64–0.67) and Hispanic patients (OR=0.75; 95% CI: 0.67–0.84) were significantly less likely than non-Hispanic white patients to see a specialist. Compared with commercial/HMO insurance, all other types were less likely to see a specialist, and even more so for rural patients. The interaction of race by rurality was not significant. Conclusions: Specialists play a key role in CRC screening and can affect later downstream outcomes. This study has shown that ethnic minorities and adults with public or other insurance, particularly in rural areas, are most likely not to see a specialist. These results are consistent with disparities in CRC incidence, mortality, and survival.
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Affiliation(s)
- Michele J Josey
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina.,Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina
| | - Cassie L Odahowski
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina.,Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina
| | - Whitney E Zahnd
- Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina
| | - Mario Schootman
- Department of Clinical Analytics and Insights, Center for Clinical Excellence, SSM Health System, St. Louis, Missouri
| | - Jan M Eberth
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina.,Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina
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18
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Ran T, Cheng CY, Misselwitz B, Brenner H, Ubels J, Schlander M. Cost-Effectiveness of Colorectal Cancer Screening Strategies-A Systematic Review. Clin Gastroenterol Hepatol 2019; 17:1969-1981.e15. [PMID: 30659991 DOI: 10.1016/j.cgh.2019.01.014] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Widespread screening for colorectal cancer (CRC) has reduced its incidence and mortality. Previous studies investigated the economic effects of CRC screening. We performed a systematic review to provide up-to-date evidence of the cost effectiveness of CRC screening strategies by answering 3 research questions. METHODS We searched PubMed, National Institute for Health Research Economic Evaluation Database, Social Sciences Citation Index (via the Web of Science), EconLit (American Economic Association) and 3 supplemental databases for original articles published in English from January 2010 through December 2017. All monetary values were converted to US dollars (year 2016). For all research questions, we extracted, or calculated (if necessary), per-person costs and life years (LYs) and/or quality-adjusted LYs, as well as the incremental costs per LY gained or quality-adjusted LY gained compared with the baseline strategy. A cost-saving strategy was defined as one that was less costly and equally or more effective than the baseline strategy. The net monetary benefit approach was used to answer research question 2. RESULTS Our review comprised 33 studies (17 from Europe, 11 from North America, 4 from Asia, and 1 from Australia). Annual and biennial guaiac-based fecal occult blood tests, annual and biennial fecal immunochemical tests, colonoscopy every 10 years, and flexible sigmoidoscopy every 5 years were cost effective (even cost saving in most US models) compared to no screening. In addition, colonoscopy every 10 years was less costly and/or more effective than other common strategies in the United States. Newer strategies such as computed tomographic colonography, every 5 or 10 years, was cost effective compared with no screening. CONCLUSIONS In an updated review, we found that common CRC screening strategies and computed tomographic colonography continued to be cost effective compared to no screening. There were discrepancies among studies from different regions, which could be associated with the model types or model assumptions.
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Affiliation(s)
- Tao Ran
- Division of Health Economics, German Cancer Research Center, Heidelberg, Germany.
| | - Chih-Yuan Cheng
- Division of Health Economics, German Cancer Research Center, Heidelberg, Germany; Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Benjamin Misselwitz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Jasper Ubels
- Division of Health Economics, German Cancer Research Center, Heidelberg, Germany; Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Ladabaum U, Mannalithara A, Meester RGS, Gupta S, Schoen RE. Cost-Effectiveness and National Effects of Initiating Colorectal Cancer Screening for Average-Risk Persons at Age 45 Years Instead of 50 Years. Gastroenterology 2019; 157:137-148. [PMID: 30930021 PMCID: PMC7161092 DOI: 10.1053/j.gastro.2019.03.023] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/12/2019] [Accepted: 03/15/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The American Cancer Society has recommended initiating colorectal cancer (CRC) screening at age 45 years instead of 50 years. We estimated the cost effectiveness and national effects of adopting this recommendation. METHODS We compared screening strategies and alternative resource allocations in a validated Markov model. We based national projections on screening participation rates by age and census data. RESULTS Screening colonoscopy initiation at age 45 years instead of 50 years in 1000 persons averted 4 CRCs and 2 CRC deaths, gained 14 quality-adjusted life-years (QALYs), cost $33,900/QALY gained, and required 758 additional colonoscopies. These 758 colonoscopies could instead be used to screen 231 currently unscreened 55-year-old persons or 342 currently unscreened 65-year-old persons, through age 75 years. These alternatives averted 13-14 CRC cases and 6-7 CRC deaths and gained 27-28 discounted QALYs while saving $163,700-$445,800. Improving colonoscopy completion rates after abnormal results from a fecal immunochemical test yielded greater benefits and savings. Initiation of fecal immunochemical testing at age 45 years instead of 50 years cost $7700/QALY gained. Shifting current age-specific screening rates to 5 years earlier could avert 29,400 CRC cases and 11,100 CRC deaths over the next 5 years but would require 10.7 million additional colonoscopies and cost an incremental $10.4 billion. Improving screening rates to 80% in persons who are 50-75 years old would avert nearly 3-fold more CRC deaths at one third the incremental cost. CONCLUSIONS In a Markov model analysis, we found that starting CRC screening at age 45 years is likely to be cost effective. However, greater benefit, at lower cost, could be achieved by increasing participation rates for unscreened older and higher-risk persons.
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Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California.
| | - Ajitha Mannalithara
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Reinier G S Meester
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, Division of Gastroenterology, Department of Internal Medicine, Moores Cancer Center, University of California-San Diego, San Diego, California
| | - Robert E Schoen
- Division of Gastroenterology, Hepatology and Nutrition, and Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Medical Diagnostic Tests: A Review of Test Anatomy, Phases, and Statistical Treatment of Data. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2019; 2019:1891569. [PMID: 31275427 PMCID: PMC6558629 DOI: 10.1155/2019/1891569] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 04/25/2019] [Accepted: 05/08/2019] [Indexed: 12/20/2022]
Abstract
Diagnostic tests are approaches used in clinical practice to identify with high accuracy the disease of a particular patient and thus to provide early and proper treatment. Reporting high-quality results of diagnostic tests, for both basic and advanced methods, is solely the responsibility of the authors. Despite the existence of recommendation and standards regarding the content or format of statistical aspects, the quality of what and how the statistic is reported when a diagnostic test is assessed varied from excellent to very poor. This article briefly reviews the steps in the evaluation of a diagnostic test from the anatomy, to the role in clinical practice, and to the statistical methods used to show their performances. The statistical approaches are linked with the phase, clinical question, and objective and are accompanied by examples. More details are provided for phase I and II studies while the statistical treatment of phase III and IV is just briefly presented. Several free online resources useful in the calculation of some statistics are also given.
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Robertson DJ, Ladabaum U. Opportunities and Challenges in Moving From Current Guidelines to Personalized Colorectal Cancer Screening. Gastroenterology 2019; 156:904-917. [PMID: 30593801 DOI: 10.1053/j.gastro.2018.12.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 12/09/2018] [Accepted: 12/10/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Douglas J Robertson
- Department of Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth and The Dartmouth Institute, Hanover, New Hampshire.
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
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Contrasting Effectiveness and Cost-Effectiveness of Colorectal Cancer Screening Under Commercial Insurance vs. Medicare. Am J Gastroenterol 2018; 113:1836-1847. [PMID: 29904156 PMCID: PMC6768591 DOI: 10.1038/s41395-018-0106-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/09/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Most cost-effectiveness analyses of colorectal cancer (CRC) screening assume Medicare payment rates and a lifetime horizon. Our aims were to examine the implications of differential payment levels and time horizons for commercial insurers vs. Medicare on the cost-effectiveness of CRC screening. METHODS We used our validated Markov cohort simulation of CRC screening in the average risk US population to examine CRC screening at ages 50-64 under commercial insurance, and at ages 65-80 under Medicare, using a health-care sector perspective. Model outcomes included discounted quality-adjusted life-years (QALYs) and costs per person, and incremental cost/QALY gained. RESULTS Lifetime costs/person were 20-44% higher when assuming commercial payment rates rather than Medicare rates for people under 65. Most of the substantial clinical benefit of screening at ages 50-64 was realized at ages ≥65. For commercial payers with a time horizon of ages 50-64, fecal occult blood testing (FOBT) and fecal immunochemical testing (FIT) were cost-effective (<$61,000/QALY gained), but colonoscopy was costly (>$185,000/QALY gained). Medicare experienced substantial clinical benefits and cost-savings from screening done at ages <65, even if screening was not continued. Among those previously screened, continuing FOBT and FIT under Medicare was cost-saving and continuing colonoscopy was highly cost-effective (<$30,000/QALY gained), and initiating any screening in those previously unscreened was highly effective and cost-saving. CONCLUSIONS Modeling suggests that CRC screening is highly cost-effective over a lifetime even when considering higher payment rates by commercial payers vs. Medicare. Screening may appear relatively costly for commercial payers if only a time horizon of ages 50-64 is considered, but it is predicted to yield substantial clinical and economic benefits that accrue primarily at ages ≥65 under Medicare.
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Wolf AMD, Fontham ETH, Church TR, Flowers CR, Guerra CE, LaMonte SJ, Etzioni R, McKenna MT, Oeffinger KC, Shih YCT, Walter LC, Andrews KS, Brawley OW, Brooks D, Fedewa SA, Manassaram-Baptiste D, Siegel RL, Wender RC, Smith RA. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin 2018; 68:250-281. [PMID: 29846947 DOI: 10.3322/caac.21457] [Citation(s) in RCA: 1123] [Impact Index Per Article: 187.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/23/2018] [Indexed: 12/11/2022] Open
Abstract
In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.
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Affiliation(s)
- Andrew M D Wolf
- Associate Professor and Attending Physician, University of Virginia School of Medicine, Charlottesville, VA
| | - Elizabeth T H Fontham
- Emeritus Professor, Louisiana State University School of Public Health, New Orleans, LA
| | - Timothy R Church
- Professor, University of Minnesota and Masonic Cancer Center, Minneapolis, MN
| | - Christopher R Flowers
- Professor and Attending Physician, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA
| | - Carmen E Guerra
- Associate Professor of Medicine of the Perelman School of Medicine and Attending Physician, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Samuel J LaMonte
- Independent retired physician and patient advocate, University of Washington and the Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ruth Etzioni
- Biostatistician, University of Washington and the Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Matthew T McKenna
- Professor and Director, Division of Preventive Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kevin C Oeffinger
- Professor and Director of the Duke Center for Onco-Primary Care, Durham, NC
| | - Ya-Chen Tina Shih
- Professor, Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Louise C Walter
- Professor and Attending Physician, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA
| | - Kimberly S Andrews
- Director, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Otis W Brawley
- Chief Medical and Scientific Officer and Executive Vice President-Research, American Cancer Society, Atlanta, GA
| | - Durado Brooks
- Vice President, Cancer Control Interventions, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Stacey A Fedewa
- Strategic Director for Risk Factor Screening and Surveillance, American Cancer Society, Atlanta, GA
| | | | - Rebecca L Siegel
- Strategic Director, Surveillance Information Services, American Cancer Society, Atlanta, GA
| | - Richard C Wender
- Chief Cancer Control Officer, American Cancer Society, Atlanta, GA
| | - Robert A Smith
- Vice President, Cancer Screening, Cancer Control Department, American Cancer Society, Atlanta, GA
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Arafa MA, Farhat KH. Recent diagnostic procedures for colorectal cancer screening: Are they cost-effective? Arab J Gastroenterol 2017; 18:136-139. [PMID: 28988790 DOI: 10.1016/j.ajg.2017.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/27/2017] [Indexed: 12/28/2022]
Abstract
Colorectal cancer (CRC) is the third most common cancer worldwide and the fourth most common cause of death. Reduction in mortality rates in some countries worldwide are most likely ascribed to CRC screening and/or improved treatments. We reviewed the most relevant articles which discuss the cost-effectiveness of colorectal cancer screening procedures, in particular, the recent ones through the last eight years. The effectiveness of screening estimated by discounted life years gained (LYGs) compared to no screening, differed considerably between the studies. Despite these differences, all studies consistently emphasized that screening for CRC was cost-effective compared with no screening for each of the recognized screening strategies. Newer technologies for colorectal cancer screening, including computed tomographic colonography (CTC), faecal DNA test, and Pillcam Colon are less invasive and accurate, however, they are not cost-effective, as their cost was higher than all other established screening strategies. When compliance and adherence to such new techniques are increased more than the established strategies they would be more cost-effective particularly CTC.
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Affiliation(s)
- Mostafa Ahmed Arafa
- Cancer Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Karim Hamda Farhat
- Cancer Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Macpherson AJ, Heikenwalder M, Ganal-Vonarburg SC. The Liver at the Nexus of Host-Microbial Interactions. Cell Host Microbe 2017; 20:561-571. [PMID: 27832587 DOI: 10.1016/j.chom.2016.10.016] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The liver receives blood from the intestine, from the spleen, and directly from the heart and holds a vital position in vertebrate physiology. It plays a role in intermediary metabolism, bile secretion, maintaining blood sterility, serum homeostasis, xenobiotic detoxification, and immunological activity. This article provides our perspective on the liver as a nexus in establishing and maintaining host microbial mutualism. We discuss the role of the liver not only in sanitizing the blood stream from penetrant live microbes, but also in metabolizing xenobiotics that are synthesized or modified by intestinal microbes, and how microbiota modify the signaling potential of bile acids. The combination of bile acids as hormones and the metabolic control from pervasive effects of other absorbed microbial molecules powerfully shape hepatic metabolism. In addition, intestinal microbial metabolites can be sensed by liver-resident immune cells, which may disturb liver homeostasis, leading to fibrosis and liver cancer.
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Affiliation(s)
- Andrew J Macpherson
- Maurice Müller Laboratories (DKF), Universitätsklinik für Viszerale Chirurgie und Medizin Inselspital, Murtenstrasse 35, University of Bern, 3010 Bern, Switzerland.
| | - Mathias Heikenwalder
- Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Stephanie C Ganal-Vonarburg
- Maurice Müller Laboratories (DKF), Universitätsklinik für Viszerale Chirurgie und Medizin Inselspital, Murtenstrasse 35, University of Bern, 3010 Bern, Switzerland.
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26
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Brenner H, Chen H. Fecal occult blood versus DNA testing: indirect comparison in a colorectal cancer screening population. Clin Epidemiol 2017; 9:377-384. [PMID: 28761377 PMCID: PMC5516775 DOI: 10.2147/clep.s136565] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background A multitarget stool DNA test (MSDT) that showed higher sensitivity but lower specificity than a fecal immunochemical test (FIT) for hemoglobin in one recent study from the US and Canada, is increasingly used for colorectal cancer (CRC) screening, despite its ~20-fold higher costs compared to FITs. We aimed to assess diagnostic performance of a quantitative FIT in an independent study among participants of screening colonoscopy and to compare it with the previously reported performance of MSDT. Methods A total of 3494 participants, aged 50–84 years, who underwent screening colonoscopy in private gastroenterological practices in Germany, and who provided a stool sample before colonoscopy to be evaluated by a commercially available quantitative FIT (FOB Gold®) were included. Diagnostic performance (sensitivity, specificity) for detecting CRC or advanced precancerous lesions (APCLs) was evaluated by comparison of test results with findings at screening colonoscopy. In addition to the original cutoff, we used an adjusted cutoff yielding the same specificity as reported for the MSDT to enhance comparability. Results The most advanced finding at colonoscopy was CRC and APCL in 30 (0.86%) and 359 (10.3%) cases, respectively. At a cutoff yielding the same specificity as reported for MSDT (86.6%), the sensitivities (95% CI) of the FIT for detecting CRC and APCL >1 cm were 96.7% (82.8–99.9%) and 54.3% (48.3–60.3%), respectively. These sensitivities are higher than those reported for MSDT (92.3% and 43.6%, p=0.66 and 0.003, respectively). Conclusion In this large screening population, FIT showed equivalent or better diagnostic performance in comparison to reported performance of MSDT.
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Affiliation(s)
- Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ).,Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT).,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hongda Chen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ).,Program Office for Cancer Screening in Urban China, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Chaoyang District, Beijing, People's Republic of China
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Rex DK, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Levin TR, Lieberman D, Robertson DJ. Colorectal Cancer Screening: Recommendations for Physicians and Patients From the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2017; 153:307-323. [PMID: 28600072 DOI: 10.1053/j.gastro.2017.05.013] [Citation(s) in RCA: 446] [Impact Index Per Article: 63.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This document updates the colorectal cancer (CRC) screening recommendations of the U.S. Multi-Society Task Force of Colorectal Cancer (MSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy. CRC screening tests are ranked in 3 tiers based on performance features, costs, and practical considerations. The first-tier tests are colonoscopy every 10 years and annual fecal immunochemical test (FIT). Colonoscopy and FIT are recommended as the cornerstones of screening regardless of how screening is offered. Thus, in a sequential approach based on colonoscopy offered first, FIT should be offered to patients who decline colonoscopy. Colonoscopy and FIT are recommended as tests of choice when multiple options are presented as alternatives. A risk-stratified approach is also appropriate, with FIT screening in populations with an estimated low prevalence of advanced neoplasia and colonoscopy screening in high prevalence populations. The second-tier tests include CT colonography every 5 years, the FIT-fecal DNA test every 3 years, and flexible sigmoidoscopy every 5 to 10 years. These tests are appropriate screening tests, but each has disadvantages relative to the tier 1 tests. Because of limited evidence and current obstacles to use, capsule colonoscopy every 5 years is a third-tier test. We suggest that the Septin9 serum assay (Epigenomics, Seattle, Wash) not be used for screening. Screening should begin at age 50 years in average-risk persons, except in African Americans in whom limited evidence supports screening at 45 years. CRC incidence is rising in persons under age 50, and thorough diagnostic evaluation of young persons with suspected colorectal bleeding is recommended. Discontinuation of screening should be considered when persons up to date with screening, who have prior negative screening (particularly colonoscopy), reach age 75 or have <10 years of life expectancy. Persons without prior screening should be considered for screening up to age 85, depending on age and comorbidities. Persons with a family history of CRC or a documented advanced adenoma in a first-degree relative age <60 years or 2 first-degree relatives with these findings at any age are recommended to undergo screening by colonoscopy every 5 years, beginning 10 years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier. Persons with a single first-degree relative diagnosed at ≥60 years with CRC or an advanced adenoma can be offered average-risk screening options beginning at age 40 years.
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Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana.
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, University of Washington, Seattle, Washington
| | | | | | - Tonya Kaltenbach
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | | | | | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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28
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Rex DK, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Levin TR, Lieberman D, Robertson DJ. Colorectal Cancer Screening: Recommendations for Physicians and Patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2017; 112:1016-1030. [PMID: 28555630 DOI: 10.1038/ajg.2017.174] [Citation(s) in RCA: 422] [Impact Index Per Article: 60.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This document updates the colorectal cancer (CRC) screening recommendations of the U.S. Multi-Society Task Force of Colorectal Cancer (MSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy. CRC screening tests are ranked in 3 tiers based on performance features, costs, and practical considerations. The first-tier tests are colonoscopy every 10 years and annual fecal immunochemical test (FIT). Colonoscopy and FIT are recommended as the cornerstones of screening regardless of how screening is offered. Thus, in a sequential approach based on colonoscopy offered first, FIT should be offered to patients who decline colonoscopy. Colonoscopy and FIT are recommended as tests of choice when multiple options are presented as alternatives. A risk-stratified approach is also appropriate, with FIT screening in populations with an estimated low prevalence of advanced neoplasia and colonoscopy screening in high prevalence populations. The second-tier tests include CT colonography every 5 years, the FIT-fecal DNA test every 3 years, and flexible sigmoidoscopy every 5 to 10 years. These tests are appropriate screening tests, but each has disadvantages relative to the tier 1 tests. Because of limited evidence and current obstacles to use, capsule colonoscopy every 5 years is a third-tier test. We suggest that the Septin9 serum assay (Epigenomics, Seattle, Wash) not be used for screening. Screening should begin at age 50 years in average-risk persons, except in African Americans in whom limited evidence supports screening at 45 years. CRC incidence is rising in persons under age 50, and thorough diagnostic evaluation of young persons with suspected colorectal bleeding is recommended. Discontinuation of screening should be considered when persons up to date with screening, who have prior negative screening (particularly colonoscopy), reach age 75 or have <10 years of life expectancy. Persons without prior screening should be considered for screening up to age 85, depending on age and comorbidities. Persons with a family history of CRC or a documented advanced adenoma in a first-degree relative age <60 years or 2 first-degree relatives with these findings at any age are recommended to undergo screening by colonoscopy every 5 years, beginning 10 years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier. Persons with a single first-degree relative diagnosed at ≥60 years with CRC or an advanced adenoma can be offered average-risk screening options beginning at age 40 years.
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Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, University of Washington, Seattle, Washington, USA
| | | | | | - Tonya Kaltenbach
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | | | | | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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29
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Rex DK, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Levin TR, Lieberman D, Robertson DJ. Colorectal cancer screening: Recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2017; 86:18-33. [PMID: 28600070 DOI: 10.1016/j.gie.2017.04.003] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/06/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA.
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, University of Washington, Seattle, Washington, USA
| | | | | | - Tonya Kaltenbach
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | | | | | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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30
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Patel SS, Kilgore ML. Cost Effectiveness of Colorectal Cancer Screening Strategies. Cancer Control 2016; 22:248-58. [PMID: 26068773 DOI: 10.1177/107327481502200219] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Several screening tests are available to detect colorectal cancer (CRC) and reduce the incidence and mortality of CRC. The purpose of this review was to determine how current CRC screening strategies for CRC compare with no screening and whether agreement exists with regard to the cost effectiveness of different strategies. METHODS Databases were searched for cost-effectiveness analyses focused on CRC screening strategies in the United States and published between May 2007 and February 2014. We analyzed the uses of fecal occult blood, fecal immunochemistry, and stool DNA tests, as well as sigmoidoscopy, colonoscopy, and virtual colonoscopy. A paired comparison of each screening strategy with no screening across each of the studies reviewed was conducted. A series of paired comparisons of the results reported in each of the studies is also included. RESULTS When compared with no screening, all CRC screening strategies evaluated in this review were cost effective. There was disagreement as to which screening strategy was the most cost effective. However, sigmoidoscopy combined with fecal blood testing always dominated either strategy alone. Studies comparing colonoscopy with fecal blood testing, sigmoidoscopy, or both had mixed results. CONCLUSIONS Compared with no screening, all CRC screening strategies are more cost effective. Study results disagree as to which screening strategy should be the preferred method.
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Affiliation(s)
- Shaan S Patel
- Department of Health Care Organization and Policy, Birmingham, AL 35294-0022, USA.
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31
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Cevik M, Ergun MA, Stout NK, Trentham-Dietz A, Craven M, Alagoz O. Using Active Learning for Speeding up Calibration in Simulation Models. Med Decis Making 2015; 36:581-93. [PMID: 26471190 DOI: 10.1177/0272989x15611359] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 07/17/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Most cancer simulation models include unobservable parameters that determine disease onset and tumor growth. These parameters play an important role in matching key outcomes such as cancer incidence and mortality, and their values are typically estimated via a lengthy calibration procedure, which involves evaluating a large number of combinations of parameter values via simulation. The objective of this study is to demonstrate how machine learning approaches can be used to accelerate the calibration process by reducing the number of parameter combinations that are actually evaluated. METHODS Active learning is a popular machine learning method that enables a learning algorithm such as artificial neural networks to interactively choose which parameter combinations to evaluate. We developed an active learning algorithm to expedite the calibration process. Our algorithm determines the parameter combinations that are more likely to produce desired outputs and therefore reduces the number of simulation runs performed during calibration. We demonstrate our method using the previously developed University of Wisconsin breast cancer simulation model (UWBCS). RESULTS In a recent study, calibration of the UWBCS required the evaluation of 378 000 input parameter combinations to build a race-specific model, and only 69 of these combinations produced results that closely matched observed data. By using the active learning algorithm in conjunction with standard calibration methods, we identify all 69 parameter combinations by evaluating only 5620 of the 378 000 combinations. CONCLUSION Machine learning methods hold potential in guiding model developers in the selection of more promising parameter combinations and hence speeding up the calibration process. Applying our machine learning algorithm to one model shows that evaluating only 1.49% of all parameter combinations would be sufficient for the calibration.
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Affiliation(s)
- Mucahit Cevik
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, WI, USA (MC, MAE, OA)
| | - Mehmet Ali Ergun
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, WI, USA (MC, MAE, OA)
| | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA (NKS)
| | - Amy Trentham-Dietz
- Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin, Madison, WI, USA (AT-D, OA)
| | - Mark Craven
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA (MC)
| | - Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, WI, USA (MC, MAE, OA),Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin, Madison, WI, USA (AT-D, OA)
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Wong MCS, Ching JYL, Chan VCW, Sung JJY. The comparative cost-effectiveness of colorectal cancer screening using faecal immunochemical test vs. colonoscopy. Sci Rep 2015; 5:13568. [PMID: 26338314 PMCID: PMC4559662 DOI: 10.1038/srep13568] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 07/30/2015] [Indexed: 01/07/2023] Open
Abstract
Faecal immunochemical tests (FITs) and colonoscopy are two common screening tools for colorectal cancer(CRC). Most cost-effectiveness studies focused on survival as the outcome, and were based on modeling techniques instead of real world observational data. This study evaluated the cost-effectiveness of these two tests to detect colorectal neoplastic lesions based on data from a 5-year community screening service. The incremental cost-effectiveness ratio (ICER) was assessed based on the detection rates of neoplastic lesions, and costs including screening compliance, polypectomy, colonoscopy complications, and staging of CRC detected. A total of 5,863 patients received yearly FIT and 4,869 received colonoscopy. Compared with FIT, colonoscopy detected notably more adenomas (23.6% vs. 1.6%) and advanced lesions or cancer (4.2% vs. 1.2%). Using FIT as control, the ICER of screening colonoscopy in detecting adenoma, advanced adenoma, CRC and a composite endpoint of either advanced adenoma or stage I CRC was US$3,489, US$27,962, US$922,762 and US$23,981 respectively. The respective ICER was US$3,597, US$439,513, -US$2,765,876 and US$32,297 among lower-risk subjects; whilst the corresponding figure was US$3,153, US$14,852, US$184,162 and US$13,919 among higher-risk subjects. When compared to FIT, colonoscopy is considered cost-effective for screening adenoma, advanced neoplasia, and a composite endpoint of advanced neoplasia or stage I CRC.
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Affiliation(s)
- Martin C S Wong
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China.,School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China
| | - Jessica Y L Ching
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China
| | - Victor C W Chan
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China
| | - Joseph J Y Sung
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China
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Coldman AJ, Phillips N, Brisson J, Flanagan W, Wolfson M, Nadeau C, Fitzgerald N, Miller AB. Using the Cancer Risk Management Model to evaluate colorectal cancer screening options for Canada. ACTA ACUST UNITED AC 2015; 22:e41-50. [PMID: 25908920 DOI: 10.3747/co.22.2013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Several screening methods for colorectal cancer (crc) are available, and some have been shown by randomized trials to be effective. In the present study, we used a well-developed population health simulation model to compare the risks and benefits of a variety of screening scenarios. Tests considered were the fecal occult blood test (fobt), the fecal immunochemical test (fit), flexible sigmoidoscopy, and colonoscopy. Outcomes considered included years of life gained, crc cases and deaths prevented, and direct health system costs. METHODS A natural history model of crc was implemented and calibrated to specified targets within the framework of the Cancer Risk Management Model (crmm) from the Canadian Partnership Against Cancer. The crmm-crc permits users to enter their own parameter values or to use program-specified base values. For each of 23 screening scenarios, we used the crmm-crc to run 10 million replicate simulations. RESULTS Using base parameter values and some user-specified values in the crmm-crc, and comparing our screening scenarios with no screening, all screening scenarios were found to reduce the incidence of and mortality from crc. The fobt was the least effective test; it was not associated with lower net cost. Colonoscopy screening was the most effective test; it had net costs comparable to those for several other strategies considered, but required more than 3 times the colonoscopy resources needed by other approaches. After colonoscopy, strategies based on the fit were predicted to be the most effective. In sensitivity analyses performed for the fobt and fit screening strategies, fobt parameter values associated with high-sensitivity formulations were associated with a substantial increase in test effectiveness. The fit was more cost-effective at the 50 ng/mL threshold than at the 100 ng/mL threshold. CONCLUSIONS The crmm-crc provides a sophisticated and flexible environment in which to evaluate crc control options. All screening scenarios considered in this study effectively reduced crc mortality, although sensitivity analyses demonstrated some uncertainty in the magnitude of the improvements. Where possible, local data should be used to reduce uncertainty in the parameters.
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Affiliation(s)
| | - N Phillips
- BC Cancer Research Centre, Vancouver, BC
| | - J Brisson
- Institute de Santé Publique, Quebec City, QC
| | | | | | | | - N Fitzgerald
- Canadian Partnership Against Cancer, Toronto, ON
| | - A B Miller
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON
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Meester RGS, Doubeni CA, Zauber AG, Goede SL, Levin TR, Corley DA, Jemal A, Lansdorp-Vogelaar I. Public health impact of achieving 80% colorectal cancer screening rates in the United States by 2018. Cancer 2015; 121:2281-5. [PMID: 25763558 PMCID: PMC4567966 DOI: 10.1002/cncr.29336] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 02/09/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND The National Colorectal Cancer Roundtable, a national coalition of public, private, and voluntary organizations, has recently announced an initiative to increase colorectal cancer (CRC) screening rates in the United States to 80% by 2018. The authors evaluated the potential public health benefits of achieving this goal. METHODS The authors simulated the 1980 through 2030 United States population of individuals aged 50 to 100 years using microsimulation modeling. Test-specific historical screening rates were based on National Health Interview Survey data for 1987 through 2013. The effects of increasing screening rates from approximately 58% in 2013 to 80% in 2018 were compared to a scenario in which the screening rate remained approximately constant. The outcomes were cancer incidence and mortality rates and numbers of CRC cases and deaths during short-term follow-up (2013-2020) and extended follow-up (2013-2030). RESULTS Increasing CRC screening rates to 80% by 2018 would reduce CRC incidence rates by 17% and mortality rates by 19% during short-term follow-up and by 22% and 33%, respectively, during extended follow-up. These reductions would amount to a total of 277,000 averted new cancers and 203,000 averted CRC deaths from 2013 through 2030. CONCLUSIONS Achieving the goal of increasing the uptake of CRC screening in the United States to 80% by 2018 may have a considerable public health impact by averting approximately 280,000 new cancer cases and 200,000 cancer deaths within <20 years. Cancer 2015;121:2281–2285. © 2015 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
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Affiliation(s)
- Reinier G S Meester
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, and the Department of Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Leonard Davis Center for Health Economics and Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - S Luuk Goede
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | | | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Stracci F, Zorzi M, Grazzini G. Colorectal cancer screening: tests, strategies, and perspectives. Front Public Health 2014; 2:210. [PMID: 25386553 PMCID: PMC4209818 DOI: 10.3389/fpubh.2014.00210] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/10/2014] [Indexed: 12/18/2022] Open
Abstract
Screening has a central role in colorectal cancer (CRC) control. Different screening tests are effective in reducing CRC-specific mortality. Influence on cancer incidence depends on test sensitivity for pre-malignant lesions, ranging from almost no influence for guaiac-based fecal occult blood testing (gFOBT) to an estimated reduction of 66–90% for colonoscopy. Screening tests detect lesions indirectly in the stool [gFOBT, fecal immunochemical testing (FIT), and fecal DNA] or directly by colonic inspection [flexible sigmoidoscopy, colonoscopy, CT colonography (CTC), and capsule endoscopy]. CRC screening is cost-effective compared to no screening but no screening strategy is clearly better than the others. Stool tests are the most widely used in worldwide screening interventions. FIT will soon replace gFOBT. The use of colonoscopy as a screening test is increasing and this strategy has superseded all alternatives in the US and Germany. Despite its undisputed importance, CRC screening is under-used and participation rarely reaches 70% of target population. Strategies to increase participation include ensuring recommendation by physicians, introducing organized screening and developing new, more acceptable tests. Available evidence for DNA fecal testing, CTC, and capsule endoscopy is reviewed.
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Affiliation(s)
- Fabrizio Stracci
- Public Health Section, Department of Experimental Medicine, University of Perugia , Perugia , Italy ; Regional Cancer Registry of Umbria , Perugia , Italy
| | | | - Grazia Grazzini
- Department of Screening, ISPO Cancer Prevention and Research Institute , Florence , Italy
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Smith RA, Manassaram-Baptiste D, Brooks D, Cokkinides V, Doroshenk M, Saslow D, Wender RC, Brawley OW. Cancer screening in the United States, 2014: a review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin 2014; 64:30-51. [PMID: 24408568 DOI: 10.3322/caac.21212] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 10/14/2013] [Indexed: 12/15/2022] Open
Abstract
Answer questions and earn CME/CNE Each year the American Cancer Society publishes a summary of its guidelines for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, we summarize current American Cancer Society cancer screening guidelines. In addition, the latest data on the use of cancer screening from the National Health Interview Survey is described, as are several issues related to screening coverage under the Patient Protection and Affordable Care Act, including the expansion of the Medicaid program.
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Affiliation(s)
- Robert A Smith
- Senior Director, Cancer Control Science Department, American Cancer Society, Atlanta, GA
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Ransohoff DF, Pignone M. Colon cancer screening models: lessons and challenges. Clin Gastroenterol Hepatol 2013; 11:1167-8. [PMID: 23660420 DOI: 10.1016/j.cgh.2013.04.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 04/11/2013] [Indexed: 02/07/2023]
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